What do we know about the health impacts of urban regeneration programmes? A systematic review of UK regeneration programmes ( ) Hilary Thomson, 1 Rowland Atkinson, 2 Mark Petticrew, 1 Ade Kearns 2 1 MRC Social & Public Health Sciences Unit, Glasgow, 2 Department of Urban Studies, University of Glasgow

Background Area Based Initiatives (ABI) are major means of urban regeneration to alleviate socio-economic deprivation Massive public investment tackling deprivation: »over £11bn (€16bn) 20 years Intuitive links between positive investment to tackle deprivation and improved health and reduction in health inequalities

A strategy to tackle health inequalities ‘Local neighbourhood renewal and other regeneration initiatives are in a particularly good position to address health inequalities because they have responsibility for dealing with the wider determinants that have impact on people’s physical and mental health.’ Tackling health inequalities: summary of the 2002 cross cutting spending review. London: HM Treasury & Department of Health, Programme vision: New Deal for Communities, 2000 ‘to have lower worklessness; less crime; better health; better skills and better housing’ A new commitment to neighbourhood renewal: national strategy action plan. London: HMSO: Social Exclusion Unit, The Cabinet Office, 2001.

Developing evidence base to support healthy public policy ‘every opportunity to generate evidence from current policy and practice needs to be realised’ Wanless D. Securing good health for the whole population. London: HM Treasury & Department of Health. HMSO, 2004.

‘every opportunity to generate evidence from current policy and practice needs to be realised’… Little or no research evidence of the health impacts of regeneration Evaluations of previous national regeneration programmes  of central policy relevance  previously untapped resource in grey literature Systematic review of health impacts AND impacts on socio-economic determinants of health

Systematic review of national regeneration programmes (UK) Review questions What is the available evidence that national programmes of urban regeneration have an impact on: –population health? –socio-economic determinants of health? »employment, education, income, housing –health inequalities?

Methods: search strategy Nine UK programmes included 1980 to 2004: –Urban Programme –Urban Development Corporations –Estate Action –City Challenge –Small Urban Renewal Initiatives –Single Regeneration Budget –New Deal for Communities –Social Inclusion Partnerships –New Life for Urban Scotland Seven electronic bibliographic databases searched (1980 to 2004) Experts contacted

Methods: review inclusion/exclusion criteria Included: evaluations which reported on achievements or impacts of regeneration programme- qualitative or quantitative Excluded: evaluations of strategy or process issues evaluations of only one target area evaluations of single projects within local ABI areas Two reviewers screened identified documents independently to ensure agreement about included evaluations

Search results 896 references identified 86 evaluations identified: examined independently by 2 researchers 10 evaluations reporting impacts on health or socio-economic outcomes All data from not relevant n=810 Process evaluation n=51 Inadequate assessment of health or socio- economic impacts n=25

Evaluation quality & methods Inadequate assessment of impacts n=25 –Gross outputs and activity reported as impact e.g. how many miles of new road built n=17 –Impacts reported but with no supporting data n=2 –Retrospective assessment by stakeholders n=6

Evaluation quality & methods Inadequate assessment of impacts n=25 –Gross outputs and activity reported as impact e.g. how many miles of new road built n=17 –Impacts reported but with no supporting data n=2 –Retrospective assessment by stakeholders n=6 Impact evaluations n=10 –Poor reporting of methods, sample sizes, response rates, data sources

Impacts: self-reported health and mortality Self-reported 3 years 1 SRB evaluation (panel survey of same residents before and after) –3 measures deteriorated (+/- 3.8%, ranges included zero) –1 measure improved (range +2% to +4%)

Impacts: self-reported health and mortality Self-reported 3 years 1 SRB evaluation (panel survey of same residents before and after) –3 measures deteriorated (+/- 3.8%, ranges included zero) –1 measure improved (range +2% to +4%) Mortality 4-6 years crude mortality: 1 evaluation –decreased (-0.6%, range -1% to -0.2%) standardised mortality: 2 evaluations –decreased (-4, range -7 to -1) –decreased (-17, range -29 to +12)

Impacts: self-reported health and mortality Self-reported 3 years- unclear effect 1 SRB evaluation (panel survey of same residents before and after) –3 measures deteriorated (+/- 3.8%, ranges included zero) –1 measure improved (range +2% to +4%) Mortality 4-6 years- improvement but no comparison with national trend crude mortality: 1 evaluation –decreased (-0.6%, range -1% to -0.2%) standardised mortality: 2 evaluations –decreased (-4, range -7 to -1) –decreased (-17, range -29 to +12)

What about impacts on determinants of health? Employment Education Income Housing

Impacts: employment Overall improvement Effect sizeRange of effects in same direction Improvement compared to wider trend? New Life (after 10 years)  +6% (41% v 47%)  (-9% to +20%) SRB (after 3 years)  +4% (56% v 60%)  (+3% to +5%)  Employment rate Wider trend: compared to changes in regional or national figures over same time period

Impacts: 2-10 years Nine evaluationsOverall improvement Effect size Range of effects in same direction Improvement compared to wider trend? SRB  -1.3%  SRB  -10.8%n/a  SRB  -4%  Estate Action  -29.5%  SIP  -3.8%  SIP  -32%  New Life  -5.3%  Urban Programme  +3.25%  City Challenge  +0.3% 

Impacts: educational achievement at school Overall improvement Effect size Range of effects in same direction Improvement compared to wider trend? Five evaluations (New Life, City Challenge, SRB x3)  mean +6.25%  Pupils gaining ‘>4 GCSEs’ or ‘>2 Standard Grades’

Impacts: household income Overall improvement Effect sizeRange of effects in same direction Improvement compared to wider trend? New Life  -16.5%  SRB  -4%  Households with incomes of <£100/week

Impacts: housing quality & rent Overall improvement Effect size Range of effects in same direction Improvement compared to wider trend? UDC (residents from target area now living in improved housing)  +42.5% Estate Action (average weekly rent local authority tenants)  +99.3% 

Available evidence from existing policy population health? »self reported health: unclear »mortality: small improvement but no comparison with national trends socio-economic determinants of health? health inequalities?

Available evidence from existing policy population health? »self reported health: unclear »mortality: small improvement but no comparison with national trends socio-economic determinants of health? »housing, education, employment, income: small improvements but rarely in addition to wider trends »adverse impacts a possibility health inequalities?

Available evidence from existing policy population health? »self reported health: unclear »mortality: small improvement but no comparison with national trends socio-economic determinants of health? »housing, education, employment, income: small improvements but rarely in addition to wider trends »adverse impacts a possibility health inequalities? »remains unknown

Available evidence from existing policy Very little available Poor quality

What does it all mean? Positive health and social impacts of regeneration investment cannot be assumed Methods to evaluate outcomes need further development –accountability for massive public investment –improve effectiveness of future regeneration investment –identify and prevent unintended negative health and social impacts

Generating usable evidence through evaluation Evaluations designed with possible evidence use in mind » Usefulness of cheap routine data v costly panel surveys looking at impacts for target groups » Improve reporting- methods, samples, response rates, range of effects across case study areas » Outcomes: impacts on determinants of health may be more feasible than health impacts

In the meantime… » Lack of impact data is not grounds for inaction » No evidence does not mean that regeneration has not had an impact- more that we don’t know- can’t assume » Be aware that actual impacts may be counter intuitive and may include adverse impacts