بهبود مسکن و پریشانی روانی خود گزارش شده در میان ساکنان املاک شورای شهر

This paper is concerned with how housing improvements instigated either publicly or privately influence the degree of psychological stress reported by council estate residents in South Manchester. Stress is measured on the GHQ12 scale containing standard symptomatic items. Potential sources of variation in this indicator are analysed within a geographical setting where repeated samples of residents were drawn from two adjacent suburban council housing estates before and after the implementation of a single regeneration budget (SRB) housing initiative in late 1999. The residents of one of these estates (Wythenshawe) were targeted by this funding while those in the other (Mersey Bank) were not. The latter, therefore, serve as a control for the effects of the enhanced incidence of housing improvement activity promoted by this SRB. Regression analyses revealed that stress was raised significantly among the SRB residents perhaps on account of the additional environmental nuisance they encountered. The experience of stress among all residents, however, was dominated by measures of personal psychosocial risk and it is argued that future regeneration initiatives should address the manifestation of these risks in the effort to achieve better mental health.

The supposition that changing socio-economic circumstances might affect the mental health of a community has been informed through the refinement of a number of psychological constructions (Weich & Lewis, 1998; Marmot & Bobak, 2000; Rogers et al., 2001; WHO, 2001). The initial ideas concerning this connection emphasised the importance of social structure evidenced by the positive association between psychiatric morbidity and social disadvantage and adversity (Holingshead & Redlich (1958)) and, later, with disparities in resources like income, occupation and years in education (Bartley, Blane & Davey-Smith, 1998). A second strand of this debate, often referred to as the psychosocial perspective, has noted the more immediate contribution to the onset of mental distress of precipitating personal factors like the experience of stressful life events or changed social circumstances (Dohrenwend & Dohrenwend, 1982; Brown & Harris, 1978). The evolution of this research has also witnessed a switch from a preoccupation with the psychiatric epidemiology elicited from individuals being treated for mental health problems to a more recent focus on the origins of symptomatic distress among the community as a whole (Aneshensel & Sucoff, 1996; Elliott, 2000). A corollary of all this effort is that initiatives aimed at improving the local environment might impact indirectly upon the mental health of the recipients of these actions. More particularly, the research reported here is concerned with how housing improvements instigated either publicly or privately influence the degree of psychological stress reported by those most immediately affected. The measurement of stress is made quantitatively by recourse to the General Health Questionnaire 12 point scale (GHQ12) containing standard symptomatic items (Goldberg & Williams, 1988). Potential sources of variation in this indicator are analysed within a geographical setting where repeated samples of residents were drawn from two adjacent suburban council housing estates in South Manchester before and after the implementation of a single regeneration budget (SRB) housing initiative in late 1999. The residents of one of these estates (Wythenshawe) were targeted by this funding while those in the other (Mersey Bank) were not. The latter, therefore, serve as a control for the effects of the enhanced incidence of improvement activity promoted by this SRB. This design facilitates the exploration of two general hypotheses. First, are the GHQ12 scores of residents altered either negatively or positively by the experience of housing improvement? Second, are such possible outcomes further affected by the more intense occurrence of regeneration activity in the targeted estate? The assessment of these essentially environmental stimuli also includes an examination of their leverage relative to known psychological risks factors for the susceptibility to mental distress. The paper is organised as follows. Section 2 considers recent research concerning the relationship between environmental influences and the psychosocial risks for mental distress. Section 3 describes the survey methods together with the experimental design. The latter consists of a sequence of multiple regression models specified first to establish the leverage of the incidence of housing improvements on GHQ12 scores and then to include variation associated with the presence of known psychosocial risks. Section 4 describes the results of these statistical procedures. The discussion relates these findings to the debate about the influence of spatially tailored social policy interventions on community mental health. Environmental and individual risks for mental distress The structural and psychosocial constructions of mental distress are not mutually exclusive because both attach importance to the generalised risks associated with socio-economic deprivation. The former, however, emphasises the influence of environmental deprivation while the latter highlights the more immediate contribution of adverse personal experiences. A hierarchical framework that integrates these perspectives has been proposed by Stansfeld, Head and Marmot (1998) and Stansfeld, Fuhrer, Cattell, Wardle, and Head (1999). In their scheme, risks originate in the physical environment through the gradation of material resources. In turn, this variation affects the frequency with which psychological risk factors are present in the local social environment. Poverty, for example, might be expected both to enhance the likelihood of unemployment and to exacerbate the personal consequences of such an event. Alternatively, access to financial resources might act positively to buffer these potential impacts. Whether or not such circumstances are expressed as symptoms of distress depends upon the perceptions of each individual, which is presumed to serve as the last filter on the pathway to poor mental health. A method for operationalising the main elements of this scheme has been outlined in Thomas et al (2002) where the distinction was made between risk factors defined by state variables and those that represent discrete events. States refer to persistent effects that gradually enhance the likelihood of psychosocial risk. They may be chosen to reflect structural characteristics of the physical environment, like living in a community with persistently high levels of unemployment, or to measures of personal vulnerability more specifically linked to the prevalence of common mental health problems. Instances of such vulnerability include people with a limiting disability or those with parents who died during childhood. By contrast, events refer to occurrences thought to precipitate the onset of symptomatic distress like the encounter of psychosocial risks. In addition, individual perceptions may be reflected as events representing reactions to current life circumstances. Feelings of entrapment, for example, which have been found to be crucial to the formation of depression in both patient and non-patient series (Brown, Harris, & Hepworth, 1995), may be evident by the reporting of a restricted opportunity like being unable to move home. Such feelings may also become manifest in the failure to achieve personal goals like the work aspirations of those currently unemployed (Nordenmark & Strandh, 1999). Powerlessness, loss and humiliation characterise the final pathway to depression and both naturalistic studies and controlled trials suggest that psychosocial situations reflecting new hope (or fresh starts) characterise a similar pathway to remission from depression (Harris, 2001). Relationships between variables representing these constructs have been analysed using data surveyed from the South Manchester council estate residents prior to the Wythenshawe SRB (Thomas et al., 2002). The analysis revealed that the variation in GHQ12 scores correlated more strongly with psychosocial event variables than those representing environmental states. In addition both GHQ12 and the event variables were found to be inversely related to the age of the resident. These results are consistent with previous studies that, in particular, report a relatively low incidence of depression in old age (Paykel, 1991). Similarly, the less frequent occurrence of the precipitators of stress (life events, goal-setting and restricted opportunities) among the elderly also helps to account for their comparatively better mental health. Housing is seen to be implicit in the structure of this general framework as a state of the physical environment. Type of tenure, for example, has been viewed as a relational resource linked to psychological characteristics such as a sense of identity and aspirations which provide the basis for security, mastery, self-esteem and overall life satisfaction (Mcintyre, Hiscock, Kearns, & Ellaway, 2001; Nettleton & Burrows, 2000). This research has demonstrated that psychological characteristics are distributed unequally among residents in ways that are likely to have different health impacts on those who rent property compared to owner-occupiers. The distribution of housing stressors, like overcrowding and dampness, together with perceptions of the local environment (area reputation) have been shown to partly explain the relationship between housing tenure and both physical and mental health (Ellaway & Macintyre 1998). In addition, there is more limited evidence to suggest that such potential health risks can be reduced by interventions targeted at those with specific vulnerabilities. Favourable outcomes have been found for improved housing conditions (Halpern, 1980) and, in particular, for those re-housed on the grounds of poor mental health (Elton & Packer 1986). Similar findings have been reported for local interventions aimed at the unemployed (Price, van Ryan, & Vinokur, 1992) and pregnant teenagers living in poverty (Olds, Henderson, Tatelbaum, & Chamberlin, 1988). The effects of area-based housing improvement initiatives, however, are more ambiguous. While better living conditions are anticipated to be beneficial in the long term, the immediate effects of repair and construction are more likely to be sources of stress. Such outcomes have led a recent review of the health effects of housing improvement interventions (Thomson, Petticrew, & Morrison, 2001) to conclude that large scale studies investigating their wider social context are required. This claim, therefore, provides a rationale for our investigation of the mental health consequences of the Wythenshawe SRB.