Are area-based initiatives able to improve area safety in deprived areas? A quasi-experimental evaluation of the Dutch District Approach.

BACKGROUND: Numerous area-based initiatives have been implemented in deprived areas across Western-Europe with the aim to improve the socio-economic and environmental conditions in these areas. Only few of these initiatives have been scientifically evaluated for their impact on key social determinants of health, like perceived area safety. Therefore, this study aimed to assess the impact of a Dutch area-based initiative called the District Approach on trends in perceived area safety and underlying problems in deprived target districts. METHODS: A quasi-experimental design was used. Repeated cross-sectional data on perceived area safety and underlying problems were obtained from the National Safety Monitor (2005-2008) and its successor the Integrated Safety Monitor (2008-2011). Study population consisted of 133,522 Dutch adults, including 3,595 adults from target districts. Multilevel logistic regression analyses were performed to assess trends in self-reported general safety, physical order, social order, and non-victimization before and after the start of the District Approach mid-2008. Trends in target districts were compared with trends in various control groups. RESULTS: Residents of target districts felt less safe, perceived less physical and social order, and were victimized more often than adults elsewhere in the Netherlands. For non-victimization, target districts showed a somewhat more positive change in trend after the start of the District Approach than the rest of the Netherlands or other deprived districts. Differences were only statistically significant in women, older adults, and lower educated adults. For general safety, physical order, and social order, there were no differences in trend change between target districts and control groups. CONCLUSIONS: Results suggest that the District Approach has been unable to improve perceptions of area safety and disorder in deprived areas, but that it did result in declining victimization rates.

The impact of area-based initiatives on physical activity trends in deprived areas; a quasi-experimental evaluation of the Dutch District Approach.

BACKGROUND: Numerous area-based initiatives (ABIs) have been implemented in deprived neighbourhoods across Europe. These large-scale initiatives aim to tackle the socio-economic and environmental problems in these areas that might influence physical activity (PA). There is little robust evidence of their impact on PA. This study aimed to assess the impact of a Dutch ABI called the District Approach on trends in leisure-time PA in deprived districts. METHODS: Repeated cross-sectional data on 48401 adults across the Netherlands were obtained from the Integrated Survey on Household Living Conditions (POLS) 2004-2011. 1517 of these adults resided in deprived target districts and 46884 adults resided elsewhere in the Netherlands. In a quasi-experimental interrupted time-series design, multilevel logistic regression analyses were performed to assess trends in leisure-time walking, cycling, and sports before and during the intervention. Trends in deprived target districts were compared with trends in various control groups. The role of the intensity of environmental interventions was also assessed. RESULTS: Deprived target districts showed a significantly positive change in walking trend between the pre-intervention and intervention period. The trend change in the deprived target districts was significantly larger compared to the rest of the Netherlands, but not compared to other deprived districts. For cycling and sports, neither deprived districts nor control districts showed a significant trend change. For all leisure-time PA outcomes, trend changes were not related to the intensity of environmental interventions in the deprived target districts. CONCLUSION: Some evidence was found to suggest that ABIs like the District Approach have a positive impact on leisure-time PA in deprived districts, regardless of the intensity of environmental interventions.

Area-based interventions to ameliorate deprived Dutch neighborhoods in practice: does the Dutch District Approach address the social determinants of health to such an extent that future health impacts may be expected?

OBJECTIVE: We studied the local manifestation of a national procedural program that addressed problems regarding employment, education, housing and the physical neighborhood environment, social cohesion, and safety in the most deprived neighborhoods in the Netherlands. We aimed to assess if such a program, without the explicit aim to improve health, results in area-based interventions that address the social determinants of health to such an extent that future health impacts may be expected. METHODS: We used standardized questionnaires and face-to-face interviews with 39 local district managers. We analyzed the content of the area-based interventions to assess if the activities addressed the social determinants of health. We assessed the duration and scale of the activities in order to estimate their potential to change social determinants of health. RESULTS: Most districts addressed all six categories of social determinants of health central to the procedural program. Investments in broad-based primary schools, housing stock, green space, and social safety seemed to have the potential to result in district-level changes in social determinants. The scale of activities aimed at employment, income, educational attainment, and the social environment seemed too small to expect an impact at the district level. CONCLUSION: We conclude that the area-based interventions addressed the neighborhood environment to such an extent that future health impacts of the Dutch District Approach may be expected. The health effects in the long term might be more substantial when area-based interventions were devoted more to the improvement of the socioeconomic circumstances of residents.

Is it better to invest in place or people to maximize population health? Evaluation of the general health impact of urban regeneration in Dutch deprived neighbourhoods.

AIM: To study the general health impact of urban regeneration programmes in deprived Dutch districts. We compared initiatives that focused on the improvement of place with initiatives that mainly invested in people. METHOD: A quasi-experimental design compared the trend in good perceived general health in the target districts with comparison districts. Generalized general mixed models assessed the rate of change in prevalence of good health per half year during a prolonged period before and after the start of the interventions. RESULTS: Neither the target districts that invested mainly in place nor the ones with interventions focused on people showed trends in general health different than comparison districts (p>0.05). However, only districts with interventions focused on place showed no deterioration in general health during the intervention period. The trend change in these districts differed significantly from the change in the districts that invested mainly in people (p<0.05). CONCLUSION: Urban regeneration programmes that focus on place may be effective in promoting general health.

The impact of intervening in green space in Dutch deprived neighbourhoods on physical activity and general health: results from the quasi-experimental URBAN40 study.

BACKGROUND: Many problems concentrate in deprived neighbourhoods, among which is poor health. One possible way to address these health problems is to invest in the green space in deprived neighbourhoods. The number of evaluations of the public health impact of actual changes in neighbourhood green space is still limited. This study investigated the impact of real-life changes in the quality or quantity of green space in severely deprived neighbourhoods on physical activity and perceived general health. METHODS: Repeated cross-sectional surveys from 2004 till 2011 yielded self-reported information on leisure time walking, cycling and sports, and perceived general health of 48,132 adult residents. We fitted generalised mixed models to assess the rate of change per half year, estimate the linear trend, and the change in trends before and after the start of the urban regeneration mid-2008. Using a quasi-experimental design, we compared the trends in the intervention neighbourhoods with different selections of control areas. RESULTS: The deprived neighbourhoods that intervened in green space did not show more favourable changes in the trend of physical activity and good general health compared to all the different groups of control areas. CONCLUSIONS: We did not observe short-term positive effects on physical activity and general health among adults from improvements in green space in deprived neighbourhoods. This suggests that greening interventions that have been carried out in the context of the Dutch District Approach did not achieve short-term health gains among adults.

Impact of a Dutch urban regeneration programme on mental health trends: a quasi-experimental study.

BACKGROUND: This paper aims to assess the mental health impact of an urban regeneration programme implemented from 2008 onwards in the 40 most deprived districts in the Netherlands. Interventions varied from improvements in the built environment to activities promoting social cohesion. METHODS: We accessed repeated cross-sectional data from the annual Health Interview Survey, for the period 2004-2011 among adults (n target districts=1445, n rest of the Netherlands=44 795). We used multilevel logistic regression models to compare the development of mental health in the target districts with the rest of the Netherlands and with comparably deprived districts. Results were presented as 'slope estimates' with corresponding 95% CIs. Finally, we analysed the trends by gender and by the intensity of the programme. RESULTS: The trend change in mental health between the intervention and preintervention period was approximately the same in the target districts as in broadly comparably deprived control districts (Δ slope 0.06 (-0.08 to 0.20)). However, among women, a tendency was found towards more positive trend changes in the target districts compared with control districts (Δ slope 0.17 (-0.01 to 0.34)). Those districts that implemented an intensive programme experienced an improvement in mental health, while residents of the comparably deprived control districts experienced a deterioration, resulting in a statistically significantly more positive trend change between the preintervention and intervention period in those target districts (Δ slope 0.19 (0.01 to 0.38)). CONCLUSIONS: Implementing an urban regeneration programme with a wide range of intensive interventions may be effective in promoting good mental health. Further research is required to examine which mix of interventions is needed for the programme to be effective.

The relationship between physical activity and the living environment: a multi-level analyses focusing on changes over time in environmental factors.

There is limited evidence on the causality of previously observed associations between neighborhood characteristics and physical activity (PA). We aimed to assess whether individual-level PA was associated with changes in fear of crime, social cohesion, green spaces, parking facilities, social disorder, and physical disorder that occurred over the past 3 years. In general, in neighborhoods where residents had more favorable perceptions of the environment in 2006, residents were more likely to be physically active in 2009. In addition, improvements between 2006 and 2009 with respect to perceived social cohesion, green spaces, social disorder, and physical disorder were associated with increased odds of being active in 2009. For both the levels in 2006 and trends in the period 2006-2009, the associations were somewhat stronger among women than among men, but associations did not vary by age or length of residence. For several environmental factors, we observed that not only the levels at a certain point in time, but also recent improvements over time were related to PA. These results provide new support for a causal relationship between these environmental factors and PA.

Migration and geographical inequalities in health in the Netherlands: an investigation of age patterns.

OBJECTIVES: This paper estimates, for six different age groups, whether and how migration influences inequalities in health between deprived and non-deprived neighbourhoods in the Netherlands. METHODS: Data were accessed from the Netherlands Housing Survey 2006. Using multi-level logistic regression analyses, we compared the health of migrants with that of nonmigrants in the area of origin and assessed the role of demographic and socioeconomic characteristics. Next, we assessed the magnitude of health differences between deprived versus non-deprived areas among migrants and non-migrants. RESULTS: For many age groups, migrants into non-deprived areas were healthier and migrants into deprived areas had similar levels of health compared with non-migrant populations in the area of origin. These differences in health were not explained by demographic and socio-economic characteristics. For all ages and for people aged 25-34 years we found smaller area inequalities in health among migrants compared with non-migrants. For most other age groups, about equally large differences were observed. CONCLUSIONS: For most age groups, the results do not provide empirical support to the expectation that migration would enlarge health differences between deprived and non-deprived neighbourhoods.

Why residents of Dutch deprived neighbourhoods are less likely to be heavy drinkers: the role of individual and contextual characteristics.

BACKGROUND: Earlier research has shown that residents of Dutch deprived neighbourhoods drink less alcohol than people in other areas. We aimed to assess the role of individual and neighbourhood characteristics in a cross-sectional, nationwide, multilevel study. METHODS: Individual data of 30,117 Dutch adults, living in 1722 neighbourhoods across the Netherlands, were obtained from the 2004 to 2009 national health survey (POLS). Chronic heavy alcohol consumption was measured as ≥14 drinks/week for women and ≥21 for men, and episodic heavy drinking as ≥6 drinks/day at least once a week. Neighbourhood deprivation was dichotomous; deprived districts as selected by the Dutch government versus other areas. Multilevel logistic regression models of the association between deprivation and heavy drinking were corrected for age, gender, household composition, population density and potential predictors ethnicity, socioeconomic status (education, income), neighbourhood-level social cohesion and percentage Muslims. RESULTS: The prevalence of heavy drinking was lower in deprived neighbourhoods than in the rest of the Netherlands. This association was found for both chronic and episodic heavy drinking (OR=0.58 (0.47 to 0.72) and OR=0.57 (0.45 to 0.72), respectively). Adding ethnicity to the model reduced these associations by approximately one half. Socioeconomic composition did not contribute to the relationship. The proportion of Muslims explained a small part, while social cohesion explained even less of the association. Stronger associations were observed for women and older adults than for men and younger adults. CONCLUSIONS: The lower prevalence of heavy drinking occurring in deprived areas is largely explained by the ethnicity of neighbourhood residents.

Change in neighborhood traffic safety: does it matter in terms of physical activity?

BACKGROUND: There is limited evidence on the causality of previously observed associations between neighborhood traffic safety and physical activity (PA). This study aims to contribute to this evidence by assessing the extent to which changes over time in neighborhood traffic safety were associated with PA. METHODS: Data were accessed from the national survey Netherlands Housing Research for 2006 and 2009. The two samples of in total 57,092 Dutch residents aged 18-84 years lived in 320 neighbourhoods. Using multi-level hurdle models, the authors assessed whether the odds of being physically active and the mean hours of PA among active people (in 2009) were related to the levels of neighborhood traffic safety (in 2006) and changes in the levels of neighborhood traffic safety (between 2006 and 2009). Next, we examined if these associations varied according to gender, age, and employment status. RESULTS: Higher levels of neighborhood traffic safety were associated with higher odds of being active (OR 1.080 (1.025-1.139)). An increase in levels of neighborhood traffic safety was associated with increased odds of being active (OR 1.060 (1.006-1.119)). This association was stronger among women, people aged 35 to 59, and those who were gainfully employed. Neither levels of traffic safety nor changes in these levels were associated with the mean hours of PA among people who were physically active (OR 0.997 (0.975-1.020); OR 1.001 (0.978-1.025), respectively). CONCLUSION: Not only levels of neighborhood traffic safety, but also increases in neighborhood traffic safety were related to increased odds of being active. This relationship supports claims for a causal relationship between neighborhood traffic safety and PA.

Migration does not enlarge inequalities in health between rich and poor neighbourhoods in The Netherlands.

We estimate to what extent migration contributes to inequalities in health between rich and poor neighbourhoods in The Netherlands. We used a sample from the survey WoonOnderzoek Nederland 2006. Using multilevel logistic regression analyses, we assessed the magnitude of health differences between poor vs. rich areas for the migrant and total population. Next, we compared the health of migrants to non-migrant populations and we assessed the role of sociodemographic characteristics. For most health indicators, area inequalities in health were much smaller in the migrant population than in the total population. The health of migrants was generally in-between the health of non-migrants who lived in areas of origin and destination. The differences in health with the population in the areas of origin were almost completely explained by sociodemographic characteristics. Health is related to risk of migration between poor and rich areas, mostly through sociodemographic selection instead of a direct effect of health. Despite the relationship with health, migration does not enlarge inequalities in health between poor and rich neighbourhoods but possibly attenuates the health differences.