ORIGINAL PAPER

Anne Rogers Æ Peter Huxley Æ Sherrill Evans Æ Claire Gately

More than jobs and houses: mental health, quality of lifeand the perceptions of locality in an area undergoing urbanregeneration

Received: 2 February 2007 / Accepted: 18 January 2008 / Published online: 14 February 2008

j Abstract Background Urban regeneration initia-tives are considered to be one means of making acontribution to improving people’s quality of life andmental health. This paper considers the relationshipbetween lay perceptions of locality adversity, mentalhealth and social capital in an area undergoing urbanregeneration. Methods Using qualitative methods aspart of a larger multi-method study, perceptions ofmaterial, and non-material aspects of the locality andthe way in which people vulnerable to mental healthproblems coped with living in adversity were identi-fied as being more highly valued than intended oractual changes to structural elements such as theprovision of housing or employment. Results Themesderived from narrative accounts included concernsabout the absence of social control in the locality, thereputation of the area, a lack of faith in local agenciesto make changes considered important to local resi-dents, a reliance on personal coping strategies tomanage adversity and perceived threats to mentalhealth which reinforced a sense of social isolation. Wesuggest these elements are implicated in restrictingopportunities and enhancing feelings of ‘entrapment’contributing to low levels of local collective efficacy.The gap between social capital capacity at an indi-vidual level and links with collective community re-sources may in part have accounted for the absence ofimprovements in mental health during the early life of

the urban regeneration initiative. Implications/con-clusions In order to enhance quality of life or mentalhealth, agencies involved in urban initiatives need as abasic minimum to promote security, increase leisureopportunities, and improve the image of the locality.

j Key words urban regeneration – mental health –quality of life – UK – social housing

Introduction

A range of evidence points to the potential of urbanregeneration initiatives to make a contribution toimproving quality of life and mental health. Withinsocial and psychiatric epidemiology both structural1

and psychosocial aspects2 of neighbourhood livinghave previously been considered risks to mentalhealth [1–4, 18] and data linking geographical loca-tion and properties of neighbourhood have suggesteda link between social conditions and mental healthstatus (e.g. [5, 17, 31]). Recent research suggests thatpeople living in ‘socially disorganised’ urban areas aremore likely than others living elsewhere to experiencepsychological distress because of exposure to theimpact of uncontrollable life events, psycho-socialinsults and the negative impact of unemployment,family disruption, violence and crime and lack of

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Prof. A. Rogers (&) Æ C. GatelyNational Primary Care Research and Development CentreUniversity of Manchester5th Floor Williamson BuildingOxford RoadManchester, M13 9PL, UKTel.: +44-161/275-7601Fax: +44-161/275-7600E-Mail: anne.rogers@manchester.ac.uk

P. Huxley Æ S. EvansSchool of Human SciencesDept. of Applied Social SciencesUniversity of SwanseaSwansea, UK

1Traditional ‘structural’ approaches to mental health inequalitiessuch as the community studies of the impact of the environment onmental health conducted in the 1950s and 1960s (e.g. [10, 15])suggested links between social conditions and disadvantage (e.g.unemployment, poverty and racism) and psychiatric morbidity.Recent research into the prevalence of mental disorder amongstwomen and impact of employment, unemployment and standard ofliving point to the importance of macro-structural variables andenvironmental causes in determining mental health [20, 24, 28, 31].2Psycho-socially orientated perspectives are concerned with chan-ges in and experience of life events, the social world of individualsand the way in which social environmental demands generatepsychological stress [3, 18].

Soc Psychiatry Psychiatr Epidemiol (2008) 43:364–372 DOI 10.1007/s00127-008-0316-2

supportive relationships [26]. Stansfeld et al. [27]have previously suggested a hierarchical framework inwhich the influence of environmental deprivation isintegrated with more immediate contribution of ad-verse personal experiences. In order to understandthe relationship between those aspects and mentalhealth attempts have been made to extend a focusbeyond the compositional and contextual effects oflocalities in order to view neighbourhood living as aset of ‘relational resources’ providing a sense ofidentity and aspirations linked to ontological security,mastery, self-esteem and overall life satisfaction [15,19]. Neighbourhood resources may increase individ-ual vulnerability to stress by reducing the effective-ness of individual resources such as a personal senseof control [4] and in terms of individual responses toadversity, there is some evidence to suggest that be-liefs about personal control mediate the relationshipbetween environmental stressor and depressivesymptoms [2].

Aspects of social capital in urban environments arealso thought to mediate individual and communitylevel resources in a way, which is likely to impact onmental health [10]. The combined resources of indi-viduals (e.g. trust, norms, social networks) [21, 22]and their integration into collective activity (e.g.sporting, religious, educational, cultural and artisticevents and routines) have been linked with changes inrates of emotionally related behaviour across differentneighbourhoods [25]. Psychological well-being hasbeen associated with social support networks whichenhance individuals self-esteem and self-efficacy inareas with low social capital where these features oflocal life are sparse or absent [13]. However, there is aneed to describe more precisely the linkages betweensocial membership, social connectedness and psy-chological well-being [29]. The purpose here is tobegin to explore the way in which individual re-sources, and responses to mental health vulnerabilityand broader collective or structural aspects of theenvironment might be related. In particular ourintention is to focus on people’s subjective percep-tions of structural change and possible connectionsbetween the social environment and ways of dealingwith adversity in an area undergoing change and theway in which this may be connected to the presence ofsocial capital resources relevant to mental health.

Methods

j A multi-method research design

A major urban regeneration programme in a disadvantaged area inSouth Manchester (the index area) provided an opportunity toinvestigate the impact of changes in socio-economic and localitycircumstances on the mental health of different groups and indi-viduals and to compare this to a control area where no such ini-tiative existed. The aims of the overall study were to further theunderstanding of: the role played by urban regeneration in alteringthe degree and distribution of socio-economic variations in mental

health; the impact of socio-economic and locality changes onpeoples’ mental health vulnerability and subjective well-being. Amulti-level multi method longitudinal study approach was usedwith a 22-month follow-up in a Single Regeneration Budget area,and matched control area in South Manchester. A total of 1,344subjects responded to a postal questionnaire survey. The mainoutcome measures were GHQ12 (mental health) status, MANSA(life satisfaction), and GP use. Mental health outcome in the indexand control areas showed no improvement over time and restrictedopportunities, a variable closely related to mental health, were notremoved by the urban regeneration initiative. The results of thisstudy were published in an earlier paper in this journal [12].

j The linked qualitative study

The large longitudinal survey in which we collected informationabout mental health status, quality of life, personal circumstancesand consulting behaviour was followed by a more focused interviewsurvey of 200 people carried out at two time points which exploredin greater detail, mental health and quality of life perceptions andexperience of living in, and changes to, the community3. From thissample of 200 people a further smaller purposive sample (n = 20)were chosen for in-depth qualitative interviews on the bases ofsignificant changes to CIS scores between the first and second stageinterviews (between T1 and T2). The qualitative interviews weredesigned to obtain further details about the subjective views of thelocality, effects of the urban regeneration programme, psychosocialwell-being and perceptions of mental health were ascertained froma sub-group of the main sample.

As Huberman and Miles [11, p 434] point out qualitativestudies can identify causal relationships through exploring ‘thelocal processes underlying a temporal series of events and states’.In this regard the qualitative study sought to link subjectiveunderstanding of the influences of neighbourhood character onindividuals as a means of understanding the full personal and socialpicture relevant to mental health. Narrative accounts of people’ssubjective evaluations in which lay respondents make regularallusions to biographical, social and cultural factors in explaininghealth status and behaviour are the capacity to provide comple-mentary insights to those produced from more traditional epide-miological and psychological perspectives and measures [23]. Ourevaluation examined how individuals and communities ‘feel’ andparticipate in areas undergoing community regeneration and ex-plored how structural community elements of change as part of theregeneration are perceived and experienced. This was to enable usto focus on events and aspects of the environment relevant toperceived changes in psychological well-being. The qualitativestudy was aimed at exploring the influences that might be impli-cated in change in mental health status from the individual per-spective. In particular we explored people’s subjective meaning andexperience of mental health in relationship to a sense of place,social and community networks and changes occurring within thelocality. The qualitative interviews explored the following areas:

• Personal history of living in the locality and perceptions ofmajor problems and their causes in the locality

• Awareness of and attitude toward involvement in the regenera-tion initiative and other policy changes

• Lay epidemiology, knowledge and conceptions of the maincauses of mental health problems and determinants of mentalhealth (an examination of the peoples’ perceptions of the rela-tionship between employment and mental health and other localenvironmental determinants of mental health)

• Assessment of personal vulnerability to mental health problemsand stressors

3The main measures used in the study are measures of mentalhealth—the General Health Questionnaire (GHQ-12) (Goldberg1978) [7] and the Clinical Interview Schedule - Research version(CIS-R) (Lewis et al. 1992) [30].

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• Perceived ways of maintaining mental health and available layand professional strategies for averting mental health problemsarising

• Perceived sources of social support

• Contact with primary, secondary and voluntary organisations.

The interviews were taped, fully transcribed and analysed the-matically.

Results

The interpretation of the dynamic between the sub-jective perceptions of locality change (e.g. in terms ofemployment and involvement of external agencies)and the possible links to personal resilience at anindividual level are summarised in Fig. 1. This inter-pretation of the relationships are derived from the-matic analysis of respondents statements aboutaspects of perceived locality change on the one handand accounts of their psychological well-being andcoping strategies on the other.

The accounts of people interviewed suggestedthat a range of factors commensurate with well-proven aetiological and triggering factors accountedfor both deterioration and improvement in mentalstatus in respondents between Time 1 and Time 2(T1 and T2, see Table 1). These related to major lifeand familial events including those related to health,employment and divorce. In dealing with mentalhealth distress, people mainly referred to a relianceon personal resources, support from significantothers or help-seeking from primary care. The latterwas clearly identified as a formal agency attributedwith providing counselling, advice and treatment inrelation to emotional problems. Our focus in thequantitative study was on the factors, which may belinked to the formation of mental distress in alocality. Correspondingly in the qualitative analysisattitudes and perceptions of the structural influ-

ences previously associated with risks to mentalhealth and the variable of restricted opportunitieswere the most important to illuminate. In the multi-variate analysis ‘restricted opportunities’ had thestrongest association with mental health. (Thisvariable referred to residents’ frustrated attempts tomake desired improvements in all life domains.)This finding corresponds with other studies showingthat blocked or absent personal goals are associatedwith poor mental health outcomes.

The experience of living in the locality and usinglocal resources could enhance or ameliorate feelingsof psychological distress. It was clear from people’saccounts that the most important direct locality factorwas anti-social behaviour such as harassment /van-dalism and the type of employment available (i.e. low-paid temporary employment) and newly createdemployment opportunities being made available tolocal people. In this respect locality factors wereimplicated as mediating influences by increasing asense of increasing personal vulnerability or resilienceto an existing mental health state.

Like I said I feel like it is becoming a war zone.These kids and what they are doing and thesedruggies are all nasty people, they are ruining whatcould be a nice area. They should be dealt with, youknow… It would be quite happy and everyonecould get on with their little lives and there wouldbe probably less stress and anger and rage and allthis sort of thing… I need these yobbos to leave mealone and I will be alright.ID 2224 44-year-old single female, in full employ-ment

In addition to these direct references to the connec-tion between external influences and mental healthstate the qualitative data provided a more elaboratepicture of the way in which people conceptualised

Personal Vulnerability/Resilience

Restricted Opportunities

Non-Material ChangeLack of Social ControlReputation

Ineffectual External Agencies

Social Captial

Ontological SecurityThreat to Personal Safety

Sense of Entrapment

Coping Strategy

AvoidanceIsolation

Low sense of collective efficacy

Predominance ‘weak’ familial tiesLack of community organisation

e.g. Police, Housing Association

Perceptions of Locality

Infrastructure - Housing

- Employment - Transport

Change

Factors Accounting for Deterioration in Mental Health T1 and T2

Fig. 1 Interpretation of the dynamic betweenperceptions of locality change and personalvulnerability

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each of the key structural changes and their relativeimportance to peoples’ everyday lives.

Perceptions of locality change

j Changes to the infrastructure of the locality

The quantitative data analysis showed an associationbetween higher mental health symptom scores and‘less neighbourliness/security’, fewer leisure oppor-tunities and a reported sense that their area is indecline [12]. The importance ascribed to this wasexpanded upon in the narrative accounts with sug-gestions that changes made under the rubric of theregeneration initiative in the locality were viewed asbeing superficial or having a relatively neutral,ambivalent or marginal impact on present and futureaspirations of people living in the locality. This wasclearly seen in relation to responses to housingimprovements, which constituted a key feature of thelocal regeneration initiative. Whilst the quantitativesurvey of people in the index area found a majorityreporting changes to their homes, accounts givensuggested mixed feelings about the experienced andperceived benefits of ‘housing improvements’:

I don’t think they {those responsible for housingimprovement} have done anything like extraordi-nary. The work they had done … is basically whatthey had the grants for, like your windows and yourkitchen is supposed to be getting done and themin…ID 8410 43-year-old divorced male, unable to workdue to a disabilityOn the outskirts of the Willow Park Estate, its doneup to all look nice and that but as soon as (you) go

straight into the heart of the estate itself, its just likea dump, it’s like a bombs hit it… I mean it’s justlike appearances, if someone was driving throughgoing to the airport, they might think oh right it’s abit done up round here but if they turn left into theestate they’d be like blimey…ID 6124 24-year-old single male, in full employ-mentThere’s so much private housing being done roundhere now. Now we’re supposed to aspire to that.But we don’t it just winds us up because if they canafford to do that why can’t they afford to do it witheverybody. Why aren’t we all given the right to livein places like that…?ID 9837 55-year-old widowed female, unable towork due to a disability

A similar set of ambivalent comments were madeabout the provision of employment and leisureopportunities.

We’ve got the airport, which is lucky but I mean thejobs at airport are only seasonal, they’re onlytemporary, they’re only for six months. And then ifyou get kept on, another thing it only seems to bepeople out of the area that get kept on.ID 13513 28-year-old single male, in full employ-mentLike the theatre at the Forum, that was a fabuloustheatre but half the population of Wythenshawedidn’t even know it was there and the other half …it’s people from out of the area who drive in, watchthat and then drive out for something to eat.ID 9837 55-year-old widowed female, unable towork due to a disabilityYou go over to the Forum and the library and thatbut that’s about all that you’ve got … it’s not the

Table 1 Respondents who were identified for in-depth interview (n = 20)

Sex Age (years) +/) Mental health score Self-defined reasons for change in mental health status

Female 56 +5 Frustration with ‘problem’ neighboursFemale 44 +8 Increased anti-social behaviour by local youths—feels a constant targetMale 61 )14 Sought help from GP and was prescribed anti-depressantsMale 45 )2 UnemploymentFemale 41 )11 Learnt to live with the situation she was in and became more involved in the areaFemale 36 )11 Sought help from GPMale 22 +2 Believes that area impacts on mental health but tries to remain positiveFemale 25 )1 MH remained the sameMale 52 )15 Improvement with family problemsMale 49 +20 Deterioration in chronic illnessFemale 48 +11 Family problemsMale 26 )16 Gained regular employment/improvement in financial situationFemale 51 +9 LonelinessFemale 50 +22 Less motivation to go out and do things—unhopeful for the futureMale 60 )5 Improvements in physical healthFemale 54 +3 Life remains unchangedFemale 27 )12 Returning to collegeFemale 28 +1 Improvements at workFemale 38 )7 The possibility of achieving goals set/seeing a futureMale 42 )14 Coming to terms with physical illness

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gym it’s leisure facilities you need like a picturehouse.ID 12995 29-year-old divorced female, unable towork due to a disabilityThey’ve got the Forum for swimming and recrea-tion but they could with, all the clubs are downManchester, you know … they should have a clubup here. And some of the local pubs you can’t reallygo in to.ID 12622 61-year-old married male, unable to workdue to a disability

One structural element of change that was viewed in amore favourable light was the proposed alteration totransport arrangements. These were seemingly linkedto the perception that this would ‘connect’ up the areawith other desirable resources, which were viewed asmaking a positive contribution to peoples’ quality oflife (shopping, nightlife, the countryside) that laybeyond the immediate area.

They are supposed to be putting the Metrolinkdown here as well so it’s going to be like thetransport infrastructure for the Wythenshawe intwo or three years time will be really good.ID 6174 24-year-old single male, in full employ-ment

j Perceived impact of locality reputationon opportunities

The impact of non-material or structural aspects ofthe environment were stressed more than changesproposed to the infrastructure of the area. This wasparticularly the case when respondents discussed themeaning and impact of the reputation of the area [16].The respondents who lived in the Wythenshawe areaconsidered that the relative standing of their area hadimproved in recent years.

… the place is lovely and green. In other places allyou can see is houses. Everything is lovely andgreen. There’s plenty of green belts, you’ve gotWythenshawe Park, you’ve got a few parks …there’s trees everywhere. You go to other areas likeRusholme and you never see a tree… It’s just that Ithink that is more freedom up here, you can takethe dogs out in the park. Everything seemsbrighter. I think it is going to take off here in thenext couple of years with the Metro and the thirdrunway.ID 12622 61-year-old married male, unable to workdue to a disability

However, the marginal improvement to the area’sstatus which was apparent to local residents did notextend to the way in which outsiders were seen to

make and act upon negative judgements about thelocality as intimated by these respondents:

You’re from Wythenshawe; you’re looked down on.And if you the other side … if you say you lived inStockport or Heald Green or Gatley then you getdifferent respect definitely.ID 8952 31-year-old married female, in fullemploymentAnd then when you mention Wythenshawe they goWythenshawe you can’t walk through at night, youcan’t do this, you can’t do that, you know leaveyour car unlocked.ID 13986 40-year-old divorced female, unemployed

A flawed sense of self was at times tied up with theascribed reputation of the area which was viewed ashaving implications at an individual level for personaland social opportunities:

I think, just by being in Wythenshawe you’re not100%. You’re living in an area of need so you mustneed. They don’t realise the skills that are in this area.ID 9837 55-year-old widowed female, unable towork due to a disabilityWhen I went for a job they said where do you live and Isaid Benchhill: you could forget the job. Oh yes. Youcould forget the job, you had no chance of getting it, assoon as you mentioned Benchhill that was because likeI said it had a very bad name and it’s still got it now.ID 13388 56-year-old divorced male, unemployedI sent off an application from and where it had onyour address and your postcode, it had M22, they’dbe like that bin … Just because of the area you livein you get tarred with the same brush of the otherpeople that live there.ID 6174 24-year-old single male, in full employment

These last two comments illustrate the prominence ofthemes relating to social control more generally in thelocality—‘Nuisance families’, gangs, bored youths,drugs, vandalism of and taking over public areas, carnoise and offences and threatening behaviour. Mostpeople regarded these things to have got worse overthe period of the study.

Its anti-social behaviour more than anything Ithink it’s increased. I really do think it’s increased… there’s a hell of a lot of anti-social behaviourwith kids. I mean I had a twelve-year-old exposehimself to me and nobody could understand that Iwas upset about it…ID 1329 59-year-old divorced female, unable towork due to a disabilityThat’s another thing there’s so many heroin addictsin Wythenshawe it’s just like methadone. They aregetting more methadone dosage than they were onheroin. You can see it outside the chemist some-times as well, the dealers selling the methadone to

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the kids who were swapping it with the addicts, abottle of methadone for heroin. And the kids hav-ing it on the streets.ID 6174 24-year-old single male, in full employment

j Perceived attitudes of agencies charged withbringing about change

The perception of ineffectual agencies compounded theperceived problems that cosmetic rather than sub-stantive changes had or were likely to occur. Accountsabout housing were replete with caveats about the gapbetween expectations and what local agencies couldactually deliver in terms of housing and employmentopportunities. Additionally agencies were viewed asperpetuating the problem by failing to deal with matterseffectively and for policies that brought problems to thearea (e.g. attributions about providing housing for‘nuisance’ families who disrupted everyday life andposed a threat to personal safety).

I think the police are no good, I’ll be honest the policedon’t seem too good at all … you phone them up ittakes them two or three hours to come…ID 9980 51-year-old married female, not in paidwork due to caring for the homeYou know unless they do something permanent,just laying trees there is not going to work. Andthat’s what I would like, if I could see something,which was definite improvement like stoppingthem there [joy riders], it’s there definitely so theycouldn’t get past then I would get involved more.ID 13388 56-year-old divorced male, unemployedI really am hoping that it’s going to make a changeand bring back the community because I thinkthey’re trying but they (housing agency) have notreally got it off on the right foot yet, they’ve got tofind the way round it…ID 1329 59-year-old divorced female, unable towork due to a disability

Others considered the powerlessness of externalagencies in the face of the need to change the peoplewho lived in the locality:

If you’re going to regenerate the area, then you’vegot to regenerate people’s minds, ‘cos it’s just goingto go the same way, its just going to go down hill,no matter how much money you pump into it.ID 6174 24-year-old single male, in full employment

j The impact at an individual level: restrictedopportunities and entrapment

Whereas opportunities for employment were seen tobe restricted because of the reputation perceived by

outsiders, the lack of social control within the vicinitywas seen to restrict opportunities for personalimprovement, movement and safety. Quotes fromthese two middle-aged women describe curtailment ofindividual efforts to improve living arrangements andthwarted personal goal setting. The first refers to aresponse to vandalism and petty theft from her gar-den by young people and in the second account,benefits accrued from seeking and obtaining work areunder threat:

It annoys you. It annoys you. You think you try andmake places look nice and you’ve got to comehome to this. You know when you come homefrom wherever you’ve been and you come home tothat. It’s like all the stuff out of the garden thatwent. You don’t feel as though you want to put anymore into it. You want to buy things and you think‘why should I spend that’, when it’s, you know,you’re working hard for it and you go out andthat’s gone and this has gone.ID 1047 57-year-old married female, in fullemploymentWith the new job I’ve got, in six months time I willbe entitled to a brand new car, all expenses paidexcept for petrol and I am frightened to take it.How can I live with it? They said ‘well don’t worryit is all insured and taxed and that’, but I said ‘butwhat if every five minutes I am claiming for the car?Will it get taken off me? What’s going to happen?’So I’m frightened. I keep saying ‘no’. I don’t think Iwill have the car. So I’m losing out, that’s part ofmy salary. So I’m losing that now because I’m tooscared to have a car on my drive.ID 2224 44-year-old single female, in full employ-ment

Restricted opportunities which led to feelings ofentrapment arose both from actual restrictions tophysical mobility and ready access to leisure oppor-tunities, for example from a lack of transport:

I used to go out every Wednesday with my sister inlaw and cousin, you know when the football hasbeen on, which it has been over the last, it’s fin-ished over now. We just don’t go out now ‘causetaxis don’t turn up for you, even the taxis now arenot coming out…ID 1047 57-year-old married female, in fullemploymentWe used to go to St Mary’s regular me and Mary sowhen we come out everything is pre-booked forhalf eleven to come home, the minibus is gonewhich they shouldn’t do because they’re not in-sured once someone else gets in and we are oftenleft there. It’s a long walk in the snow and the rainso we had to stop from going out there.ID 12622 61-year-old married male, unable to workdue to a disability

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Restrictions on taking up everyday social and per-sonal opportunities were also related to a sense of feargenerated by others.

I think it is an intimidating thing for the olderpeople who have to go round to the shops at thenighttime. It is frightening. A lot of them won’teven go round. It is because you have about 20youngsters/teenagers hanging round and it’s quiteintimidating, even for myself. If I knew I was goingto have a drink at night time I would make sure I bethere before 7 o’clock and have got my drink andI’m at home. I wouldn’t like to attempt to go roundthere at 9 o’clock gone. No.ID 8410 43-year-old divorced male, unable to workdue to a disabilityI like to potter in the garden and things, and youknow, if you’ve got gangs and that you feel a bitintimidated going out there.ID 930 38-year-old married female, in fullemployment

The extent to which people felt personally vulnerableor resilient to these threats and therefore the potentialto restrict opportunities varied. Women respondentsseemed more threatened than men and newcomersmore than established residents. There seemed less ofan impact too if the individuals causing trouble werepersonally known. Familiarity meant being able tonormalise matters and perhaps enabled the cognitiveminimisation of external threats:

I’ve gone to bed with my door wide open and goneto sleep because I know the people here. I mean ifI’d just moved in and did that probably the kidswould have burgled me, probably the kids who arein there would burgle me.ID 13513 28-year-old single male, in full employ-mentI mean they come and knock and say we’re havinga party, we’re going to have music and everything,is it going to, it not going to bother me, it doesn’tbother me in the slightest.ID 1472 47-year-old divorced male, unable to workdue to a disability

However, others reported distress, fear and disruptionto everyday lives. Additionally, feelings of entrapmentmay have been reinforced by strategies of avoidanceand voluntary social isolation which people deployedto deal with threats. Peoples’ accounts pointed to apreference for dealing with matters in isolation fromothers outside of immediate family and significantothers. Respondents seldom reported visiting oneanother and people commented on a palpable declinein a sense of community.

If we were going out and there was a crowd of ladsstood at the gate next door. I wouldn’t go out be-

cause that would mean my house was empty and Iwouldn’t trust (them) not to come and break in, it’sas simple as that I would wait for them to leave andthen shoot off out…ID 13089 52-year-old married male, unable to workdue to a disabilityLike there was a problem with dogs and everybodywas out shouting about these dogs keep attackingpeople … and I went over and says I’m willing togo and report it, if somebody else will say they’llreport because it’s no use just me doing it. And itturned out I was the only one who went. It justdepends. It’s not really got the community spirit…ID 1329 59-year-old divorced female, unable towork due to a disabilityAnd people see things here but they don’t see it,you know what I mean? I am the one who is alwaysreporting. I know they are spying out of theirwindows and they play dumb, I know.ID 2224 44-year-old single female, in full employ-mentI tried to get a petition up but they are just notinterested, oh they won’t do any good. They’ve putup with it for so long with nothing being done.ID 12300 55-year-old divorced male, unable towork due to a disabilityI mean you might not, apart from saying goodmorning or hello or something like that, during thewinter months you might not see you neighboursfrom one month to the next.ID 1972 47-year-old divorced male, unable to workdue to a disability

The reluctance of residents to engage in collectiveactivities and a lack of faith in agencies to bring aboutsubstantive changes which mattered to individualsmay have acted to increase a sense of having to dealwith things at an individual level and fitted into a pre-existing culture of self-reliance and keeping ‘oneselfto oneself’.

Discussion

There has been growing interest in the relationshipbetween the impact of neighbourhood environmenton mental health and in the interplay between agencyand structure in understanding how locality effectscan influence mental health. The analysis of qualita-tive data reported here formed part of a larger studydesigned to explore the relationship between socio-economic policy interventions (in this case an urbanregeneration initiative and its impact on mentalhealth [14, 12]). Within the field of mental healthqualitative methods are increasingly being used as ameans of illuminating aspects that remain hidden orare latent in quantitative methods [30, 24] and herethe qualitative investigation aimed to illuminate moreabout the perceptions of the socio-economic and

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structural changes in the locality environmentalongside respondents personal strategies which theydescribed as being against potential threats to mentalhealth.

A key theoretical pre-supposition underlying themain quantitative study was that locality socio-eco-nomic circumstances such as poverty, which exacer-bate the personal consequences of adverse events aremediated through the perceptions of individuals whichact as the last filter on the pathway to poor mentalhealth. In the quantitative multi-variate analysis re-stricted opportunities were found to have the strongestassociation with improvements in mental health scores[12]. Restricted opportunities refer to residents’ frus-trated attempts to make desired improvements in alllife domains and from the qualitative interviews acorresponding notion of ‘entrapment’ emerged whichimplicated perceptions of changes (or lack of them)introduced in the locality undergoing regenerationtogether with the way in which people attempted to dealwith limitations and threats to mental health. Thepersonal strategies people adopted to protect emo-tional well-being and relationships to others suggestedone aspect of the way in which low levels of socialcapital in an area are maintained. The material changesto the infrastructure were not highly valued and wereconsidered to be seen as cosmetic rather than sub-stantive. Moreover, in terms of making improvementsto peoples’ quality of life the need to bring about actualmaterial change was viewed as less important thanneeding to improve matters related to ‘a sense of place’[6] and in particular the reputation of the locality andthreats to personal safety. The way in which these as-pects were experienced in everyday life were clearlyrelated to feelings of entrapment and the inability toescape from negative situations—factors which havebeen found to be central to the formation of depression[1]. Agencies charged with bringing about change inthese areas (e.g. police and housing authorities) werethought to be ineffective in managing these non-material aspects of the environment and as such wereperceived as failing to address the concerns which wereof key importance to people’s sense of well-being andproviding a decent place to live in.

At a personal level coping with an adverse envi-ronment was characterised by avoidance and con-tainment strategies (which from the narrative analysiswere the most frequently identified principal means ofdealing with external threats) that involved a retreatinto ones’ own living space and sharing matters withclose family members where there was a chance ofmaintaining a sense of mastery and control. Although‘avoidant’ coping has been associated with adaptivefunctioning in relation to depression at higher levelsof stress it has been positively associated withdepression at low levels of stress [8]. It is likely thatenforced social isolation served to enhance ratherthan militate against entrapment and that the per-ceived ineffectiveness of change agents and the

ambient norms in the locality reinforced this.Respondents reported a reliance on ‘strong’ ties withsignificant others and a street culture emphasising anethos of individuality and privacy as the best way ofprotecting oneself from external threats.

The connectedness between different elements ofthe relationship between individuals and wider influ-ences within a locality (depicted in Fig. 1) suggests thepresence of a vicious circle in which low levels of socialcapital at a community level are maintained throughthe interplay with individual means of managingthreats to psychological well-being. At the individuallevel cognitive forms of social capital such as trust andnorms of reciprocity, which ideally, one might havebeen expected to have been present in relation to peo-ple’s perceptions about community agencies were notapparent or abundant. This suggests that the condi-tions for engaging local residents by local partnershiporganisations associated with the urban regenerationinitiative had not seemingly been established. An in-stance of the latter was clearly demonstrated when theresearch team outnumbered local residents at one ofthe regeneration open meetings about the healthcomponent of the SRB programme. Given the failure toengender a sense of faith in the ability of key localityagencies to make changes to key areas of peoples’everyday lives individualised strategies were by com-parison experienced as more reliable and efficient. It islikely that in the absence of ‘linking’ social capital be-tween individual and community levels [27] existingpattern of relationships runs the risk of reinforcingfeelings of entrapment and acting to further restrictalready restricted opportunities both of which areassociated with poor mental health and quality of life[14, 12]. Accounts from individuals suggested littlemotivation for people to engage with initiatives at acollective level or to work with external agencies incontributing to change in the locality.

Breaking this vicious circle appears to be a majorchallenge for regeneration initiatives. It is likely torequire the promotion of an environment likely toenhance levels of positive mental health, lower a senseof entrapment and temper a trend on the over-reli-ance of individualised responses to environmentalproblems. Agencies involved in urban initiatives needto develop practices which promote a sense of secu-rity, increase leisure opportunities, and where neces-sary improve the image of the locality. It seems whatwas needed to improve engagement and participationmight have been aspects of the environment seen ascausing major restrictions (e.g. using initiative moneyto build and patrol a number of secure play areas,addressing the safety at night travel problem, theprovision of cheap or free transport back from thecentre of town). Additionally, the involvement ofagencies seen to help with individual distress such asprimary care might be able to act as catalysts topromote the ‘strength of weak ties’ [9] between indi-viduals and other community agencies. Restoring

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faith in agencies might in turn lead to the re-buildingof the social capital resources needed to bring aboutsustainable change.

References

1. Brown GW, Harris TO, Hepworth C (1995) Loss, humiliationand entrapment among women developing depression: a pa-tient and non-patient comparison. Psychol Med 25:7-21

2. Deardorff J, Gonzales NA, Sandler IN (2003) Control beliefs as amediator of the relation between stress and depressive symp-toms among inner-city adolescents. J Abnorm Child Psychol31(2):205–217

3. Dohrenwend BP, Dohrenwend BS (1982) Perspectives on thepast and future of psychiatric epidemiology. Am J Public Health72:1271–1279

4. Elliott M (2000) The stress process in its neighbourhood con-text. Health Place 6:287–299

5. Faris RE, Dunham HW (1939) Mental disorders in urban areas:an ecological study of schizophrenia and other psychoses. TheUniversity of Chicago Press, Chicago

6. Gesler WM (1992) Therapeutic landscapes: medical issues inlight of the new cultural geography. Soc Sci Med 44(5):657–671

7. Goldberg D (1992) General health questionnaire (GHQ-12).NFER-Nelson, Windsor

8. Gonzales NA, Tein JY, Sandler IN, Freidman RJ (2001). On thelimits of coping: interaction between stress and coping for in-ner-city adolescents. J Adolesc Res 16(4):372–395

9. Granovetter MS (1973) The strength of weak ties. Am J Soc78(6):1360

10. Hawe P, Shiell A (2000) Social capital and health promotion: areview. Soc Sci Med 51(6):871–885

11. Huberman MA, Miles M (1994) Data management and analysismethods. In: Denzin NK, Lincoln YS (eds) The sage handbookof qualitative research, 3rd edn. Sage, Beverly Hills

12. Huxley P, Evans S, Leese M, Gately C, Rogers A, Thomas R et al.(2004) Urban regeneration and mental health. Soc PsychiatryPsychiatr Epidemiol 39(4):280–285

13. Khan N, Bower P, Rogers A (2007) Guided self-help in primarycare mental health—meta-synthesis of qualitative studies ofpatient experience. Br J Psychiatry 191:206–211

14. Lewis G, Pelosi A J, Araya R et al (1992) Measuring psychiatricdisorders in the community: a standardised assessment for useby lay interviewers. Psychol Med 22:465–486

15. Lomas J (1998) Social capital and Health: implications forpublic health and epidemiology. Soc Sci Med 47(9):1181–1188

16. Macintyre S, Ellaway A, Cummins S (2002) Place effects onhealth: how can we conceptualise, operationalise and measurethem. Soc Sci Med 55(1):125–139

17. Macintyre S, Maciver S, Sooman A (1993) Area, class andhealth: should we be focusing on places or people? J Soc Policy122(2):23–34

18. Mullick MSI, Goodman R (2005) The prevalence of psychiatricdisorders among 5–10 year olds in rural, urban and slum areasin Bangladesh. Soc Psychiatry Psychiatr Epidemiol 40(8):663–671

19. Myers J, Bean L (1968) A decade later: a follow up of social classand mental illness. Wiley, New York

20. Nettleton S, Burrows R (1998) Mortgage debt, insecure homeownership and health: an exploratory analysis. Sociol HealthIlln 20(5):731–754

21. Paykel ES, Abbott R, Jenkins R, Brugha TS, Meltzer H (2000)Urban-rural mental health differences in Great Britain: findingsfrom the National Morbidity Survey. Psychol Med 30(2):269–280

22. Portes A (1998) Social capital: its origins and applications inmodern sociology. Annu Rev Sociol (August) 24:1–24

23. Putnam R (1993) Making democracy work: civic traditions inmodern Italy. Princeton University Press, Princeton

24. Rogers A, Day J, Randall F, Bentall RP (2003) Patients’understanding and participation in a trial designed to improvethe management of anti-psychotic medication—a qualitativestudy. Soc Psychiatry Psychiatr Epidemiol 38(12):720–727

25. Rogers A, Pilgrim D (1997) The contribution of lay knowledgeto understanding and promoting mental health J Ment Health6(1):23–35

26. Sampson RJ, Raudenbush SW, Earls F (1997) Neighbourhoodsand violent crime: a multilevel study of collective efficacy.Science 277(5328):918–924

27. Stansfeld SA, Head J, Marmot MG (1998) Explaining social classdifferences in depression and well being. Soc Psychiatr Epi-demiol 33(1):1–9

28. Szreter S (2002) The state of social capital: bringing back inpower, politics and history. Theory Soc 31:573–621

29. Thoits PA (1986) Multiple identities: examining gender andmarital status differences in distress. Am Sociol Rev 51(2):259–272

30. Thomas R, Huxley P, Robson B, Rogers A, Evans S, Stordy J,Gately C (2002) State-event interactions among indicators ofsusceptibility to mental distress in Wythenshawe. Soc Sci Med6:921–935

31. Turner B (2003) Social capital, inequality and health: theDurkheiminan revival. Soc Theory Health 1:4–20

372