Review of Physical Environment Effects On Mental Health

A systematic review on the effect of the built and
physical environment on mental health
Report prepared by Charlotte Clark, Bridget Candy and

Stephen Stansfeld for the Mental Health Foundation
Centre for Psychiatry
Wolfson Institute of Preventive Medicine
Queen Marys School of Medicine & Dentistry
University of London
January 2006
Sections of this report were prepared in expert consultation with Ben Cave, Clair Chilvers
(Director, NHS R&D Portfolio in Mental Health, DH), Sarah Curtis, Hugh Freeman,
Lynne Friedli, Rowan Myron (Senior Researcher, Mental Health Foundation), and the
Environmental Law Foundation, Health, Environment and Law Group.
CONTENTS
FIGURES AND TABLES ............................................................................................................................ 3
EXECUTIVE SUMMARY .......................................................................................................................... 4
ABBREVIATIONS....................................................................................................................................... 6
STATISTICAL TERMS .............................................................................................................................. 6
INTRODUCTION ........................................................................................................................................ 7
METHOD...................................................................................................................................................... 7
SCOPE OF REVIEW: SUBJECT AREA .............................................................................................................. 7
EXPERT GROUP OF ADVISERS ...................................................................................................................... 8
SEARCHING FOR THE EVIDENCE .................................................................................................................. 8
Search terms ......................................................................................................................................... 8
Search Strategy ..................................................................................................................................... 9
Data sources ......................................................................................................................................... 9
THE REVIEW PROCESS ................................................................................................................................. 9
Eligibility screening of paper titles and abstracts ................................................................................ 9
Inclusion of studies ..............................................................................................................................10
Data extraction ....................................................................................................................................10
Data Synthesis......................................................................................................................................10
RESULTS.....................................................................................................................................................11
DATABASE SEARCHES................................................................................................................................11
EVIDENCE FOR ACCESS TO RESIDENTIAL GREEN OR OPEN SPACES .............................................................14
EVIDENCE FOR EXPOSURE TO NEIGHBOURHOOD VIOLENCE .......................................................................14
EVIDENCE FOR HOUSING OR NEIGHBOURHOOD QUALITY AND REGENERATION ..........................................15
Housing and neighbourhood quality....................................................................................................15
Housing or neighbourhood regeneration.............................................................................................16
EVIDENCE FOR HOUSING TENURE ..............................................................................................................17
EVIDENCE FOR NEIGHBOURHOOD DISORDER .............................................................................................18
EVIDENCE FOR THE CHRONIC NOISE EXPOSURE DOMAIN............................................................................19
EVIDENCE FOR SPATIAL AND POPULATION DENSITY ..................................................................................20
Household spatial density ....................................................................................................................20
Population density ...............................................................................................................................20
EVIDENCE FOR URBAN BIRTH ....................................................................................................................23
ELEMENTS OF THE PHYSICAL OR BUILT ENVIRONMENT WHERE LITTLE EVIDENCE WAS IDENTIFIED ...........24
DISCUSSION...............................................................................................................................................25
RANGE OF THE EVIDENCE ..........................................................................................................................25
STRENGTH OF THE EVIDENCE.....................................................................................................................25
IMPLICATIONS FOR FUTURE ENVIRONMENTAL DEVELOPMENTS .................................................................26
LIMITATIONS OF THE REVIEW ....................................................................................................................27
CONCLUSION............................................................................................................................................27
REFERENCES ............................................................................................................................................28
REFERENCE LIST OF INCLUDED PAPERS......................................................................................................28
PAPERS IDENTIFIED AS POTENTIALLY RELEVANT BUT UNABLE TO GET ......................................................33
PAPERS EXCLUDED WITH REASON FOR EXCLUSION IN ITALICS ...................................................................34
OTHER REFERENCES ..................................................................................................................................36
APPENDIX 1. PREDICTORS: TERMS USED IN THE SEARCH STRATEGY DESCRIBING

FEATURES OF THE PHYSICAL ENVIRONMENT.............................................................................37
APPENDIX 2. DATA EXTRACTIONS FOR FULL TEXT PAPERS INCLUDED IN THE REVIEW
.......................................................................................................................................................................39
TABLE 1. ACCESS TO RESIDENTIAL GREEN OR OPEN SPACES AND MENTAL HEALTH ..................................39
TABLE 2. EXPOSURE TO STREET VIOLENCE AND MENTAL HEALTH.............................................................41
TABLE 3. HOUSING AND NEIGHBOURHOOD QUALITY AND REGENERATION AND MENTAL HEALTH.............45
TABLE 4. HOUSING TENURE AND MENTAL HEALTH ...................................................................................54
TABLE 5. NEIGHBOURHOOD DISORDER AND MENTAL HEALTH ..................................................................56
TABLE 6. NOISE AND MENTAL HEALTH ......................................................................................................59
TABLE 7. SPATIAL/POPULATION DENSITY AND MENTAL HEALTH ...............................................................64
TABLE 8 URBAN BIRTH AND MENTAL HEALTH...........................................................................................73
TABLE 9. URBANICITY (NOT SPECIFICALLY OR WEAKLY DEFINED) AND MENTAL HEALTH ......................75
TABLE 10 ASPECTS OF PHYSICAL AND BUILT ENVIRONMENT WHERE A LACK OF RESEARCH EVIDENCE WAS
IDENTIFIED ................................................................................................................................................76
FIGURES AND TABLES

FIGURE 1: PROJECT FLOW CHART ...................................................................................................................13
TABLE 1. CITATION DATABASES SEARCHED, YEARS SEARCHED AND NUMBER OF CITATIONS IDENTIFIED ......12
TABLE 2: NUMBER OF STUDIES IDENTIFIED, BY AGE GROUP AND HIGHEST LEVEL OF EVIDENCE, FOR THE
ASSOCIATION BETWEEN LACK OF ACCESS TO GREEN OR OPEN SPACE AND MENTAL HEALTH.................14
ASSOCIATION BETWEEN EXPOSURE TO NEIGHBOURHOOD VIOLENCE AND MENTAL HEALTH. ................15
ASSOCIATION BETWEEN POOR NEIGHBOURHOOD AND/OR POOR HOUSING QUALITY AND MENTAL
HEALTH.................................................................................................................................................16
ASSOCIATION BETWEEN HOUSING/NEIGHBOURHOOD REGENERATION AND MENTAL HEALTH...............17
ASSOCIATION BETWEEN RENTAL HOUSING TENURE AND MENTAL HEALTH. ..........................................17
ASSOCIATION BETWEEN NEIGHBOURHOOD DISORDER AND MENTAL HEALTH........................................18
ASSOCIATION BETWEEN CHRONIC NOISE EXPOSURE AND MENTAL HEALTH...........................................20
ASSOCIATION BETWEEN HOUSEHOLD SPATIAL DENSITY AND MENTAL HEALTH.....................................20
TABLE 10: NUMBER OF STUDIES IDENTIFIED, BY AGE GROUP AND HIGHEST LEVEL OF EVIDENCE, AND THE
ASSOCIATION BETWEEN HIGH POPULATION DENSITY AND PSYCHOLOGICAL MORBIDITY .......................22
ASSOCIATION BETWEEN HIGH POPULATION DENSITY AND SCHIZOPHRENIA ...........................................22
ASSOCIATION BETWEEN LOWER POPULATION DENSITY AND SUICIDE ....................................................23
ASSOCIATION BETWEEN URBAN BIRTH AND SCHIZOPHRENIA. ...............................................................24
Executive Summary
Background & Aim
There is a emerging body of evidence that the physical environment can affect mental
health. The aim of this systematic review was to assess the strength of the evidence of the
impact of the physical environment on mental health and well-being and to establish the
level of evidence available, which could usefully inform legal cases evaluating health and
environmental impacts.
Method
The systematic review identified studies published in English, in peer-reviewed journals
between January 1990 and August 2005, which examined the effect of the physical or
built environment on the incidence or prevalence of psychological morbidity. The
physical environment was defined as relating to residential, neighbourhood or natural
environments; mental health outcomes ranged from general psychological distress to
more specific psychiatric diagnoses. The systematic review was undertaken with strict
inclusion and exclusion criteria: studies included were reviews or primary research
studies that examined populations of any age, including children, from industrially
established market economy countries.
Peer-reviewed papers were identified using several large citation databases (Medline,
Embase, Psychinfo, Web of Science, BIDS, Geobase, ICONDA), relating to architecture,
health, human geography, psychology and the social sciences. One reviewer screened all
citations for eligibility and a second reviewer checked a random sample to ensure
agreement on eligibility for inclusion in the review. One reviewer assessed the full text
articles for eligibility; papers where eligibility was unclear were referred to a second
reviewer.
Papers eligible for the review were then subject to data extraction, which was undertaken
using published guidelines for systematic reviews. One reviewer undertook data
extraction, with a second reviewer double checking all data extraction summaries for
accuracy. The information extracted from the papers was type of study design and study
population, definition and measurement of the predictor(s), mental health outcome and
how they were measured, main results and any adjustments made in the analysis for
confounding factors, and any limitations or weaknesses of the study.
Results
In total 54,395 papers were identified using the search strategy, although there was a
considerable degree of overlap in citation identification between the databases searched.
Of these, 99 papers were identified which assessed the effect of the physical or built
environment on mental health: 3 papers were systematic reviews, 2 papers were narrative
reviews and the remaining 94 were primary research papers. The majority of papers were
of cross-sectional design and there were fewer longitudinal studies. One-third of the
studies used UK populations and the remainder were largely studies of European or
North American populations.
The papers were categorised into the following research domains: access to green spaces,
exposure to neighbourhood violence, housing and neighbourhood quality and
regeneration, housing tenure, neighbourhood disorder, chronic noise exposure, spatial
and population density, and urbanicity. The methodological quality of the studies varied
enormously, both within and across research domains, which affected the conclusions
which could be drawn about the strength of the evidence for each domain.
The strength of the evidence for environmental effects on mental health varied and was
strongest for the effects of urbanicity on mental health: there was longitudinal evidence
that urban birth was associated with schizophrenia, and that rural residence in adulthood
was associated with suicide rates for males. Evidence for an effect of the neighbourhood
on mental health was convincing: there was longitudinal evidence for exposure to
violence in the neighbourhood and perceived neighbourhood disorder being associated
with poorer mental health, as well as housing and neighbourhood regeneration being
associated with improved mental health. There was cross-sectional evidence that chronic
noise exposure was associated with poorer mental health, however the lack of
longitudinal research in this domain limited this conclusion, as individuals with poorer
psychological health are more likely to evaluate the environment negatively, bringing
into question the direction of causality between noise exposure and mental health.
Evidence for an effect of housing on mental health was weaker: robust longitudinal
studies were few and cross-sectional studies in this area were often methodologically
poor.
Conclusion
This review identified a range of peer-reviewed papers, which examined the association
between the physical environment and mental health. The strength of the evidence varied
and was strongest for the effects of urban birth (on risk of schizophrenia), rural residence
(on risk of suicide for males), neighbourhood violence, neighbourhood regeneration and
neighbourhood disorder. Evidence for an effect of housing on mental health was weaker.
There was a lack of robust research in some areas and some aspects of the environment
have been very little studied to date. The lack of evidence of environmental effects in
some domains, does not necessarily mean that there are no effects: rather that they have
not yet been studied. The evidence identified in this review will be utilised by the ELF
Health, Environment and Law group, to establish possible implications for planning laws.
Abbreviations
ADHD
dBA
BSI
CES-D
CDI
CIDI
CIS-R
DH
DIS
DSL-90
DSRS
EIA
ELF
GHQ
HADS
HEL
HIA
K10
KINDL
LAeq
MHF
MHI
MOS
NGO
NWS
ONS
PANAS
PERI
PTSD
SAD
SCL-90
SDQ
SF-36
SPHERE
Attention Deficit Hyperactivity Disorder

Measure of sound level in decibels (A-weighted to
approximate the typical sensitivity of the human ear).
Brief Symptom Inventory
Centre for Epidemiologic Studies Depression Scale
Child Depression Inventory
Composite International Diagnostic Interview
Revised Clinical Interview Schedule
Department of Health
Diagnostic Interview Schedule
Symptom Checklist- 90
Depression Self-Rating Scale
Environmental Impact Assessment
Environmental Law Foundation
General Household Questionnaire
Hospital Anxiety and Depression Scale
Health, Environment and Law
Health Impact Assessment
Kessler 10 Scale
Kindl Quality of Life Index
Equivalent continuous sound level
Mental Health Foundation
Rand Mental Health Inventory
Medical Outcomes Study
Non-government Organisation
National Womens Study Depression Module
Office of National Statistics
Positive and Negative Affect Scale
Psychiatric Epidemiology Research Instrument
Post Traumatic Stress Disorder
Symptoms of Anxiety and Depression Scale
The Symptom Checklist
Strengths and Difficulties Questionnaire
Short Form 36 item General Health Survey
SPHERE measure of psychological and somatic symptoms
Statistical terms
CI
NS
or B
SD
SE
Confidence interval
Not significant
Beta statistic
Standard deviation
Standard error
Introduction
The Environmental Impact Assessment (EIA) directive (85/337/EEC) ensures that the
environmental consequences of planning decisions are taken into account, prior to
planning consent being granted. During an EIA, evidence for the actual or potential
impacts of the development on the environment are assessed, along with stakeholders
opinions about the development, including those of the affected community. EIAs can
also incorporate a Health Impact Assessment (HIA), as it is increasingly recognised that
health is determined by a broad range of factors, including the environment. EIAs
empower individuals and communities to protect the environment, ensure sustainable
development and to protect human and environmental rights.
The Environmental Law Foundation (ELF) is a national UK charity, linking communities
and individuals to legal and technical expertise to prevent damage to the environment; it
aims to increase awareness of how the law can be used to promote equitable, sustainable
and healthy environments. Whilst there is an emerging body of evidence concerning the
effect of the physical environment on mental health, the Environmental Law Foundation,
Health, Environment and Law Group (HEL - a sub-group of ELF, with a specific focus
on health, including mental health and well-being), identified the need to assess the level
of evidence available, which can usefully inform legal cases evaluating health and
environmental impacts. The aim of this systematic review was to assess the strength of
the evidence of the impact of the physical environment on mental health and well-being.
This systematic review was funded by the Mental Health Foundation (MHF) and
conducted over 4 months (August-November 2005).
Method
Scope of review: subject area
The aim of the review was to identify reviews and evaluative studies, both of qualitative
and quantitative design, of the effect of the physical environment on mental health for
children (including adolescents) and adults. For the purposes of this review, the physical
environment was defined in terms of built and natural aspects of residential and
neighbourhood environments. Work environments and the effects of conflicts or natural
disasters on residential or neighbourhood environments were not included in the review.
Mental health was defined in terms of symptoms of psychological well-being and
diagnoses of psychiatric illness, including suicide.
Expert group of advisers

A panel of subject experts advised and assessed the findings, throughout the review
process. Advice was obtained concerning the selection of data sources, the terms used in
the search strategy, and the identification of key papers. The expert panel also
commented on drafts of the final report. The experts and their affiliations are listed
below.
Ben Cave*
Clair Chilvers
Sarah Curtis
Hugh Freeman*
Lynne Friedli*
Rowan Myron
Ben Cave Associates Ltd

NHS R & D Portfolio in Mental Health, DH
Queen Mary, University of London
Fellow, Green College, Oxford
Mental Health Promotion Specialist
Mental Health Foundation
* Members of the ELF HEL group
Searching for the evidence

Search terms
A list of search terms to describe the physical and built environment, mental health
outcomes and research methodologies were compiled by the research team, in
consultation with the expert panel. The search terms are briefly summarised below: see
Appendix 1 for the complete list of search terms.
The physical and built environment search terms related to:
1. the physical quality of housing and neighbourhoods in relation to tenure,
household crowding, housing quality, waste disposal, chronic noise exposure,
community facilities, maintenance, access to green/open space, traffic level,
transport quality, and pollution.
2. the perceived sense of safety in the neighbourhood and exposure to violence
in the neighbourhood.
3. spatial density/crowding in the home and neighbourhood.
The mental health terms related to:
1. general mental health (psychiatric disorder, psychiatric illness, mental
disorder, mental well being, mental stress, psychological health, psychological
well being, psychological illness, mental health, mental illness).
2. specific mental illnesses (anxiety, stress disorder, phobic disorder, panic
disorder, obsessive-compulsive disorder, compulsive behaviour, obsessive
behaviour, mood, seasonal affective disorder, depression, depression
postpartum, dysthymic disorder, psychosis, schizophrenia, Attention Deficit
Hyperactivity Disorder, bipolar disorder, conduct disorder, hyperactivity,
suicide).
The research methodology terms related to the study design or type of review
(systematic, review, random, trial, study, control, before and after, cohort, case control,
cross-sectional, longitudinal, qualitative, prospective, retrospective, survey, intervention,
observational).
Search Strategy
We planned, if feasible within the four month time limit, to identify published citation
evidence from January 1980 to August 2005, of papers published in English, which
explored the effect of the physical environment on mental health in populations from
industrially established countries or regions. These included Australasia, Europe, Japan
and North America. Due to the time constraints of the project, we only identified studies
published in peer-reviewed journals: grey literature such as government and nongovernment organisation (NGO) reports, journal letters and book chapters were not
included.
Data sources
Papers were identified using large citation databases (listed below), which were selected
because they hold citation records from peer-reviewed publications in the subject areas of
health, psychology, architecture, human geography and the social sciences (Weaver
2002). We also hand searched the journal Environment and Behaviour from 1995 to
20051. The reference lists of identified papers were additionally checked for further
relevant studies. The expert panel checked a preliminary final list of references identified
for the review, to ensure that the search process had been comprehensive.
Evidence was identified from the following large citation databases:
1. Medline
2. Embase
3. Psychinfo
4. Web of Science
5. BIDS
6. Geobase
7. ICONDA.
The review process
Eligibility screening of paper titles and abstracts
One reviewer (BC) screened all titles and abstracts of the papers identified from the
search strategy, to assess eligibility for inclusion in the review. Eligibility screening was
undertaken by year per citation database. To assess and reach an acceptable level of
consistency and agreement on paper eligibility, the eligibility screening was double
checked by a second reviewer (CC). Double checking was continued until the reviewers
reached complete agreement, which was when approximately 10% of the individual year
searches had been double checked.
1995, 1996, 1997 were incomplete collections.
Inclusion of studies
The full-text of the journal paper was retrieved (either electronically or in paper format)
for potentially eligible papers. One reviewer (BC) undertook the text retrieval, read the
paper and re-assessed eligibility. Where eligibility was unclear the paper was referred to a
second reviewer (CC) for agreement on eligibility. Papers that were initially selected for
inclusion by one reviewer (BC) were checked for eligibility by a second reviewer (CC).
Data extraction
Papers eligible for the review were then subject to data extraction which was undertaken
according, where appropriate (depending upon study design), to published guidelines for
systematic reviews (Begg 1996; Stroup 2000). For each paper descriptions of the
methodology and findings were extracted by one reviewer (BC). All extractions were
checked by a second reviewer (CC). The information extracted from the papers was:
1. Type of study design and study population (including age, gender, ethnicity,
indicator(s) of socioeconomic position and study response rate).
2. Definition and measurement of the predictor(s) aspects of the physical environment.
3. Mental health outcome(s) and how measured.
4. Main results and any adjustments made to the analysis for confounding factors.
5. Any limitations or weaknesses of the study in any of the above domains.
The data extractions were categorised by the aspect of the physical environment under
investigation into the following domains2.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Access to residential green or open spaces.

Exposure to neighbourhood violence.
Housing and neighbourhood quality and regeneration.
Housing tenure.
Neighbourhood disorder.
Noise.
Spatial/population density.
Neighbourhood population density.
Urbanicity.
For each of these categories, results were collated for children (including adolescents)
and adults. Where sufficient evidence was available, results were also differentiated by
type of mental health outcome. A minority of studies (N=5) could not be categorised, as
they examined a unique aspect of the physical or built environment, for which no other
evidence was available.
Data Synthesis
A hierarchy of the strength of the quantitative evidence was applied to each extraction,
relating to the robustness of the study design and findings, as well as any study
limitations, using the Oxford Centre for Evidence-based Medicine Level of Evidence and
2
These domains were defined after data extraction, based upon the range of papers identified, and were not
predetermined.
10
Grades of Recommendation scale (http://www.cebm.net/levels_of_evidence.asp#levels).

This is a well recognised, frequently used scale for summarising the level and strength of
research evidence relating to health outcomes. The scale ranges from 1a (the highest
level of evidence) to 4 (the lowest level of evidence). The specific levels of evidence are:
1a. Systematic review of randomised controlled trials with homogeneity of findings.
1b. Individual randomised controlled trials with narrow confidence intervals.
2a. Systematic review of cohort studies with homogeneity of findings.
2b. Individual cohort studies or poor quality randomised controlled trials.
3a. Systematic review (with homogeneity) of case-control studies.
3b. Individual case-control study.
4. Case-series (and poor quality cohort and case-control studies).
In this systematic review, because of the heterogeneity of studies in terms of the study
design, study population characteristics, the measurement of the physical and built
environment and the measurement of mental health, it was not possible to conduct a
meta-analysis to compare the homogeneity of findings of the identified studies.
Results
Database searches
We searched the seven selected databases (Medline, Embase, Psychinfo, WOS, BIDS,
GEOBASE and ICONDA). Due to time constraints, each database was searched back to
19903, rather than 1980 as originally planned. Table 1 shows the number of citations per
database that were identified using our search strategy; the number of citations identified
varied considerably by database, reflecting a difference in the number of papers available
for the different disciplines covered by the databases.
In total 54,395 citations were identified from a search of the seven databases, but there
was a degree of overlap in citation identification between the databases. Figure 1 shows a
flow chart, detailing the number of citations available at each stage of the search strategy.
Screening of the citations identified 147 which were potentially relevant, of which 99
were included and 43 were excluded after full text retrieval; we were unable to retrieve a
further 5 papers which were potentially relevant. Studies which were excluded at the full
text retrieval stage, are listed in the Reference section, along with reasons for each
exclusion.
GEOBASE was searched back only until 2000, because of a delay in access which reduced the time
available to search the database and conduct data extraction.
11
Table 1. Citation databases searched, years searched and number of citations

identified
Database
Years searched
Medline
1990 to August 2005
Embase
1990 to August 2005
Psychinfo
1990 to August 2005
WOS
1990 to August 2005
BIDS
1990 to August 2005
GEOBASE
2000-2005
ICONDA
1990 to September 2005
(search used mental health outcomes only)
Number of citations identified

16,137
24,116
7,328
4,230
599
1,768*
217*
The search strategy identified 99 papers, which assessed the effect of the physical or built
environment on mental health and well-being; 3 studies were systematic reviews, 2 were
narrative reviews and the remaining 94 were primary research studies. During the project,
we were unable to retrieve the full text for a further 5 papers.
The design of the primary research studies varied, but the majority were of crosssectional design. There were far fewer of the more robust studies of quantitative design
such as randomised controlled trials or prospective cohort studies. Only one qualitative
study was identified. The mental health outcomes assessed in the studies varied. The
most frequent outcomes examined were general psychological well-being, depression,
anxiety, schizophrenia and suicide. The majority of studies used validated scales to
measure mental health and examined adult populations. One-third of the studies (32/94)
examined UK populations.
In terms of the physical or built environment, the studies covered several domains: access
to green spaces, exposure to neighbourhood violence, housing and neighbourhood quality
and regeneration, housing tenure, neighbourhood disorder, noise exposure, spatial
density, population density and urbanicity.
The following sections summarise and discuss the evidence for each of these domains
and conclude with a table summarising the available level of evidence for each domain,
using the Oxford Centre for Evidence-based Medicine Level of Evidence and Grades of
Recommendation scale. The data extractions for each individual paper, by domain, are in
Appendix 2.
12
Figure 1: Project flow chart

Citations identified
From database search = 54,395
Citations identified at
screening as potentially relevant = 147*
Citations excluded
at full text = 43
Reasons:
Letter = 1
Study in progress = 1
Discussion paper = 9
Inappropriate sample = 5
Not mental health outcome = 8
Article superseded by another
by same group = 5
Does not assess the effect of the built or
physical environment = 14
Citations included
after full text retrieval = 99
Type of physical or urban environment**:
Urban birth = 7
Spatial density
Household = 7
Neighbourhood = 23
Neighbourhood violence = 7
Neighbourhood disorder = 8
Neighbourhood/household quality = 11
Neighbourhood/household regeneration = 10
Housing tenure = 5
Noise = 11
Roads = 1
Pollution = 1
Territorial domestic space = 1
Green space =5
Public amenities = 1
Urban hassles =1
Five citations unable to get full text.

**types of physical or urban environment does not add to total as some citations related to same study (but different analysis),
while other citations have explore effect of several elements of the environment.
13
Evidence for access to residential green or open spaces

Five papers were identified that explored residential accessibility to green or open space
and mental health (see Appendix 2: table 1 for data extractions). Four papers examined
the effect in adults (Lewis and Booth 1994; Kaplan 2001; Kou and Sullivan 2001;
McIntyre 2003), and one in children (Wells 2003). The papers explored the effect of
gardens and natural areas, either available as views from the home or in terms of having
physical access, on mental health. The studies varied in mental health outcome; three
measured psychological distress including anxiety and depression, whilst two examined
mental fatigue. Most studies used validated mental health measures. Two studies were
conducted in the UK, both of which had study samples of several thousand adults (Lewis
and Booth 1994; McIntyre 2003).
All the studies found that having access, either as a view or through physical access, to
green or open spaces such as gardens or natural areas was associated with better mental
health (Table 2). However, this conclusion should be treated with caution as all of the
studies were of less robust cross-sectional design: all except one (Kuo & Sullivan 2001),
had poor response rates: and some used subjective measures of green space, such as selfor interviewer-ratings of access. Table 2 below summarises and evaluates the level of
evidence for these studies.
Table 2: Number of studies identified, by age group and highest level of evidence (in
brackets), for the association between lack of access to green or open space and
mental health.
Age group
Children
Adults
A beneficial association
0
0
No clear association
0
0
A harmful association
1 (3b)*
4 (3b)*
3b= evidence from cross-sectional study.

Level of evidence score range 1 to 4 and a to b, with 1a being the highest value.
* In one study the association found was beneficial in that living nearby nature improved mental health outcome.
Evidence for exposure to neighbourhood violence

Seven studies were identified that explored the association between exposure to
neighbourhood violence and mental health (Norris and Kaniasty 1994; Pastore 1996; Lai
1999; Mazza 1999; Moses 1999; Hurt 2001; Latzman and Swisher 2005) (see Appendix
2: table 2 for data extractions). One study was a prospective longitudinal cohort study
(Norris and Kaniasty 1994) while the other studies were of cross-sectional design.
Neighbourhood violence was defined as witnessing an arrest, mugging, shooting or
stabbing, having possessions stolen or damaged, and being verbally or physically
threatened or attacked. Six studies examined the effects of exposure to violence in child
samples (Pastore 1996, Lai 1999, Mazza 1999, Moses 1999, Hurt 2001, Latzman &
Swisher 2005) and one in adults (Norris and Kaniasty 1994). All studies used USA-based
populations, except one which was undertaken in Canada (Lai 1999).
The more robust longitudinal study (Norris & Kaniasty 1994) found that being a victim
of property or violent crime was associated with poorer mental health for adults, 15
months after the crime occurred: victims of violent crime were also more psychologically
14
symptomatic than victims of property crime. All of the cross-sectional studies in children
found that being a witness or victim of crime was associated with poorer mental health:
in one study this effect was found for females and not males (Moses 1999). Table 3
below summarises and evaluates the level of evidence for these studies.
brackets), for the association between exposure to neighbourhood violence and
mental health.
Age group
Children
Adults
0
0
0
0
6 (3b)*
1 (2b)
2b = evidence from longitudinal cohort study, 3b= evidence from cross-sectional study.
*In one study an association was found for females but not males; in another study the association was found for PTSD but not for
depression or suicide.
Evidence for housing or neighbourhood quality and regeneration

Housing and neighbourhood quality
Ten studies (Saito 1993; Hopton 1996; Silveria and Ebrahim 1998; Evans 2000; Ellaway
2001; Evans 2002; Weich 2002; McIntyre 2003; Sundquist 2004; Galea 2005) and one
review (Chu 2004) explored aspects of neighbourhood or housing quality and mental
health (see Appendix 2: table 3a for data extractions). All of the primary studies defined
neighbourhood quality using a number of characteristics including living in an area with
derelict property, graffiti, lack of recreation space or private gardens, speeding traffic,
high crime levels and uneven payments. Housing quality was also multifaceted in its
definition and included living in damp homes, condensation problems, dissatisfaction
with housing and desire to be re-housed. Half of the studies were conducted in the UK
and the remainder were from Australia, Canada, Sweden and the USA. All the studies
examined adult populations, except one (Evans 2002), which explored the effects of
residential quality on childrens mental health. Only one study was a prospective
longitudinal cohort study (Sundquist 2004) and the others were of cross-sectional design.
One narrative review explored the effect of the physical environment on mental wellbeing (Chu 2004).
The longitudinal cohort study followed a large sample of Swedish adults over an 8 year
period, to examine associations between neighbourhood quality, defined as the level of
destruction of public spaces, satisfaction with street cleanliness and the level of perceived
neighbourhood noise, and psychiatric illness (Sundquist 2004). The study found no
association between these aspects of neighbourhood quality and psychiatric illness. The
cross-sectional studies demonstrated associations between poor housing or
neighbourhood quality and mental health. However, some of these studies were limited
by poor response rates. Table 4 below summarises and evaluates the level of evidence for
these studies.
15
brackets), for the association between poor neighbourhood and/or poor housing
quality and mental health.
Age group
Children
Adults
0
0
0
1 (2b)
1 (3b)
9 (2b)
2b = evidence from a longitudinal cohort study, 3b= evidence from a cross-sectional study.
Housing or neighbourhood regeneration

One systematic review (Thomson 2001 and 2003), one randomised controlled trial
(Leventhal 2003) and six longitudinal studies (Dalgard and Tambs 1997; Evans 2000;
Kahlweier 2000; Blackman and Harvey 2001; Blackman 2003; Huxley 2004 and Thomas
2005) explored the effects of housing or neighbourhood regeneration schemes on mental
health (see Appendix 2: table 3b). Four of these studies compared residents who
experienced housing or neighbourhood regeneration with control groups who did not
experience housing or neighbourhood regeneration (Evans 2000; Kahlweier 2000;
Blackman and Harvey 2001; Blackman 2003). Three of the studies were undertaken in
the UK (Blackman and Harvey 2001; Blackman 2003; Huxley and Thomas 2005) and the
rest were conducted in Europe and the USA. Several types of regeneration scheme were
evaluated: neighbourhood regeneration encompassing improving deteriorated housing,
repairing vandalised facilities, removal of graffiti, installing regular rubbish clearance,
building new schools, playgrounds, sports and park areas: housing regeneration
encompassing damp proofing, re-roofing and installing new windows in homes: and
relocation to better housing and/or neighbourhoods. The effect of regeneration on mental
health was measured up to 5 years after the implementation of the scheme.
The systematic review identified 9 studies that explored the effects of housing and
neighbourhood regeneration on mental health. Some of these studies are identified as
primary research papers in this review, but some are not included as they were published
before 1990 (Thomson 2001). The review found consistent evidence of an improvement
in mental health after housing and neighbourhood regeneration but this conclusion was
limited by a lack of detail about the design of the available studies. The randomised
controlled trial found that a housing relocation scheme had a positive effect on the mental
health of adults and male children, three years after implementation (Leventhal 2003).
However, this effect was not found for female children.
The six longitudinal studies all demonstrated a positive association between housing or
neighbourhood regeneration and mental health, with one exception (Huxley 2004 and
Thomas 2005), which found no improvement in mental health nearly two years after the
implementation of a housing improvement scheme on a council estate. However, the
consistent findings for the longitudinal studies should be treated with some caution, as
four of the studies were affected by a low response rate. Table 5 below summarises and
evaluates the level of evidence for these studies.
16
brackets), for the association between housing/neighbourhood regeneration and
mental health.
Age group
Children
Adults
1(2b)*
7(2a-**)
0
1(2b)
0
0
2a= evidence from a systematic review, 2b = evidence from a longitudinal cohort study.
*In male children but not in female children.
**A minus is applied as review under-reports the methods.
Evidence for housing tenure

Five studies were identified that explored the effects of living in rental accommodation
on mental health (Ellaway 1998; Dunn 2002; Hiscock 2003; McIntyre 2003 Cairney
2005) (see Appendix 2: table 4). Three studies explored the effects of rental tenure on UK
samples and the other studies were conducted in Canada. All studies explored the effects
in adults, except one which used a child sample (Cairney 2005). All the studies were of
less robust cross-sectional design.
The findings of the studies were equivocal, with three studies demonstrating no
association between housing tenure and mental health, one finding an association
(Hiscock 2003) and another finding an association for only a sub-sample of adolescents,
aged 12 to 14 years, but not for older adolescents (Cairney 2005). One explanation for the
equivocal findings may be methodological weaknesses of the studies; all of the identified
studies either have a low response rate or lack detail about the methodology of the study.
Table 6 summarises and evaluates the level of evidence for these studies.
brackets), for the association between rental housing tenure and mental health.
Age group
Children
Adults
0
0
0
3 (3b)
1* (3b)
1**(3b)
3b= evidence from a cross-sectional study.

*For children aged 12-14, not found in 15-19 year olds,
** The strength of the association is unclear: the effect may be related to other factors.
17
Evidence for neighbourhood disorder

Seven studies were identified that explored associations between neighbourhood disorder,
such as crime and vandalism and mental health (Ross 2000; Ellaway 2001; Green 2002;
Latkin and Curry 2003; Macintyre 2003; Christie-Mizell 2004; Ziersch 2005) (see
Appendix 2: table 5). One further study explored the association between sense of
belonging to the community and mental health (Young 2004). Two studies were of
longitudinal design (Latkin & Curry 2003; Christie-Mizell 2004) and six were crosssectional (Ross 2000; Ellaway 2001; Green 2002; Macintyre 2003: Young 2004; Ziersch
2005). All the studies examined adult samples, and one focused on older adults, aged 7378 years (Young 2004). Three of the studies were conducted in the UK, three in the USA
and two in Australia.
The two longitudinal studies examined the effects of multiple characteristics of perceived
neighbourhood disorder including vandalism, crime, derelict housing, litter, drug selling
in the street, graffiti and teenagers hanging around, on mental health in North American
populations (Latkin & Curry 2003; Christie-Mizell 2004). Despite contrasting follow-up
periods, 9 months compared with 14 years, both studies found that perceived
neighbourhood disorder was associated with poorer mental health. However, these results
should be treated cautiously as neither study reports the response rate and although the
Latkin & Curry study describes itself as a community sample, it is a community HIV
outreach sample, which may limit representativeness.
All of the cross-sectional studies that explored perceived neighbourhood disorder found
that greater neighbourhood disorder was associated with poorer mental health. The study
of sense of belonging, also demonstrated associations between positive perceptions of
neighbourhood safety and neighbourhood community and better mental health. Table 7
below summarises and evaluates the level of evidence of these studies.
brackets), for the association between neighbourhood disorder and mental health.
Age group
Children
Adults
Older adults
0
0
0
0
0
0
0
7 (2b)
1 (3b)
2b = evidence from a longitudinal cohort study, 3b= evidence from a cross-sectional study
18
Evidence for the chronic noise exposure domain

Eleven studies were identified that examined the effects of chronic noise exposure on
mental health (Nivison & Endresen 1993; Saito 1993; Stansfeld 1996; Meister 2000;
Haines et al 2001a; 2001b; 2001c; Lercher 2002; Ristovska 2004; Hardoy 2005;
Stansfeld 2005) (see Appendix 2: table 6). One narrative review that summarised the
effects of chronic noise exposure on health, including mental health was also identified
(Stansfeld 2000). The studies examined the effects of chronic noise exposure on mental
health for both children and adults and the majority of studies were carried out in Europe.
Two studies were of robust longitudinal design: one of a child sample (Haines 2001a) and
one of an adult sample (Stansfeld 1996); the rest of the studies were cross-sectional. The
type of noise exposure examined varied from general ambient neighbourhood noise to
source-specific road and aircraft noise exposure. Most studies measured chronic noise
exposure using standardised noise metrics, although a couple utilised weaker measures
such as residential distance from the noise source (Hardoy 2005) or perceived noise
exposure (Saito 1993). All of the studies used validated measures of mental health.
A longitudinal study of aircraft noise exposure in children (Haines 2001a) found that
chronic aircraft noise exposure was not associated with mental health, after a one year
follow-up. Evidence from cross-sectional studies of children is mixed: some studies have
found no association between chronic noise exposure and overall mental health measures
(Haines 2001b; Stansfeld 2005), whilst others have found an association (Lercher 2002;
Haines 2001c). Evidence for effects on specific measures of child mental health such as
hyperactivity and conduct disorder are similarly mixed: one cross-sectional UK study
(Haines 2001c) found that aircraft noise exposure was associated with increased
hyperactivity but not conduct disorder, whilst another study (Ristovska 2004) found that
community noise exposure was not associated with hyperactivity but was associated with
increased conduct disorder.
The longitudinal study of noise exposure in male adults (Stansfeld 1996), found that
exposure to road traffic noise was associated with higher scores for anxiety, over a 5 year
period: no association was found between noise exposure and depression. A recent crosssectional study supports these findings (Hardoy 2005) and also demonstrated an
association of noise with anxiety but not depression. There is further cross-sectional
support for an association (Meister 2000), although one study, with a small sample size
found no association between objective noise measurements and anxiety and depression
(Nivison & Endresen 1993). Subjective responses to noise exposure, such as annoyance
and potential mediating factors such as noise sensitivity were associated with mental
health outcomes (Nivison & Endresen 1993; Saito 1993) but these cross-sectional studies
are limited as they may confound the perception of noise with psychological state. Table
8 below summarises and evaluates the level of evidence of these studies.
19
brackets), for the association between chronic noise exposure and mental health
Age group
Children
Adults
A beneficial
association
0
0
3 (2b)
1 (3b)
3 (3b)*
4 (2b)
*One study found effect for social adaptability and opposing behaviour but not hyperactivity or anxiety
No association for objective noise but association observed for subjective noise.
Two studies found effect for anxiety but not depression.
Evidence for spatial and population density

Household spatial density
Seven studies explored the effects of spatial density in the household on mental health
(Saito 1993; Ruback 1994; Maxwell 1996; Sadowski 1999; Agerbo 2001; Evans 2001;
Wahlbeck 2001) (see Appendix 2: table 7a). Three studies were of longitudinal design
(Saito 1993; Sadowski 1999; Wahlbeck 2001) and the rest were cross-sectional studies.
Five studies explored the effect of spatial density for adult samples and two examined the
effects for children (Agerbo 2001; Evans 2001).
Whilst one of the longitudinal studies found an association between high spatial density
in the household during childhood and adult mental health for males but not females
(Sadowski 1999), the other two studies demonstrated no association, suggesting that high
household spatial density in childhood is not associated with poorer mental health in
adulthood. The cross-sectional studies of adult populations support this conclusion, as
they also found no association between current household spatial density and mental
health. The cross-sectional studies of children (Maxwell 1996; Evans 2001) suggest that
children from crowded, high spatial density homes may have poorer psychological
health, but both these studies have methodological limitations, including small sample
sizes and unreported response rates. Table 9 below summarises and evaluates the level of
brackets), for the association between household spatial density and mental health.
Age group
Children
Adults
0
0
0
4 (2b)
2 (3b)
1 (2b)*
one study examined behavioural disturbance as the outcome
*In one study a harmful association was found in male subgroup only
Population density
A systematic review from one research group (McGrath 2004; Saha 2005) and twenty
one studies were identified that examined the effects of population density and mental
20
health (Parikh 1996; Saunderson 1998; Kennedy 1999; Turner Goins 1999; Schelin 2000;
Allardyce 2001; Singh 2002; Lehtinen 2003; Oliver 2003; Weich 2003; Caldwell 2004;
Otsu 2004; Peen 2004; Spauwen 2004; Sturm 2004; Wang 2004; Walters 2004; Fraser
2005; Levin 2005; Propper 2005; Rohrer 2005) (see Appendix 2: table 7b). The majority
of studies were of cross-sectional design and only two were longitudinal (Lehtinen 2003;
Spauwen 2004). Unfortunately, not all of the studies provided definitions of population
density: those that did grouped the study population into 3 to 5 categories based upon the
number of people per km or the total population living in an area. A range of mental
health outcomes were evaluated including psychological distress (depression and
anxiety), schizophrenia and suicide; as there were several studies in this domain, it was
possible to describe and evaluate the evidence individually for each of these outcomes.
Psychological distress
Eleven studies explored the association between population density and rates of
depression and anxiety in adults. All studies were of cross-sectional design. Depression
and anxiety were measured using validated scales and covered differing levels of severity
of psychological distress. The studies were conducted in the UK, USA, Canada and
Scandinavia.
The only cross-national study found that there was an increased risk of depressive
disorder for women living in high density urban areas, but this association was only
found for women in the UK and Ireland: strangely no similar association was observed
for Finnish or Norwegian women (Lehtinen 2003). However, there are some
methodological anomalies for this paper, which suggest that caution should be given to
the findings: firstly, the confidence intervals for the odds ratio for the Irish sample are
extremely wide (95% CI 1.09, 303.80), suggesting that the data for the sample lacks
power: secondly, few adjustments were made to the analysis for specific socio-economic
factors, which may confound the association between population density and mental
health. The results of the other cross-sectional studies are also equivocal: some studies
have found that there is no clear association between population density and mental
health (Parikh 1996; Sturm 2004; Propper 2005) while others have found that higher
population density was associated with higher rates of psychological morbidity (Oliver
2003; Wang 2004; Weich 2003; Rohrer 2005). Furthermore, some studies suggest that
these associations are evident only in specific sub-groups. In one American study an
association was found for the suburban residents and not for the urban or rural residents
(Rohrer 2005) and a recent UK study found an association between population density
and depression but only for individuals who were resident in urban areas and who were
economically inactive (Weich 2003). Two studies explored the effects of population
density for older adults (Turner Goins 1999; Walters 2004): the UK study suggested that
living in an area of higher residential density was associated with an increased risk of
depression and anxiety (Walters 2004), whilst the American study found that within rural
areas, living in high density areas was associated with fewer depressive symptoms
(Turner Goins 1999). Table 10 below summarises and evaluates the level of evidence for
these studies.
21
Table 10: Number of studies identified, by age group and highest level of evidence
(in brackets), and the association between high population density and psychological
morbidity
Age group
Children
Adults
Older adults
0
1(3b)
1(3b)**
0
3 (3b)
0
0
5* (3b)
1 (3b)
3b= evidence from a cross-sectional study

Declining rural population associated with poorer mental health
*In one study in the female population in UK and Ireland not in Norway or Finland, in another increased risk for those in suburban
area only, and in another study association only found for those who were not employed.
**In a rural population
Schizophrenia
The association between population density and schizophrenia was explored in one
longitudinal cohort study (Spauwen 2004) and three cross-sectional studies (Schelin
2000; Allardyce 2001; Peen 2004). A systematic review was also identified (McGrath
2004; Saha 2005) but this review did not describe how the previous studies defined
urbanicity.
The more robust, longitudinal study found no association between population density and
schizophrenia in a sample of young German adults followed up over a 4 to 5 year period
(Spauwen 2004); whilst the three less robust, cross-sectional studies found that higher
population density was associated with increased rates of schizophrenia. However, one of
these studies found that the urban-rural difference observed in rates of schizophrenia
between rural Dumfries and Galloway and urban Camberwell, were explained by the
high incidence of non-whites in urban Camberwell (Allardyce 2001). The systematic
review found equivocal evidence for an association between high population density and
schizophrenia: an association was found for incidence rates of schizophrenia but not for
prevalence rates. The authors suggest that this difference may have been because the
prevalence analysis included more data from developing countries, than the incidence
analysis, but this explanation is unconvincing. Table 11 below summarises and evaluates
the level of evidence for these studies.
(in brackets), and the association between high population density and
schizophrenia
Age group
Adults
0
3 *(2b)
2(3b)
*One study found no effect after adjusting for ethnicity.
22
Suicide
Six cross-sectional studies examined the association between population density and rates
of suicide (Saunderson 1998; Singh 2002; Otsu 2004; Caldwell 2004; Kennedy 2005;
Levin 2005). Studies were undertaken in the UK, as well as Australia, Japan and the
USA. All these studies used national suicide mortality data over one or more years,
except one which used suicide data from London boroughs (Kennedy 1999). All of the
studies provided findings separately for male and female samples, with one exception
(Kennedy 1999).
Living in more sparsely populated areas was associated with higher rates of suicide in
males (Saunderson 1998; Singh 2002; Caldwell 2004; Levin 2005). In the North
American study, the suicide rate was double for rural areas, compared with urban areas
(Singh 2002). These findings are supported by a Japanese study which found that males
living in areas of economic development with high population density had a lower risk of
suicide (Otsu 2004). The evidence concerning an association between population density
and suicide for females was equivocal with three studies finding no effect and two
studies, which provided analysis stratified by age group, demonstrating an association.
One Australian study (Caldwell 2004) found that women aged 30-44, living in areas of
medium population density had a higher rate of suicide compared with their counterparts
in rural and urban areas and an American study found that rates of suicide were higher for
women aged 15-24 living in the least populated areas (Singh 2002). One study, which
focused on urban areas London boroughs, found that greater population density and
higher deprivation was associated with an increased risk of suicide (Kennedy 1999).
Table 12 below summarises and evaluates the level of evidence for these studies.
(in brackets), and the association between lower population density and suicide
Age group
Adults
1(3b)
0
5* *(3b)
3b= evidence from a cross-sectional study

**In one study living in urban areas had a lower risk of suicide
Evidence for urban birth

Longitudinal cohort studies which explored the effects of urban versus non-urban birth
and the development of schizophrenia in adulthood were identified from Denmark (Eaton
2000; Agerbo 2001; Pedersen 2001; Van Os 2004), the Netherlands (Marcelis 1998 and
1999) and Finland (Haukka 2001) (see Appendix 2: table 8). The Danish studies were
carried out by the same research group and utilised the same data set. All of the studies
defined urbanicity of birth place using measures of population density and used data from
national registers to measure schizophrenia in adulthood.
All of these longitudinal studies found an association between being born in an urban
area and schizophrenia, with most studies identifying an increasing gradient of risk with
increasing urbanicity. Haukka (2001), in comparing the strength of association in
23
different cohorts born between 1950-1969, found that the risk for urban born individuals
increased and was stronger for the younger cohorts. An interesting study in the
Netherlands examined not only the effect of urban birth, but also its interaction with
urbanicity of area of residence in adulthood. This study found that individuals who were
born in urban areas, but did not live in an urban area in adulthood were at greater risk of
schizophrenia compared with those who were born in rural areas but resident in urban
areas as adults (Marcelis 1999). Table 13 below summarises and evaluates the level of
(in brackets), and the association between urban birth and schizophrenia.
Age group
Adults
0
0
7 (2b)
2b = evidence from a longitudinal cohort study

Elements of the physical or built environment where little evidence was identified
There were six research domains where minimal studies (only one or two papers) were
identified: these were remoteness, community amenities, pollution, road improvements,
urban hassles and territorial spaces in the home. These studies were all of cross-sectional
design. Data extractions for these studies are provided in Appendix 2: table 10.
24
Discussion
Range of the evidence
This review identified 99 papers that have examined the association between the physical
environment and mental health. The papers identified examined a range of environmental
factors and mental health outcomes including access to green spaces, exposure to
neighbourhood violence, housing and neighbourhood quality and regeneration, housing
tenure, noise exposure, household and population density, and urban birth.
One of the conclusions of this review is that there is a lack of robust research in some of
the domains that have been examined previously and some aspects of the environment
have been very little studied to date. It was surprising that no peer-reviewed journal
papers, examining the longitudinal effects of major developments, such as changes to
transport infrastructures and facilities, on mental health were identified. It is possible that
studies of this type may be published in the future, given the more recent focus on
environmental and health impact assessment methods in Europe and the evaluation of
large scale developments upon the population. This implies that the absence of evidence
of environmental effects in some domains does not necessarily mean there are no effects
simply that they have not been studied.
Strength of the evidence
The methodological quality of the studies identified by this systematic review varied
enormously, both within and across domains. This affected the conclusions which could
be drawn about the strength of the evidence for each domain.
The most compelling evidence for an environmental effect on mental health comes from
studies of the effect of urban environments, usually defined by population density, on
mental health. Longitudinal studies have found consistent evidence for an association
between urban birth and schizophrenia, as well as an association between rural residence
in adulthood and suicide rates for males, but not females. The association between rural
residence and suicide may relate to a lack of employment opportunities in rural areas.
However, evidence for an association between urbanicity and broader psychological
distress, such as depression and anxiety, is more equivocal and there are a lack of
longitudinal studies in this area.
There was also some cross-sectional evidence for an effect of chronic noise exposure on
mental health, although the findings by type of disorder are more consistent for adults
than children. Adult mental health was also associated with subjective rather than
objective measures of noise exposure, such as noise annoyance. There is evidence that
noise annoyance is not on the pathway between noise exposure and mental health. There
is a need for further longitudinal studies in this domain and the cross-sectional
conclusions should be treated cautiously, as individuals who are experiencing poor
mental health are more likely to also evaluate the environment negatively, bringing into
question the direction of causality between subjective assessments of noise exposure and
mental health.
25
Studies have found little association between household density and mental health, either
cross-sectionally or longitudinally. However, household density and social disadvantage
may be confounded in these studies, as most studies do not make adequate adjustment for
socioeconomic factors. Evidence for associations between household tenure and mental
health was similarly limited by inadequate adjustment for socioeconomic factors: crosssectional evidence for an association between rental tenure and poorer mental health was
weak, but the studies were additionally limited by other methodological weaknesses,
including poor response rates.
As expected, there was evidence for an association between exposure to violence or
crime in the neighbourhood and poorer mental health, particularly for children; although
the majority of evidence was cross-sectional. However, these findings need to be
interpreted with some caution, as we would expect that being the victim of crime would
be associated with poorer mental health. It is difficult to theorise what contribution the
physical aspects of the neighbourhood environment would play in this association:
possibly, poorly designed neighbourhood environments may allow opportunities for
criminals to take advantage of people where they are not overlooked. Another suggestion
comes from the consistent longitudinal and cross-sectional evidence that perceived
neighbourhood disorder, such as vandalism, lack of facilities, vacant housing and litter,
was associated with poorer mental health. These environmental aspects illustrate one way
in which the environment may mediate the effect of exposure to crime on mental health.
However, it is difficult to disentangle these associations as individuals with poorer mental
health are likely to be selected into poorer neighbourhoods.
Overall, evidence for an effect of housing quality on mental health was mixed: there was
no longitudinal evidence for an association and the cross-sectional studies which
demonstrated an association were limited by poor response rates. In contrast, consistent
longitudinal evidence was available for housing and neighbourhood regeneration
improving mental health. There was also consistent cross-sectional evidence that access
to green or open spaces was also associated with better mental health, but again these
findings were limited by poor study response rates. One important finding of this review
is the need for methodologically stronger research in the domains examining the effect of
housing quality and facilities on mental health: more specifically, these associations need
to be examined with larger sample sizes, as well as longitudinally, which would enable
the causal relationship between the environment and mental health to be examined in
more detail.
Implications for future environmental developments
It is beyond the scope of this systematic review to examine the implications of the
strength of the evidence identified herewith for legal cases evaluating the health and
environmental impacts of planning developments. The evidence identified in this review
will be reviewed by the ELF Health, Environment and Law Group, and a further
publication prepared, detailing the possible implications of the evidence for planning
laws.
26
Limitations of the review

This review was extensive in sourcing evidence, which led to a vast number of citations
being identified. Due to time constraints of the review, only one reviewer scanned all of
the identified citations for eligibility. A weakness of the review was that this stage was
not undertaken independently, by two reviewers. However, a 10% sample of the searches
were screened independently by a second reviewer and this second screening process was
only terminated when the checks per year reached 100% agreement. We also sent the
panel of experts a preliminary final list of references, for the identification of omissions:
no omitted studies were identified, suggesting that the search strategy had been
comprehensive.
Conclusion
In conclusion, this review identified a range of peer-reviewed papers, which have
examined the association between the physical environment and mental health. The
majority of papers were cross-sectional and there were more studies of adult than child
populations. The strength of the evidence for environmental effects on mental health
varied and was strongest for urban birth (on risk of schizophrenia), rural residence (on
risk of suicide for males), neighbourhood violence, neighbourhood regeneration and
neighbourhood disorder. Evidence for effects of housing on mental health was weaker:
robust longitudinal studies were few and many of the cross-sectional studies were
methodologically poor. The evidence identified in this review will be utilised by the ELF
Health, Environment and Law group, to establish possible implications for planning laws.
27
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52. Maxwell LE. Multiple effects of home and day care crowding. Environment and
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32
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Papers identified as potentially relevant but unable to get
1. Cooley Quille M. Emotional and behavioural impact of exposure to community
violence in inner-city adolescents. Journal of clinical child psychology. 2001; 30:199206.
2. Chamberlain C Diala, Carles Muntaner. Mood and anxiety disorders among rural,
urban, and metropolitan residents in the United States Community Mental Health
Journal. New York: Jun 2003.Vol.39, Iss. 3; pg. 239
3. Eyles J. Worrying about waste: living close to solid waste disposal facilities in
Southern Ontario. Social Science and Medicine
33
4. Hunt and McKenna 1992 The impact of housing quality on mental health and
physical health. Housing Review. 41: 47-49.
5. Korpela K. Negative mood and adult place preference, Environment and Behaviour.
6. Lepore SJ, Evans GW, Palsane MN. Social hassles and psychological health in the
context of chronic crowding. Journal of Health and Social Behaviour. 1991;
7. Taylor Health Psychology: what is an unhealthy environment and how does it get
under the skin? Annual Review of Psychology. 1997. 48: 411-447.
Papers excluded with reason for exclusion in italics
1. Al Mousawi AHF. Schizophrenia Bulletin. 1998; 24: 529-535. Does not assess the
effect of the built or urban environment (explores time trends).
2. Blobaum and Hunecke Environment and Behaviour 2005; 37: 465-486. Not a
community sample.
3. Cackowski JM. Environment and Behaviour. 2003; 35: 736-751. Does not assess the
effect of the built or urban environment.
4. Compton MT. Social Psychiatry and Psychiatric Epidemiology. 2005; 40: 175-185.
Does not assess the effect of the built or urban environment.
5. Cramer M. The Journal of Nervous and Mental Disease. 2005; 193: 196-199. Does
not assess the effect of the built or urban environment.
6. Curtis S. Environment and Planning B. 2002: 20: 517-534. A discussion paper.
7. Dorvil H. Housing Studies. 2005; 20: 497-519. Not a community based sample.
8. Drukker M, Social Science and Medicine 2005; 61: 185-198. Does not assess the
9. Duncan DF. The Journal of Primary Prevention. 1996; 16: 343-355. Discussion
paper.
10. Evans G.W. Journal of Urban Studies 2003; 80: 536-555. Discussion paper.
11. Fauth RC. Social Science and Medicine. 2004; 59: 2271-2284. Article by same group
supersedes this study.
12. Fischer EP. Psychiatric Services. 1996; 47: 980-984. Does not assess the effect of the
built or urban environment.
13. Fuller Torrey E. Schizophrenia Bulletin. 1998; 24: 321-324. Discussion paper.
14. Hill T, Angel RJ. Social Science and Medicine. 2005; 61: 965-975. Outcome not
mental health.
15. Husted. Archives of General Psychiatry. 1999; 56: 285. Letter.
16. Hutchinson G, Mallett R, Fletcher H. Are the increased rates of psychosis reported for
the population of Caribbean origin in Britain an urban effect? International Review of
Psychiatry. 1999; 11: 122-128. Not a community sample.
17. Isometsa E, Heikkinen M, Henriksson M, Martunen M, Aro H, Lonnqvist J. Acta
Psychiatrica Scandinavica, 1997; 95: 297-305. Does not assess the effect of the built
or urban environment.
18. 19. Knapp J F. Violence among children and adolescents, 1998; 45: 355-364.
Discussion paper
19. Lewis G. Journal of Epidemiology and Community Health. 1992; 46: 608-611. Does
not assess the effect of the built or urban environment.
20. Mace BL. Environment and Behaviour. 2004: 36: 5-31. A discussion paper.
34
21. McNaught. British Journal of Psychiatry. 1997; 170; 307-311. Does not assess the
22. Menezes PR. Social Psychiatry and Psychiatric Epidemiology. 2000; 35: 116-120.
Outcome health care compliance.
23. Middleton N. Social Science and Medicine 2003; 57: 1183-1194. Does not assess the
effect of the built or urban environment (Time trends).
24. Mortensen PB, Pedersen CB, Westergaard T, Wohlfahrt J, Ewald H, Mors O,
Andersen PK, Melbye M. Effects of family history and place and season of birth on
the risk of schizophrenia. New England Journal of Medicine. 1999; 25: 603-8. Does
not assess the effect of the built or urban environment
25. Mueser KT, Essock SM, Drake RE, Wolfe RS, Frisman L. Schizophrenia Research.
2001; 48: 93-107. Does not assess the effect of the built or urban environment
26. Nasar JL, Jones KM. Landscapes of fear and stress. Environment and Behaviour.
1997; 29: 291-323. Not a community sample
27. Newman SJ. Psychiatric Services 2001; 52: 1309-1317. A discussion paper.
28. Northridge ME. Journal of Urban Health. 2003; 80: 556-568. A discussion paper.
29. OCallaghan E. British Journal of Psychiatry. 1995; 166: 51-54. Does not assess the
30. Parry J. Public Health. 2004; 118: 497-505. Study in progress.
31. Raffaello M. Environment and Behaviour. 2002; 34: 651-671. Does not assess the
effect of the built or urban environment (Industrial noise at work).
32. Riediker M, Koren HS. International Journal Hygiene Environmental Health. 2004;
207: 193-201. A discussion paper.
33. Ross CE, Mirowsky J. Journal of Health and Social Behaviour. 2001; 42: 258-276.
Outcome not mental health.
34. Saegert SC. American Journal of Public Health. 2003; 93:1471-1477. Outcome not
mental health.
35. Spiegel J. International Journal of Occupational Environmental Health. 2003; 9: 118127. Inappropriate study population.
36. Takei N. Journal of Epidemiology and Community Health. 1995; 49: 106-109.
Outcome not mental health.
37. Van Os J, Hanssen M, Bak M, Bijl RV, Vollebergh W. The American Journal of
Psychiatry. 2003; 160: 477-482. Article by same group supersedes this study.
38. Van Os J, Hanssen M, de Graaf R, Vollebergh W. Social Psychiatry and Psychiatric
Epidemiology. 2002; 37: 460-464. Article by same group supersedes this study.
39. Van Os J, Hanssen M, Biji RV, Vollebergh W. Archives of General Psychiatry.
Article by same group supersedes this study.
40. Verdoux H. Schizophrenia Research. 1997; 23: 175-180. Not a mental health
outcome.
41. Weeks WB, Kazis LE, Shen Y, Cong Z, Ren XS, Miller D, Lee A, Perlin JB.
American Journal of Public Health. 2004; 94: 1762-1767. Not a mental health
outcome.
42. Weich S, Burton E, Blanchard M, Prince M, Sproston K, Erens B. Health and Place.
2001; 7: 283-292. Article by same group supersedes this study.
43. Whitley R. Social Science and Medicine. 2005; 61: 1678-1688. Not mental health
outcome.
35
Other references
1. Begg C, Cho M, Eastwood S, Horton R, Moher D, Olkin I, et al. Improving the
quality of reporting of randomised controlled trials. The CONSORT statement.
JAMA. 1996; 276: 637-639.
2. Stroup DF, Berlin JA, Morton SC et al. Meta-analysis of observational studies in
epidemiology: a proposal for reporting. JAMA 2000; 283: 2008-2012.
3. Weaver N, Williams JL, Weightman AL, Kitcher HN, Temple JMF, Jones P,
Palmer S. Taking STOX: Developing a Cross-Disciplinary Methodology for
Systematic Reviews of Research on the Built Environment and the Health of the
Public. Journal of Epidemiology and Community Health. 2002; 56: 48-55.
36
Appendix 1. Predictors: terms used in the search strategy describing features of the
physical environment
Urban
Urban population, urban environment, city population, city living, urban living,
inner city, city centre, urban design, city environment, city residence, city dweller,
built environment, urban regeneration, poor urban planning.
Non-Urban
Rural, suburban environment, suburban living, suburban population, suburban
residence, suburban dweller, green space, open space, country park, rural
regeneration, natural environment, parks, garden, rural environment, rural
population, rural residence, rural dweller, rural living, natural setting, nearby
nature.
Public space
Public space, open space, green space, public amenity, speeding traffic, poor
public transport, litter, vermin, recreation facility, public facility, graffiti, poor
transport infrastructure, poor transport system, failing transport, public resource,
museums, library, community facility, community amenity, traffic calming, street
repair, public buildings, clean streets, recreation, park, garbage, street
surveillance.
Housing/neighbourhood
Poor housing, house quality, house regeneration, housing tenure, residential
relocation, damp housing, council estate, public housing, access to garden, house
amenity, dwelling type, shared amenity, high rise flat, housing problems,
rehousing, problem neighbour, anti-social behaviour orders (ASBO),
neighbourhood disorder, area regeneration, neighbourhood regeneration,
neighbourhood renewal, house deterioration, house refurbishment, house
improvement, gentrification, central heating, replacement windows, house
renovation, poor insulation, housing satisfaction, neighbourhood revitalization,
neighbourhood spaces, low-rise.
Noise
Noise, road traffic, airport, air traffic, motorway, railway, rail traffic,
environmental noise, noise insulation, sound insulation, noise annoyance, aircraft
noise
Light
Natural light, artificial light, security light, street light*
Air
Poor air quality, air pollution, fresh air
Adverse event
37
crime, street violence, mugged, mugging, flooding, robbery, vandalism, assaults,

accident hot-spot, neighbourhood conflict, defensible space, incivilities, privacy,
fear of crime.
People/density
Overcrowding, crowding, population density, high building density, low building
density, high housing density, low housing density, personal space, propinquity,
spatial density.
Other
Place attachment, therapeutic places, sense of community, toxic contamination.
Health outcomes
Mental health terms
Psychiatric disorder, psychiatric illness, mental disorder, mental well being,
mental stress, psychological health, psychological well being, psychological
illness, mental health, mental illness.
Specific mental illness
Anxiety, stress disorder, phobic disorder, panic disorder, obsessive-compulsive
disorder, compulsive behaviour, obsessive behaviour, mood, seasonal affective
disorder, depression, depression postpartum, dysthymic disorder, psychosis,
schizophrenia, ADHD, bipolar disorder, Attention Deficit Hyperactivity Disorder,
conduct disorder, hyperactivity, suicide
Study design terms (to filter out opinion or discussion papers)
Systematic, review, random, trial, study, control, before and after, cohort, case control,
cross sectional, longitudinal, qualitative, prospective, retrospective, survey, intervention,
observational.
Terms combined as study design AND (predictor terms AND health outcomes)
38
Appendix 2. Data extractions for full text papers included in the review
Table 1. Access to residential green or open spaces and mental health
Citation
Children
Wells 2003,USA
Citation
Adults
Kaplan 2001 USA
Predictor or innovation and how

measured
Mental health
outcome and how
measured
Study design: cross-sectional
Results
Level and direction of evidence
Naturalness. A scale of the residential

environment. It consisted of 4 items
regarding whether the window view is
of nature, the number of live plants
indoors and the material in garden
(grass, dirt, concrete or other)
Childs
psychological
distress: (1) Rutter
Child Behaviour
Questionnaire and
(2) The Global
Self-Worth
Subscale of the
Harter
Competency
Scale.
Childrens
stressful life
events: The Lewis
Stressful Life
Events Scale.
Mental health
outcome and how
measured
337 children living in small towns

in rural New York. Mean age 9
yrs. 95% white, 49% female, 63%
of mothers had completed some
college education. Response rates
not reported
Regression analysis (adjusted for SES (income-to

needs ratio) of predictors of childrens psychological
distress
Living with more nature nearby (F (2,335) = 6.27,
p=0.05).
Stressful life events (F (2,336)= 53.14, p =<. 001).
Nature nearby was found to buffer the effects of
stressful life events on childrens psychological
distress (F (4.333) = 4.73, p =<. 05).
Level of evidence 3b-.
Results
Mental well being

developed
measures from
previous work
(not validated
scales) - domains
covered effective
mental
functioning, being
at peace, feeling
distracted.
564 households were invited to

participate. The overall response
rate was 34%.Response rates
varied between blocks ranging
between 19 and 46%. More
females responded 68%.
Significant predictors of mental health (regression

analysis betas and p values)
4. Effective functioning
Outdoor activities 0.16 p= <0.05, having a view of
landscaped garden 0.08 p = <0.05. (controlled for view
of the sky)
5. Being at peace:
Having a view of trees 0.25 p =<0.001. Although not
having many demands at home or at work played a
more important role in the sense of being at peace.
6. Distracted
Having a view of trees -0.18, p= <0.01, Having a view
of farmlands or field -0.16, p = <0.05. Although
external demands also played an important predictive
role.
Level of evidence 3b.

measured
View from home window. Six low
rise rental apartment blocks with
variation in the types of natural
elements. Residents have no role in
planning or maintaining the sites.
Participants were asked to rate the
view from home on 17 characteristics.
In addition respondent were asked to
rate the similarity of the view from
their apartment with a series of
photographs.
Children with more nature near the

home exhibited less psychological
distress. While children exposed to
more stressful life events
experience greater distress, living
near nature moderated the impact
of life stress for these children
Caution does not state response
rates and does not state how many
children were psychologically
distressed in the sample
Having a view of nature improved

mental well-being
Caution low response and lack of
sociodemographic information
about differences between
apartments.
39
Kuo and Sullivan

2001 USA
Lewis and Booth

1994 UK
MacIntyre 2003 UK
Apartments with trees and grassland

surroundings compared with
apartments surrounded by concrete:
defined by using standardised sets of
photographs and multiple independent
raters on a housing estate where
buildings and other structural features
were constant but level of vegetation
varied widely.
Mental fatigue:
attention
functioning/deficit
by Digit Span
Backwards test
(DSB).
Aggression by the
Conflict Tactic
Scale.
145 urban public housing female

residents randomly assigned by
state clerks to buildings with
varying levels of nearby nature.
Response rate 92%
Residential environment rated by

interviewer: urban resident with no
access to large garden or open space,
and country district.
Mental health:
GHQ
6456 adults. Response 54%.
Home features: including housing

tenure, housing fixtures,
overcrowding, dwelling type, access
to garden, are type and are amenities.
Anxiety and
depression:
HADS
2867 adults. 50% response rate.

63% owner-occupiers, 36% car
owners 25% aged 65+.
Mean DSB scores

Living in green area 5.0, SD 1.0, living in barren area
4.6, SD 1.2. p =<.05
Multiple regression of attention deficit and levels of
aggression
B=-.26, R2 = .07, f=9.9, p=<.0025
Multiple regression of whether nearby nature predicted
levels of aggression (Attention performance controlled
for) Greenness indicating greenness no longer
significant.
Regression OR for psychiatric morbidity and living in
urban area without open space
1.35(1.13,1.58).
Adjusted for gender, age social class, marital status,
unemployment, chronic illness and region of residence.
Depression Anxiety
Mean SD
Mean SD
5.71 3.9* 7.8 13.0*
No access to garden
* p = <0.001,
Analysis uncontrolled for sociodemographic factors.

Urban environments were
associated with greater mental
fatigue (than natural environments).
Natural environments reduced
aggression.
Caution minimal adjustments made
in analysis for sociodemographics.
Living in an urban area without
open space (compared with
residents in country districts) was
associated with psychiatric
morbidity.
Caution low response and weak
predictor measure.
Having no access to a garden was
associated with psychological
morbidity.
Caution: low response, direct effect

of lack of access to a garden not
the main outcome of the study and
analysis did not control for
sociodemographic factors.
Level of evidence grade: 1a= SR of RCTs with homogeneity of findings, 1b=Individual RCT with narrow confidence intervals, 2a = SR of cohort studies with homogeneity of findings, 2b = individual
cohort studies or poor quality RCTs, 3a SR (with homogeneity) of case-control studies,/cross-sectional 3b Individual case-control study/cross-sectional, 4 case-series (and poor quality cohort and casecontrol studies) From Oxford level of evidence and grades of recognition http://www.cebm.net/levels_of_evidence.asp#levels
40
Table 2. Exposure to street violence and mental health

Citation
Adults
Norris and Kaniasty
1994 USA

measured
Mental health
outcome and how
measured
Study design: longitudinal
Results
Self report of crime: property or

violent crime (does not specify if
crime was undertaken in the home or
outside).
Depression,
hostility, anxiety
and somatisation:
BSI
105 violent crime victims, 227

property crime victims and 190
non-victims. Followed from 3 to
15 months post crime.
522. Overall response rate 65%
Regression models standardised beta and p values

Effect of crime (versus non-crime victim) on
depressive symptoms at baseline and 3 and 15 months
later,
At baseline .12**,
At 3 months .09*, 3 months (with time 2 crime
controlled for) .05,
At 15 months .11**, 15 months (with time 2 (at 3
months) crime controlled for) .08, 15 months (with
time 3 (at 15 months crime controlled for) .06.
Effect of crime on symptoms of anxiety at baseline and
3 and 15 months later,
At baseline .15***,
At 3 months .11*, 3 months (with time 2 crime
controlled for) .09*,
months) crime controlled for) .08, 15 months (with
time 3 (at 15 months crime controlled for) .08.
Effect of violent crime (versus property crime) on
depressive symptoms at baseline and 3 and 15 months
later,
At baseline .22***,
At 3 months .21***, 3 months (with time 2 violence
controlled for) .17***,
controlled for)..20***.
Effect of violent crime on anxiety symptoms at
baseline and 3 and 15 months later,
At baseline .22***.
controlled for) .18***,
months) violence controlled for) .12**.
1. p<.05, **p<.01, ***p<.001
Analysis controlled for age, gender, education, marital
status, urbanicity, and crime prior to time point
measured.

In the short-term, crime (violent or
property) was associated with poor
mental health. In the longer term,
the effect of crime on mental health
was contingent on the occurrence
of subsequent crime.
Violent crime victims were more
symptomatic than victims of
property crime.
41
Citation
Children
Hurt 2001 USA
Lai 1999 Canada
Latzman and
Swisher 2005 USA

measured
Mental health
outcome and how
measured
Results
Exposure to violence (witnessing an

arrest, gun shots fired, drug deals,
physical violence, shooting or
stabbing) both in the home and the
community asked in a cartoon based
interview (20 item questionnaire) by
an interviewer.
Depression and
anxiety: Feelings
of distress scale
(the Levonn test)
119 inner city low-income

children aged 7 and 119
caregivers. 57% female, 82% in
care of biological mothers, 98%
African American. Response rate
not recorded
Witnessing violence
Depression .31 (p =<.001 ), anxiety .37(p =<.001)
Factors associated with child anxiety: linear regression
analysis (betas (p-value))
Total violence exposure
.27 (.03)
HOME environment score -.16 (.17)
Self report of exposure to violence in

the neighbourhood: having things
damaged, having things stolen, having
things taken by force or threat of
force, being verbally put down or
bullied, being threatened with hurt,
being slapped or punched or kicked,
getting threatened with a weapon and
being attacked or beaten up by a
group
Mental health:
BSI for
somatisation,
obsessivecompulsive,
interpersonal
sensitivity,
depression,
anxiety, hostility,
phobic anxiety,
paranoid ideation,
psychoticism,
Global Severity
Index, Children
Depression
Inventory.
Depression 8 item
scale of questions
(not referenced)
Street violence: 4 items on having

seen stabbings, shootings and
muggings in the neighbourhood.
347 aged 11-20 years, 53%

female, 74% white. Response rate
not reported
Predictors of mental health outcomes. Beta (p values)

Being a victim of violence in the neighbourhood:
Psychoticism 0.18 (0.0013)
Being a witness of violence in the neighbourhood:
obsessive-compulsive: 0.12(0.0304), anxiety :
0.13(0.0243), hostility: 0.16(0.001), phobic anxiety:
0.14(0.0145)
Analysis adjusted for gender, ethnicity, age, school
year
Witnessing violence was associated

with increased feelings of anxiety
and depression
Caution response rate not
reported; analysis for depression
outcome is incomplete.
Exposure to violence in the
neighbourhood was associated with
psychoticism, obsessivecompulsive disorder, anxiety,
phobic anxiety and hostility. No
association was observed for
depression.
Caution: response rate not
reported
8,939 nationally representative

sample of 11 to 21 yr olds. 52%
female. White non-Hispanic 64%.
Adolescents living with two
biological parents 54%. Primary
sampling frame included 80
schools. 79% of pupils agreed to
participate
Multivariate analysis of adolescent depression and

street violence.
Unstandardised regression coefficient with standard
error 0.015 (0.003) p = <0.001
(controlled for own violence mutually adjusted,
depression at baseline, age, gender, ethnicity,
household type and family socioeconomic status).

Street violence was associated with
adolescent depression.
42
Mazza 1999 USA
Moses 1999 USA
Exposure to violence including driveby shootings, attacks, and violence in

school
Self report of exposure to violence: 6

items covering having witnessed or
been victim of shooting, stabbing or
rape.
Post traumatic
stress disorder,
suicidal ideation
and depression:
Adolescent
Psychopathology
Scale subscale for
PTSD, the
suicidal ideation
questionnaire and
the Reynolds
Adolescent
Depression scale.
Depression and
hostility: SCL-90R
94 boys and girls aged 11 to 15

years. Low income sample. 70%
African American, 22% Hispanic,
1% native American, 1% white.
Response rate 63%
Analysis controlled for age,
gender,
337 urban teenage 14-19 yrs.

44% black, 51% Hispanic, 62%
female
Cross-sectional analysis
Exposure to violence and depression
F= 0.80, df 1,88, p=.375 (controlled for gender, age,
PTSD and suicidal ideation)
Exposure to violence and suicidal ideation
F= 0.31, df 1,88, p=5.78 (controlled for gender, age,
PTSD and depression)
Exposure to violence and PTSD
F= 19.05, df 1,88, p= <.001 (controlled for gender,
age, suicidal ideation and depression)
Follow-up regression analysis
PTSD as a mediator between exposure to violence and
depression
Exposure to violence B=-0.63, p=0.456
PTSD
B=0.774, p=0.001
PTSD as a mediator between exposure to violence and
suicidal ideation
Exposure to violence B=0.044, p=0.641
PTSD
B=0.629, p=0.001
Regression analysis of depression and exposure to
violence (adjusted for age, ethnicity)
Beta
t
p value
Male
0.058
0.651
0.522
Female
0.150
2.166
0.031

Exposure to violence was
associated with PTSD but not
depression or suicidal ideation.
Caution: small study

Exposure to violence was
significantly related to depression
for females but not males.
Caution: selective sample; does not
report response rate and consent
procedure is unclear.
43
Pastore 1996 USA
Exposure to violence: self report
Depression:
DSRS
630 urban teenage, 45% male.

Retrospective.
Response rate not reported
OR of mental health if knew someone who was

murdered
Suicidal ideation 1.95(1.07,3.54)
Witnessing violence increased the
Suicide attempt 3.59(1.50,8.54)
risk for suicide ideation and
Depression 1.07(0.66,1.74)
attempts but not depression.
OR of mental health if knew someone who witnessed a
stabbing
Caution: analysis does not adjust
for confounders, does not report
response rate.
Depression 1.28(0.71,2.31)
OR of mental health if knew someone who witnessed a
shooting
Depression 1.13(0.47,1.65).
Analysis appears not to control for confounders
cohort studies or poor quality RCTs, 3a SR (with homogeneity) of case-control studies, 3b Individual case-control study, 4 case-series (and poor quality cohort and case-control studies) From Oxford
level of evidence and grades of recognition http://www.cebm.net/levels_of_evidence.asp#levels
44
Table 3. Housing and neighbourhood quality and regeneration and mental health
Table 3a: Housing and neighbourhood quality
Citation
Children
Evans 2002 USA
Citation
Adults
Sundquist 2004
Sweden

measured
Mental health
outcome and
how measured
Results
Exposure to multiple physical

(crowding, noise and housing quality
independently rated) and
psychosocial stressors (violence,
family turmoil and child-family
separation mother report)
Socioemotional
adjustment: The
Rutter Behaviour
Questionnaire.
Harter
Competency
subscale of self
worth.
Mental health
outcome and
how measured
Low and middle income rural

children n=287. 8-10 year old
children, 97% white 51% male.
Regression coefficients of partialing out multiple

exposures with psychological morbidity and poverty
Psychological distress (maternal self report) .007* p =
<.05, Self report of psychological well being .05 p =
<.05
(analysis adjusted for mothers education, single
parent status, delayed gratification, blood pressure,
cortisol, epinephrine and norepinephrine)
Results
Psychiatric
illness: first
psychiatric
hospital
admission using
ICD-10 codes.
National random sample of 9,170

male and females aged 25-74
during 1990-91 follow-up to
1998. Response rate 78%.

measured
Physical environment based on three
questions: 1) whether there was
destruction of playgrounds, parks and
common land in the neighbourhood,
2) whether they were satisfied with
the street cleaning and rubbish
collection in the neighbourhood, 3)
whether sleep was disturbed by noise
from traffic, neighbours or another
source.
Recruited by advertisement, so
cannot determine response rate.
HR and 95% CI of poor physical environment and

psychiatric illness
0.84(0.58,1.23).
Regression analysis controlling for gender, age,
marital status, geographical region.
The link between poverty and poor

socioemotional adjustment was
partially mediated by cumulative
stressor exposure in the home and
neighbourhood.

No association between poor
physical environment and
psychiatric illness
45
Citation
Adults
Ellaway 2001 UK
Evans 2000 USA

measured
Mental health
outcome and
how measured
Results
Neighbourhood problems Perceived

quality of neighbourhood: provision
of services and perceived safety
including vandalism, litter, rubbish,
assaults, mugging, disturbance from
children, adolescents, speeding
traffic, nuisance from dogs, reputation
of neighbourhood. Environmental
problems: smells, fumes, burglaries,
discarded needles, syringes, uneven
or dangerous pavements, lack of safe
places for children to play, lack of
recreational facilities. Neighbourhood
cohesion. Question on attraction of
neighbourhood, questions on
psychological sense of community
and on neighbouring (contact with
fellow residents).
Self reported
health: mental
health- GHQ
N= 597 (males 261, females

336). 4 socially contrasting
neighbourhoods in Glasgow. 3
age cohorts - 25 years, 45 years
and 65 years.
Mean neighbourhood problems scores by correlation

with GHQ score
All problems
Anti-social
Environment
0.202*
0.182*
0.200*
*Indicates significance at 1% level.
Mean perceived neighbourhood cohesion scores by
correlation with GHQ score
Overall score Attraction Neighbouring Psychological
to neighsense of
bourhood
community
-0.149**
-0.086
-0.156**
-0.137**
**Significant at 5% level.
Analysis adjusted for age, gender, social class,
Housing quality based on various

reference indices. Six subscales
relating to structural quality of the
home, privacy (inside home), indoor
climatic conditions, hazards,
cleanliness and clutter, and child
resources (availability of toys).
Neighbourhood quality relating to
structural condition of surrounding
housing stock.
Mental health:
Demoralisation
Index of the
Psychiatric
Epidemiology
Research
Instrument.
Housing quality and psychological distress, cross

sectional (controlled for income).
Mean (SD) (range 1-4)
First (lowest quality quartile) 1.30(0.62)
Second
1.16(0.55)
Third
0.96(0.42)
Fourth
0.85(0.46)
B=-0.46, p=<. 001.
207 women with at least one

child living in the home. Low and
middle-income families, sample
97% white and resided in rural
areas.
Poorer mental health was related to

perceived neighbourhood problems
in terms of safety, environment,
amenities and poorer
neighbourhood cohesion.
Caution response rates not
reported
Poor housing quality was

associated with poorer
psychological health.
Caution: very small longitudinal
sample does not report the
response rate in both studies.
46
Galea 2005 USA
Hopton 1996 UK
MacIntyre 2003 UK
Internal (broken toilets, nonfunctioning kitchens, heating broken,

peeling plaster and paint, water
leakage) and external housing
(dilapidated, wall or window
problems, stair well problems, fires,
clean streets and communal areas)
collected by trained interviewers.
Depression: NWS
module. Life time
and in past 6
months
Inner city, 1355 adult residents of

59 neighbourhoods characterised
by poor quality built
environment. Analysis controlled
for income, age, gender, and
ethnicity. Response rate not
reported. Mean age 40 yrs, 56%
female. 35% white.
Housing conditions: self-reported

damp in public sector housing. Also
asked about coldness, noise and
crowding.
Mental health:
GHQ 30. Case 5
or above
114 women, 333 men aged 1765. 63% response rate
Home features: tenure, and damp,

condensation, heating, noise, poor
state of repair, desirability of
dwelling, crowding in home, access to
garden, housing fixtures (including
telephone, smoke alarm, deep freezer,
burglar alarm, double glazing),
vandalism, rubbish, smells fumes,
assaults and mugging, burglaries,
disturbance by children and
adolescents, speeding traffic,
discarded needles, uneven pavements,
dog problem, poor public transport,
area amenities.
Anxiety and
depression:
HADS

Regression OR (for one standard deviation increase in

the % of a particular characteristic of the built
environment) for depression in last six months
Toilet broken 1.22(0.80,1.84), non functioning
kitchens 1.38(1.05,1.83), heating broken in winter
1.43(1.04,1.95),
Inadequate heating 1.64(1.25,2.15). Plaster/paint
peeling 1.36(1.00,1.85), internal water leakage
1.18(0.87,1.59), buildings in a dilapidated condition
1.09(0.87,1.37), buildings deteriorating
1.36(1.04,1.76), external wall problems
1.06(0.72,1.54), window problems 1.13(0.78,1.63),
stairway problems 1.27(0.88,1.83), structural fires
1.39(1.02,1.88), acceptably clean streets
1.38(0.93,2.05), acceptably clean sidewalks
1.06(0.67,1.69).
Similar observations were observed for lifetime
depression.
Regression analysis OR for problems with dampness
and poor mental health
1.76(1.17,2.66). Controlled for household income,
unemployment, chronic illness, age, marital status,
number of people living in household, children living
in household, length of time living at address and
whether they moved there because of ill health
Depression Anxiety
Mean SD
Mean SD
Owner occupier
4.04 3.2 6.6 3.8
Social renter
6.09 4.0* 8.0 4.4*
Semi or detached house
4.25 3.2 6.8 3.9
Terraced/4 in block house 4.96 3.9 7.1 4.1
Stone tenement flat
4.75 3.4 7.5 4.0**
Flat
5.42 4.0* 7.6 4.3
No access to garden
5.71 3.9* 7.8 13.0*
* p = <0.001, ** p = 0.005
Pearson correlation coefficient between age, housing
and neighbourhood perceptions
Anxiety
Depression
Housing problems
0.237*
0.239*
Housing fixtures
-0.126*
-0.210*
Persons per room
0.040
0.024
Area problems
0.272*
0.253*
Poor area amenities
0.114*
0.153
* p = <0.001

People living in neighbourhoods
with poorer built environments had
an increased risk of reporting
depression
Caution response rate not reported

Perceived problems with dampness
were associated with poorer mental
health.
Associations between tenure, living
in a flat, having no access to a
garden, housing problems, lack of
household and neighbourhood
amenities, and psychological
morbidity. No association found
between household crowding and
psychological morbidity.
Caution: low response and
47
Saito 1993 Japan
Silveira and
Ebrahim 1998
UK
Weich 2002 UK
Floor level, residential density, self

report of perceived housing
environment
Poor housing: damp, infestations,

need for repairs, need for rehousing,
homelessness, feelings of home
insecurity.
The Built Environment: The Built

Environment Site Survey Checklist.
Independently rated, items included
the form, height and age of housing,
number of dwellings and type of
access, provision of gardens, use of
public space, amount of derelict land,
security and distances to local shops
and amenities.
Psychological
health: GHQ
Psychiatric
morbidity: SAD
Depression: CESD
444 households in aggregated

dwelling units in capital city.
Response rate 54%
Inner London general practice

sample. 274 Somalis, Bengalis
and white British aged 60 plus
1887 individuals aged 16 years

and over. The household
response rate was 61.3% and the
individual response rate within
participating households was
87.7%. 57% female.
GHQ score by house factor

Person to room density same or less than 0.5 = 5.3,
>1.0 = 6.4 (ns).
Floor level of low-rise apartments 1-2 = 5.1, 3-4 = 5.4,
5-8 = 5.5 (ns)
Floor level of high-rise apartments 1-4 4.7, 5-8 6.3, 914 4.4, 15-23= 4.9 (ns).
GHQ score by perceived housing environment
Dissatisfied with living facilities 5.6 (satisfied 5.1)
(ns),
Dissatisfied with room arrangements 6.2 (satisfied 5.0)
(p = <0.05),
Inadequate environment for children 7.4 (good 5.1)
(p=<0.05),
Inadequate environment for the elderly 6.5 (good 4.9)
(<0.10),
Annoyed by outdoor noise 5.5 (quiet 5.5) (ns),
Complained about outdoor noise 6.4 (never 4.7
(<0.05), Annoyed by indoor noise 6.2 (quiet 5.1)
(<0.05), Complained about indoor noise 6.6 (no 4.9)
(ns).
ns = not significant. Adjusted for age, employment
status. Floor level also adjusted for in perceived
housing environment factors.
Spearman rank correlations between poor housing and
psychiatric morbidity
Somalis 0.27 p=<0.05
Bengali 0.14
White -0.03
Regression OR(confidence interval) for depression

Deck access
1.28(1.03,1.58)
Property built 1940-69 (versus pre 40) 1.10(0.82,1.47)
Property built 1969+ (versus pre 40) 1.43(1.06,1.91)
<1/4 dwellings with private gardens
1.29(1.00,1.65)
No shared recreational space
0.80(0.60,1.07)
Graffiti
1.26(0.74,2.13)
Disused buildings
0.91(0.65,1.26)
(adjusted for age, gender, marital status, employment
status, housing tenure, car access, ethnicity, floor of
residence, and structural housing problems)

Housing dissatisfaction was related
to poorer mental health.
Floor level and household
crowding were not significantly
associated with mental health.
Caution low response rate

Poor housing was associated with
poor mental health for Somalis, but
not for Bengali or White
participants.
Caution: analysis did not adjust for
any confounders
Lack of garden access and living in
newer property (post 1969), were
associated with depression,
independently of SES and the
internal characteristics of the
dwelling.
48
Citation
Adults
Chu 2004

measured
Mental health
outcome and
how measured
Study design: review
Results
Urban and physical environment:

various measures
Mental wellbeing: various

measures
The search dates varied between

databases but all were up to
2001/2002. Does not critically
appraise studies or state type of
study design
Identified over 50 relevant studies and from these

identified five urban and physical features which may
have an impact on mental health. These were
control over internal housing environment
quality of housing design and maintenance
presence of valued escape facilities
crime and fear of crime
social participation
Unable to assign level of evidence

because of under reporting of
findings.
Review suggests certain features of
physical and urban environment
have an effect on mental health.
These were control over internal
housing environment, quality of
housing design and maintenance,
presence of valued escape
facilities, crime and fear of crime
and social participation.
Caution: review does not provide
any indication of the type and
quality of the evidence or how the
themes were derived.
49
Table 3b: Housing and neighbourhood regeneration

Citation
Adults
Thomson 2001 and
2003 UK
Citation
Adults
Leventhal 2003
USA

measured
Mental health
outcome and
how measured
Results
Housing improvements included the

impact of medical priority rehousing,
energy efficiency improvements,
refurbishments, rehousing and area
regeneration
General health
and mental health
(using various
validated scales)
Review of controlled and

uncontrolled studies but does not
critically appraise studies. Studies
reviewed ranged from 1936 to
2000
All 9 studies (of varying designs) that examined

mental health found an improvement in mental health,
after housing improvements, between one month and
five years later, except one.
Level of evidence 2a-.

measured
Health outcome
Study design: randomised

control trial
Results
Housing relocation program in which

families who resided in public
housing or received project-based
assistance and who had at least one
child under 18 years were randomised
either to receive rent subsidies for
approved housing in the private
market or in the control group who
received no benefits.
Mental health:
Behaviour
problem index for
children.
Depressive mood
inventory and
Hopkins
symptoms
checklist for
parents.
RCT 3 year follow-up. Parents

n=550, children n=512. Age
range of children 8 to 18 years,
average 12 years (SD 4.15).
69% response rate at follow-up
Summary of unstandardized regression coefficients

(standard errors) for program effects on parental
mental health at follow-up
Intervention
control
Depression
-0.19(0.11) -0.01(0.11)
Distress/anxiety -0.21(0.09)** -0.12(0.09)
(Adjusted for gender, ethnicity, age, education,
employment status martial status and number of
children in household).
Summary of unstandardized regression coefficients
(standard errors) for program effects on childrens
mental health at follow-up
Intervention
control
Total
-0.32(0.16)
-0.16(0.17)
Boys
-0.42(0.21)*
-0.33(0.24)
Girls
-0.23(0.23)
-0.03(0.24)
(Adjusted for childs age, parental education,
employment status, marital status and number of
children in household)
* = p<..05, **p=<.01
Consistent evidence of mental

health improvement with housing
improvements.
Limited by a lack of detail on key
study methods for all studies such
as design, population and analysis.
Where reported (in 2001 paper
study samples are small with little
adjustments made in the analysis
for sociodemographic factors).
There was a positive effect of
rehousing on mental health for
adults and boys, but not girls.
50
Citation
Adults
Blackman and
Harvey 2001
Blackman 2003 UK

measured
Health outcome
Results
Neighbourhood renewal program:

improving deteriorated housing and
open land, repairing vandalised
facilities, removing graffiti and
regular rubbish clearance
Self report of
psychological
distress
415 households at baseline, 234

at follow-up 5 years later. These
included 394 adults (aged 16 to
64 plus) and 131 children. Main
householder responded on behalf
of all household members.
Follow-up response 62%.
Best fitting regression model of OR of mental health

problems in adults
Serious draughts 2.28(1.41,3.69)
Not safe area 2.35(1.41,3.92) (Variables considered in
regression model were age, sex, household type,
overcrowding, employment status, receipt of housing
or council tax benefit, un/waged household, car
ownership, dwelling type, happiness with home,
damp, keeping warm, draughts, vermin, various
housing defects, acute respiratory condition, chronic
condition or disability, perception of area and burglary
in last years.)
For childrens mental health the study reports that it
was unable to identify a direct link with housing or
neighbourhood factors.
Means and standard deviations (SD) after rehoused

and changes in mean between baseline and follow-up
For mental health perception (the higher the better)
Not rehoused
Mean SD Change in mean
49.23 24.44
4.88
Rehoused
Mean SD Change in mean Change in t p value
61.45 24.25
23.60
-4.86
0.001
For role limitation due to emotional problems (the
higher the better)
Not rehoused
Mean SD
Change in mean
38.7 46.94 2.59
Rehoused
Mean SD
Change in mean Change in t p value
58.25 47.70 27.38
3.02
0.003
Medical priority rehousing in rental

social sector.
Mental health;
SF-36
253 households interviewed

before rehousing and
reinterviewed 9 to 12 months
later. Response rate 45%. Age
adult but range unclear, 77%
female. 4% black or Asian. Low
SEP. Data from 227 adults
analysed of whom 104 were
rehoused. No baseline differences
between those who were then
rehoused compared to those who
were not, except mobility worse
in those not rehoused, and those
rehoused were more likely to be
younger. Baseline response rate
54%, follow-up 45%
Adult mental health improved after

the completion of the renewal
programme and appeared to be
linked to a wide perception of the
area as safe and the improvements
to draughts in the home. No effect
was found for childrens mental
health.
Caution evidence given a minus
sign as measure of mental health
was weak.
Rehoused groups experienced

significantly greater improvements
in mental health over a 12 month
period.
51
Dalgard and Tambs

1997 Norway
Evans 2000 USA
Huxley 2004 and

Thomas 05 UK
Urban improvements: compared areas

that have experienced change in the
primary qualities of the living area
with areas that experienced less
change. Changes included new state
school, playgrounds, sports area and
park, organised activities for
adolescents, a shopping centre and a
subway line being extended to the
neighbourhood.
Mental health: 50
questions on
anxiety,
depression and
somatisation.
Change in overall housing quality by

relocation to the newly constructed
Habitat for Humanity residence
Psychological
distress: PERI
Housing improvements to a council

estate compare with a similar estate
(matched by deprivation) in a
neighbouring ward.
Improvements included damp
proofing , windows, heating,
light/electric, roofing, bathroom,
plumbing, kitchen. Area severity
included 15 items such as graffiti,
litter, car theft, burglary)
503 adults reinterviewed at 10

year follow-up. 50% response
rate
Regression of mental health at follow-up by area

(adjusted for mental health at baseline, gender, age,
marital status, education, time lived in area).
Anxiety b= -0.12, p = <0.05, depression b= -0.07 (ns)
ns = not significant
Mental health:
GHQ 12
Follow-up 7 months after

relocation. Urban sample of 31,
females with at least one child
living at home. Assessed 4
months before and 7 months after
relocation into a residence
financed and constructed
cooperatively. Mean household
size 4.0, low income, and
predominantly African American
(61%).
Longitudinal study with control
group (a neighbouring area with
similar deprivation) with 22month follow-up. Sample 1344.
17% response at baseline, follow
up 65%. More white and single
people in the control group.
Change in urban housing quality scores and

psychological health
B=-19.70, SE =7.94, t=2.48, p =<. 02.

Significant improvement in anxiety
symptoms for those who continued
to live in an area that had
undergone primary neighbourhood
improvements compared with those
who continued to live in areas with
fewer improvements.
Caution low response
Improved housing quality was
associated with reduced
psychological distress.
Caution small sample
The effect of regeneration on mental health (GHQ

mean)
Baseline Follow-up p value for diff
Intervention 2.53
2.62
0.27
Control
2.25
2.31
(analysis unadjusted)
Random effects predictive model of mental health
GHQ total Coefficient 95% CI P value
Area
-0.020 -0.104,0.605 0.635
Area severity 0.057 0.018, 0.096 0.004
(analysis adjusted for age, gender, ethnicity, tenure,
structural risk includes no car, unemployed)

No effect of the housing
intervention was found on mental
health. A poor quality
neighbourhood predicted poorer
mental health.
Caution low response rate at
baseline and not all analyses
controlled for sociodemographic
factors.
52
Kahlmeier 2001
Switzerland
New residence: changes in housing

quality.
Well-being: self
rated
North Western region of country

covering around 345,000
inhabitants. Aged 18-70 years.
N=2144. Analysis adjusted for
gender, age, household
composition, income, education
and type of housing. Response
rate 56%
OR (CI) for association between improved satisfaction

with housing quality indicators at the new residence
and improvement in self-rated health since having
moved
Location of building 1.58(1.28,1.96), perceived air
quality 1.58(1.24,2.01), suitability of apartment
1.77(1.41,2.23), comfort of apartment 1.26(0.98,1.62),
condition of apartment 1.19(0.95,1.50), relationship
with neighbours 1.46(1.19,1.80), perceived noise from
neighbours 1.32(1.07,1.64), child day care in block
1.45(0.84,2.48), clubs/associations in neighbourhood
1.28(0.99,1.65), cleanliness of surroundings
1.24(0.99,1.56), medical facilities 1.23(0.93,1.62),
facilities for daily shopping 1.22(0.96,1.54),
supply/security of sidewalks 1.21(0.96,1.54).

Greater satisfaction with the
environmental quality of the new
housing was associated with
improved well being.
Caution low response rate and
little description of well being
measure
53
Table 4. Housing tenure and mental health

Citation
Children
Cairney 2005
Canada

measured
Mental health
outcome and how
measured
Results
Housing tenure: renter or home owner

(20% of sample lived in rental
accommodation).
Psychological
well-being: major
depressive
episode CIDI
and a 6-item index
of psychological
distress
19,600 households; 96% response

rate. Of these, 1,777 households
had respondents aged 12 to 19
yrs.
Regression analysis (adjusted for gender, place of

residence, overcrowding, household income and
family structure). Among children aged 12-14 distress
was higher among adolescents living in rental
dwellings. For children aged 15-19 there was no effect
on distress. The prevalence of major depressive
episode was three times higher among adolescents
living in rental dwellings compared to those in owned
homes. For 15-19 years the gap as smaller between
rentals and homeowners (3%).(Statistical output not
given)

Living as a young adolescent (aged
12-14) in rental accommodation
had, after adjusting for other
socioeconomic factors, an impact
on psychological distress and the
prevalence of major depression.
This effect was not found for older
adolescents.
Caution: statistical output not
given.
Adults
Citation
Dunn 2002 Canada
Ellaway 1998 UK

measured
Meaningfulness of home and
neighbourhood environment
(including felt like they belonged to
community, were proud to live in
community)
Housing tenure: self-report of owneroccupier or renter. Perception of area:
(series of questions on local
amenities, local problems-litter, drugs,
and crime. traffic, reputation of area,
neighbourliness, fear of crime,
satisfaction with area), Housing type
(flat, house, four in block flat all with
separate entrance or other). Housing
stressors (damp, condensation, noise,
adequate heating, safety, and space).
Mental health
outcome and how
measured
Feeling downhearted and blue
in last 2 weeks
Results
Random sample of one adult per

650 households in city of
Vancouver. Response rate 69%
1998: Anxiety,
depression:
HADS.
1998: 691 adults aged 40 to 60

from socially contrasting
neighbourhoods. 425 lived in
rental accommodation.
Multivariate Regression OR for mental health

Rental tenure
1.86(0.85, 4.04)
Neighbourhood friendliness
2.16(0.92,5.12)
Length of residence
1.05(1.01, 1.08)
Hate to be at home
1.99(0.95, 4.15)
(adjusted for age, gender, education, housework strain,
general social support, constantly under stress)
Multivariate Regression
Anxiety
Depression
Tenure
ns
ns
Neighbourhood
ns
ns
Area assessments p<.05
p<.05
Housing types
p<.05
p<.01
Housing stressors ns
p<.05
ns= not significant
No clear association between

housing and neighbourhood
environment and mental health.
Caution weak outcome measure
Housing type, poor perceived
neighbourhood and housing
stressors were associated with
poorer mental health
Caution it is unclear which type of
housing is associated with poorer
mental health.
54
Hiscock 2003 UK
Postal survey to householders

containing questions on housing
tenure, 5 items on physical condition
of housing these were damp, cold,
noise, and state of repair and overcrowding. Condition of
neighbourhood these were mugging,
nuisance dogs, litter, rubbish, smells,
fumes, speeding traffic, burglaries,
reputation of neighbourhood, problem
children, poor transport, poor paving,
discard needles and syringes; type of
dwelling flat, type of flat, house, type
of house, number of rooms in home,
and luxury goods; meaning of home
protection, autonomy and prestige.
Anxiety,
depression:
HADS
2,838 male and female, postal

survey, 50% response rate.
Analysis controlled for gender,
age, self-esteem, mastery,
income, living alone, living as a
couple or/and living with others.
Regression
Anxiety
Wald Sig
Depression
Wald Sig
.009
**
Household type
Dwelling conditions
.005 **
Neighbourly favours
.008
**
Area conditions
.006 **
Protection
.012 ***
Tenure^
.000
ns
.003
ns
Tenure^^
.000
ns
.014 ***
** p=<.01, *** p=<.001, ^ includes all variables ^
Includes damp, cold, noise, crowding, and state of
repair. ^^Includes litter, reputation, traffic, assaults and
burglaries. ^^^Coefficients and significance for tenure
before backward elimination (where not significant
taken out of the model) process. ^^^ Coefficients and
significance for tenure after backward elimination

Poor housing conditions and
protection were predictors of
psychological morbidity (although
personal characteristics (income,
self-esteem) showed a stronger
predictive relationship
Caution low response: it is also,
unclear how recoding tenure makes
a difference to the findings

Home features: tenure, and damp,
Anxiety and
Depression Anxiety
condensation, heating, noise, poor
depression:
Mean SD
Mean SD
Owner occupier
4.04 3.2 6.6 3.8
Association between tenure, living
state of repair, desirability of
HADS
Social renter
6.09 4.0* 8.0 4.4* in a flat, having no access to a
dwelling, crowding in home, access to
* p = <0.001
garden, housing problems, lack of
garden, housing fixtures (including
household and neighbourhood
telephone, smoke alarm, deep freezer,
amenities, and psychological
burglar alarm, double glazing),
morbidity.
Caution: low response and analysis
did not control for
dog problem, poor public transport,
area amenities.
MacIntyre 2003 UK
55
Table 5. Neighbourhood disorder and mental health

Citation
Adults
Christie-Mizell
2004 USA
Latkin 2003 USA
Citation
Adults
Ellaway 2001 UK

measured
Mental health
outcome and how
measured
Results
Perceived neighbourhood disorder:

series of 8 self-report items about the
community, including respect for
rules and regulations, crime and
violence, the presence of run-down
buildings, environment for raising
children, availability of employment
for residents, and community apathy
Psychological
distress: CES-D-7
N = 2204. Women with at least

one child. Age range 29-37 years,
mean age 33 yrs. 52% white, 32%
African American, 16% Mexican
American. Unclear response rate.
13-14 year follow-up.
Psychological distress regression neighbourhood

variables
Central city -.469(.276) p = ns, rural -.182(.210) p= ns,
perceived neighbourhood disorder .170(.024) p= <.001
(analysis controlled for marital status, number and age
of children, psychological distress in past, physical
limitations, tenure, education, employment, race)
ns = not significant
Neighbourhood perception scale:

vandalism, vacant housing, litter or
trash in streets, groups of teenagers,
selling drugs, robbery, and mugging
Depression: CESD
Regression beta estimates for CES-D score and

neighbourhood perceptions scale at time 2
0.28 p = <. 01.
(Analysis adjusted for gender, education, CES-D at
baseline, church attendance)
Perceptions of a poor
neighbourhood predicted
depressive symptoms 9 months
later.
818 adults, 85% unemployed, low

earners, 41% arrested in past
year, 7% married, around half
drug illicit users, mean age 39
years. Follow-up for 9 months

measured
Mental health
outcome and how
measured
Results
Neighbourhood problems Perceived

quality of neighbourhood: provision
of services and perceived safety
including vandalism, litter, rubbish,
assaults, mugging, disturbance from
children, adolescents, speeding traffic,
nuisance from dogs, reputation of
neighbourhood. Environmental
problems: smells, fumes, burglaries,
discarded needles, syringes, uneven or
dangerous pavements, lack of safe
places for children to play, lack of
recreational facilities. Neighbourhood
cohesion. Question on attraction of
neighbourhood, questions on
psychological sense of community
and on neighbouring (contact with
fellow residents).
Self reported
health: mental
health- GHQ
N= 597 (males 261, females 336).

4 socially contrasting
neighbourhoods in Glasgow. 3
age cohorts - 25 years, 45 years
and 65 years.
Mean neighbourhood problems scores by correlation

with GHQ score
All problems
Anti-social
Environment
0.202*
0.182*
0.200*
*Indicates significance at 1% level.
Mean perceived neighbourhood cohesion scores by
correlation with GHQ score
Overall score Attraction Neighbouring Psychological
to neighsense of
bourhood
community
-0.149**
-0.086
-0.156**
-0.137**
**Significant at 5% level.
Analysis adjusted for age, gender, social class,
Perceived neighbourhood disorder

was associated with psychological
distress.
Caution response rate unclear
Caution does not report response;

describes sample as a community
sample, but is a community HIV
outreach sample.

Poorer mental health was related to
perceived neighbourhood problems
in terms of safety, environment,
amenities and poorer
neighbourhood cohesion.
Caution response rates not
reported
56
Green 2002 UK
MacIntyre 2003 UK
Ross 2000 USA
Ziersch 2005,
Australia
Fear of crime: Items from British

Crime Survey questionnaire including
how safe do you feel in (1) your
home alone at night, (2) walking alone
at night, (3) walking alone in this area
after dark?
Mental health: SF36
Neighbourhood features including

and problem dogs.
Anxiety and
depression:
HADS
Neighbourhood disorder: RossMirowsky neighbourhood disorder

scale (measuring criminal and noncriminal activities including graffiti,
noise, vandalism, abandoned houses).
2000: Depression:
CES-D
Neighbourhood pollution and social

capital (latter defined as
neighbourhood connections,
neighbourhood trust, reciprocity,
neighbourhood safety, local civic
action), measured by questionnaire.
Mental health-SF12
407 elderly adults in 21 tower

blocks in housing trust estate.
58% response rate. Age range not
specified.

2001: 2,482 adults aged 18 to 92

years., 41% males, 85% white.
Median income slightly above
average. 73% response
2400 questionnaires from male
and female respondents
(identified through electoral
register). Response rate 64%.
.
Regression effects coefficients for poor mental health

Fear of going out after dark -11.01 p = 0.01.
Analysis adjusted for age, gender
Pearson correlation coefficient between age, housing

and neighbourhood perceptions
Anxiety
Depression
Area problems
0.272*
0.253*
2. P = <0.001
Analysis uncontrolled for sociodemographic factors.
Regression coefficients for depression
Perceived neighbourhood disorder.294 p= <.01
(Analysis adjusted for neighbourhood disadvantage,
gender, ethnicity, age, education, employment,
income, family structure, household crowding, urban
residence, heavy drinking, and deviance)
Quantitative: Path analysis of direct and indirect inner
model effects for mental health
Direct Total Indirect
Mental health R2 = 0.10
Rental accommodation
0.04 0.04
Neighbourhood pollution
0.08 0.08
Neighbourhood safety *
0.15 0.15
Neighbourhood connections* 0.15 0.17 0.17
Neighbourhood trust
0.06 0.06
(controlled for gender, age, education, income, years at
address)
*significant associations

Perceived fear of the
neighbourhood was associated with
poor mental health.
Caution lacks detail on study
population age range not
specified.
Area problems associated with
psychological morbidity.
Caution: low response and analysis
did not control for
Perceived neighbourhood disorder
was associated with depression
Stronger neighbourhood
connections and higher perceived
level of safety associated with
better mental health.
57
Older adults
Citation
Young 2004
Australia

measured
Sense of belonging: 13 items
including agreement with statements
such as having a lot in common with
people in my neighbourhood, trusting
neighbours, children are safe walking
around the neighbourhood during the
day.
Mental health
outcome and how
measured
Mental health: SF36
Results
Female 9445 aged 73-78.

Response 83%. Respondents
were more likely to be Australian
born, have higher education level
and better health and well being.
The sense of neighbourhood score (correlation 0.15, p

value = <0.001) and neighbourhood safety score
(correlation 0.11, p value = <0.001) were correlated
with mental health.
Adjustments made for marital status, living alone, and

ability to manage on income.
Perceived neighbourhood safety

and perceived neighbourhood
community were associated with
positive mental health
Caution: weak analysis

58
Table 6. Noise and mental health

Citation
Children
Haines 2001a. UK
Citation
Children
Haines 2001b. UK
Haines 2001c. UK

measured
Mental health
outcome and how
measured
Results
Aircraft noise: derived from contour

maps indicating the average
continuous equivalent sound level of
aircraft noise within an area for 16
hour daily periods at baseline and
after one year.
CDI: Child
Depression
Inventory.
Revised Child
Manifest Anxiety
Scale.
275 males and females, aged 811. 81% of baseline sample were
followed up.
Depression
Anxiety

measured
Mental health
outcome and how
measured
Results

hour daily periods.
CDI: Child
Depression
Inventory.
Revised Child
Manifest Anxiety
Scale. Strengths
and difficulties
questionnaire:
overall score and
sub-scales
hyperactivity,
emotional
problems, conduct
problems and peer
problems.
340 males and females, aged 8-11

years attending schools with high
or low aircraft noise exposure
(four high noise schools, four low
noise schools). 50% female, 34%
non-white, 77% response rate for
children: 84% for parents.
Mean mental health outcome scores for the four high

noise and four low noise schools adjusted for age,
main language spoken and deprivation.
High noise Low Noise
p value
Strengths and
difficulties
questionnaire:
overall score and
sub-scales
hyperactivity,
emotional,
conduct problems
and peer
problems.
451 males and females, aged 8-10

years attending schools with high
or low aircraft noise exposure at
school (10 high noise schools, 10
low noise schools). 49% female,
56% non-white, 39% deprived.
High noise group had more ethnic
and low socioeconomic position.
Response rate 82%.
Mean differences mental health outcome scores for the

10 high noise and 10 low noise schools adjusted for
age, deprivation and main language spoken
Difference score (95% CI) p value
SDQ total
-1.17(-2.32,-0.08)
0.04
SDQ hyperactivity -0.65(-1.06,0.25)
0.001
SDQ conduct
-0.19(-0.56,0.18)
0.30
SDQ peer probs -0.11(-0.49,0.27)
0.58
SDQ emotional
-0.13(-0.57,0.32)
0.58
(adjusted for age, deprivation and

main language spoken at home)
Difference score=low noise mean minus the high noise

mean.

hour daily periods.
Difference score (95% CI) p value

0.08(-1.27,1.42)
0.92
0.18(-2.05,2.38)
0.88
Difference score=low noise mean minus the high noise

mean.
Depression
5.24
Anxiety
12.6
SDQ total
8.77
SDQ hyperactivity 3.44
SDQ conduct
1.5
SDQ peer probs 1.89
4.53
11.9
8.3
3.38
1.27
1.68
0.17
0.32
0.45
0.76
0.24
0.23

Chronic aircraft noise exposure was
not associated with mental health
problems.

not associated with mental health
problems.

associated with increased overall
SDQ scores and hyperactivity
but not conduct problems, peer
problems or emotional problems.
59
Lercher 2002
Austria
Ristovska 2004
Macedonia
Stansfeld 2005
Netherlands, Spain,
UK
Ambient neighbourhood noise

(highway, rail, and road). Residential
exposure.
Mental health:
subscales of
KINDL measured
self-report of
symptoms of
depression and
anxiety and sleep
disturbance.
Two stage design (representative

n=1280) and extreme sample
(n=123) children aged 8-11.
Representative sample range of
residential noise exposures.
Extreme sample - <50dBa Ldn
and >60 dBA Ldn.
All children in a defined area
approached- a rural valley with
small towns; response rate 80%.
Urban community noise-average 8

hours (7am to 3pm) in schoolyards,
near schools and crossroads, which
were situated in the residential area of
the sample of children. Two groups
above and below 55 dBA.
Anxiety test
(General Anxiety
Scale)
266 schoolchildren, boys and

girls, of 10-11 years of age
Aircraft and road traffic noise

measured by various external noise
measurements and modelling.
Mental Health
measured by the
Strengths and
Difficulties
Questionnaire
(validated)
2844 children aged 9-10 from

various schools. Netherlands,
Spain, UK
Child response rate 89%, parent
80%.
Childrens psychological health, multiple regression

mean differences and (CI)
Population study:
Noise exposure 30-70 dB -2.77(-5.46, -0.08)
Extreme exposure study:
Noise exposure 30-70 dB -16.09(-28.37,-5.42)
(adjusted for maternal education, gender, number of
people in house, house type, low birth weight,
premature birth, and biological risk)
Children of low birth weight and preterm delivery
were at greater risk of noise related mental health
outcomes.
Multiple regression analysis of noise exposure and
psychological characteristics, regression coefficient
Children exposed to
LAeq, 8 h > 55 dBA
<55dBA
Attention
0.270*
0.286
Social adaptability 0.303*
0.312
Opposing behaviour 0.218*
0.278
Hyperactivity
0.192
0.050
Anxiety
0.141
0.204
* Analysis significant
Mental Health
Aircraft noise: B (SE) 0.013(0.013), p=0.3098.
Road traffic noise B(SE) 0.018(0.016) p=0.2747
Regression model adjusted for socioeconomic
position, age, sex, country, long-standing illness, main
language spoken at home, parental support for school
work, type of window glazing in school classroom.

Ambient noise levels in the
community were associated with
decreased mental health.
Furthermore, children with low
birth weight and preterm delivery
may be at greater risk of noise
related mental health outcomes.

No relationship found between
chronic noise exposure and anxiety
or hyperactivity but noise was
related to decreased social
adaptability and increased opposing
behaviour.
Caution response rate not reported
Level of evidence: 3b.
No association between chronic
road or aircraft noise exposure at
school and overall mental health.
60
Citation
Adults
Stansfeld 1996 UK
Citation
Adults
Hardoy 2005, Italy.

measured
Mental health
outcome and how
measured
Results
Road traffic noise: grouped into 5

decibel street traffic noise emission
level
Psychological
health: GHQ.
1725 men aged 50-64 years.

Follow-up 5 years. 89% response
rate at baseline, 72% at followup.

measured
Mental health
outcome and how
measured
Association between road traffic noise level and

psychiatric disorder, Mean (standard error)
dB Anxiety score p value Depression score p value
51/55 4.70(0.07)
1.19(0.05)
56/60 5.20(0.18)
1.39(0.13)
61/65 4.89(0.15)
1.32(0.11)
66/70 5.02(0.21) 0.03
1.21(0.16)
0.34
Adjusted for age, social class, noise sensitivity and
psychological morbidity at baseline
Results
Aircraft noise: living within one mile

of International airport runway
compared with residents from same
region who did not live within one
mile.
Eating disorder,
anxiety and
depression
measured by CIDI
Adults 71 male and female.

Response rate 64%.Gender
difference in refusal rate.
Exposure to high levels of environmental noise OR

(CI) (univariate)
General Anxiety Disorder 2.0(1.0,4.2)
Anxiety Disorder not otherwise specified 2.9(1.0,4.1)
Major Depressive Disorder 0.7(0.6,1.2)
Depressive Disorder not otherwise specified
1.9(0.8,6.0)
Eating Disorder 3.1(0.5,5.6)
Higher road traffic noise was

associated with higher anxiety
scores, but not with depression
scores.
Level of evidence: 3b-.

High levels of environmental noise
were associated with increased
anxiety but not depressive
disorders.
Caution small study and high
refusal rate therefore minus added
No adjustments for confounding factors, control group

matched for gender, age and employment status.
61
Meister 2000 USA
Nivison and
Endresen 1993,
Norway
Saito 1993 Japan
Chronic aircraft noise. Four

neighbourhoods exposed to
commercial aircraft noise ranked
according to severity of exposure by
frequency and decibels compared with
two non-exposed communities.
Residence in low rise flats exposed to

moderate to heavy traffic noise in an
urban area
Self report of perceived housing

environment including noise.
Mental health:
MOS-36
Validated health
scales: factor
analysed to derive
a scale of nervous
symptoms which
included
depression and
anxiety.
Psychological
health: GHQ
2088 male and female residents.

Response rate 52% - rate varied
by noise exposure.
47 women and 35 men (aged 1978 yrs). Response rate unclear.

Older adults (aged 60 plus) more
likely not to take part.
Mean scores for mental health, cities ranked by level

of exposure, comparison cities had minimal exposure
Minneapolis 72.37 (highest noise exposure)
Bloomington 70.80
Egan 72.89
St Paul 74.62 (lowest noise exposure)
Comparison 75.85.
Multivariate analysis Post hoc Tukey contrasts for
mental health by neighbourhood, adjusted for
covariates
t-value
p-value
Minneapolis 3.13872
.00172
Bloomington -2.79024
.00532
Egan
1.98939
.04680
St Paul
-1.48295
1.3821
Multivariate analysis adjusted for (covariates) marital
status, BMI, gender, age, income, education and
smoking status, occupational exposure to noise, length
of residency, type of shift work and hours at home per
week.
Objective Noise levels
No association between objective noise levels and
nervous symptoms (results not shown).
Subjective Noise levels
Noise annoyance was related to nervous symptoms for
women (partial correlation 0.30, p>=0.10)
Noise sensitivity was associated with nervous
symptoms (F=9.04, p=0.005).
Noise annoyance was associated with nervous
symptoms (F=4.19, p=0.049).

Response 54%
GHQ score by perceived housing environment

Annoyed by outdoor noise 5.5 (quiet 5.5) (ns),
complained about outdoor noise 6.4 (never 4.7 (<. 05),
annoyed by indoor noise 6.2 (quiet 5.1) (<. 05),
complained about indoor noise 6.6 (no 4.9) (ns).
Ns = not significant.
Adjusted for age, employment status. Floor level also
adjusted for in perceived housing environment factors.

Residents in areas exposed to
commercial aircraft noise had
significantly worse mental health
than controls who were not
exposed to noise.
Caution low response and response
differs by exposure

Objective noise levels were not a
significant factor in explaining
levels of nervous symptoms.
Subjective noise levels, noise
annoyance and sensitivity, were
associated with increased nervous
symptoms.
Caution: small sample size and

unclear response rate.
Perceived disturbance by noise was
related to greater mental morbidity.
62
Citation

measured
Stansfeld 2000
Noise in the urban environment:

community studies
Mental health
outcome and how
measured
Psychiatric
disorder and
psychological
symptoms
Results
Descriptive review of scope of

Community studies of noise exposure have found that
Level of evidence: unable to rate
evidence of community effect of
aircraft and road traffic noise exposure are associated
because of under reporting of the
noise, does not record search
with psychological symptoms and with the use of
review methods.
strategy or critically appraise
psychotropic medication but not with the onset of
studies
clinically defined disorders.
63
Table 7. Spatial/population density and mental health

7a: Spatial density in the home
Citation
Children
Evans 2001, USA
Maxwell 1996
USA
Citation
Adults
Sadowski 1999 UK

measured
Mental health
outcome and how
measured
Results
Residential density: the number of

people residing in the home by the
number of rooms.
Psychological
health: Rutter
Child Behaviour
Questionnaire
Urban low-income sample, one

child per household sampled from
(1) predominantly black and
Hispanic neighbourhood of New
York. Urban residential density of
5.35 persons per 5.52 rooms on
average. 40 children, mean age
9.8 yrs. (2) Rural New York
sample with residential density of
4.68 persons per 7.13 rooms) 113
children mean age 9.2 years.
Urban low income sample regression line of residential

density and psychological distress for children b= 4.49,
t (38) = 2.17, p <. 05. (No interaction between gender
and density).
Home and day care crowding (defined

as more than one person per room):
classroom density (feet per child).
Behavioural
disturbance:
Behar-Spingfield
Disturbance
Rating Scale
114 Head Start (USA parenting

programme) 4 year old urban
male and female children.
Children were from high and low
density homes and classrooms.
Response rates not reported
Rural sample (interaction found between gender and

density) regression line of residential density and
psychological distress for male children, b=13.88, t
(108) = 3.87, p <. 01, for girls b= -1.76, t (108) <1.0.
Analysis of variance: Behavioural disturbance score

Classroom density
Low
Medium
High
Low home density
10.90 7.35
12.67
High home density
13.55 5.31
20.17
Children from high density homes and in high density
day care centres have the highest behavioural
disturbance scores (p =0.001).
Adjustments in analysis for whether classroom was
part or full time.
High household density, among

urban low income children,
increased the risk of psychological
symptoms. This association was
found for urban children and for
rural male children but not rural
female children.
Caution: response rate not
reported
Children from crowded homes and
crowded classrooms were more
behaviourally disturbed.
Caution: small sample size,
response rate not reported and
study undertook little adjustment
for any confounding factors

measured
Mental health
outcome and how
measured
Results
Childhood household crowding (not

defined)
Major depression:
standard
psychiatric
interview
266 male and females (130 were

female). Information on crowding
collected when participants were
5 years old, mental health
outcome measured at 33 years of
age. (90% response)
Regression beta indicating relative contribution of

overcrowding during first five years of life to
depressive symtomology at 33 years of age
Females 0.05 (not significant), males 0.22 (p=<. 01).
(Analysis adjusted for poor mothering, poor physical
care, parental relationship instability, parental physical
illness, overcrowding, and social dependence.

Crowding in childhood was
associated with increased
depressive symptomatology in
adulthood for males, but not
females.
64
Saito 1993 Japan
Wahlbeck 2001.
Finland
Citation
Adults
Agerbo 2001
Denmark
Ruback 1994 USA
Self report of perceived housing

environment including household
crowding
Psychological
health: GHQ
Childhood household crowding and

number of siblings: from school
records, defined as number of people
in household divided by the number
of rooms.
measured
Household crowding grouped in 6
categories from 1-19m per dweller to
more than 60 m per dweller.
Spatial density: defined by dividing

self report of number of rooms in
home by the number of people.

Response rate 54%
GHQ score by house factor

Person to room density same or less than 0.5 = 5.3,
>1.0 = 6.4 (ns).
Adjusted for age, employment status. Floor level also
adjusted for in perceived housing environment factors.
Schizophrenia:
Hospital discharge
register
7086 male and female cohort

born 1924-33 followed up to
1971. 92% of cohort traced at
follow-up. 98 with schizophrenia.
OR Schizophrenia
Household crowding 2.49(0.87, 7.08)
Mental health
outcome and how
measured
Results
Schizophrenia:
hospital admission
registers
Matched nested case-control.

191 cases and 17413 individually
matched controls.
Reports accurate linkage of three
vital registers used.
Risk ratio for most overcrowded housing

0.95(0.50,1.7)
Adjusted for age, time period, place of birth, family
history, and gender
Psychological
well-being self
report of 8 items
(confused,
strained, lonely,
depressed,
nervous, restless,
worthless, no
interest in things)
116 female adults aged 18 to 86,

mean 43 years. 76% married,
43% housewives, mean years of
education 11. 82% white, 78%
owned home. Response rate 78%.
Spatial density and psychological distress

Correlation coefficient .15 (partial correlations
controlling for effects of perceived control = .02) neither were significant.

Household crowding was not
associated with greater mental
morbidity.
No association between childhood
crowding and schizophrenia in
adulthood.

No association between household
crowding and schizophrenia
Caution minimal description on
how data on crowding was
collected
No association between crowding
and psychological well being.
Caution small sample size and
65
Table 7b. Population density and mental health

Citation

measured
Mental health
outcome and how
measured
Results
Urbanicity: defined as the city of

Munich versus the surrounding areas
of Munich. The population density of
the surrounding areas was 553 persons
per square mile and that of the city
were 4061 persons per square mile.
70% lived in urban area.
Schizophrenia
CIDI.
Secondary
outcomes
depression and
mania
2,548 males and females aged 1424 followed up after 4-5 years.
441 subjects had a psychotic
experience. Follow-up response
84%.
Logistic regression OR of psychiatric morbidity

Psychosis 1.23(0.96,1.58).
Depressive symptoms 1.08(0.89,1.33)
Mania 1.24(0.97,1.58)
Analysis adjusted for gender, SES (social status and
financial status), drug use, family history of psychosis
or other psychiatric diagnosis.
Citation

measured
McGrath 2004,
Saha 2005.
Urbanicity (not defined).
Mental health
outcome and how
measured
Schizophrenia:
according to any
diagnostic criteria
Adolescent/adults
Spauwen 2004
Germany
Results
2004: 21 studies with incidence

rates for urban areas, and 42 with
mixed catchment areas. All
studies published between 1965
and 2001.
2005: 31 studies with prevalence
rates for urban areas, 24 studies
with rates for rural areas and 45
studies with mixed rural/urban
rates. All studies published
between 1965 and 2002.
2004: The distribution of rates of schizophrenia

derived from urban catchment areas was higher
compared with that based on mixed urban-rural
catchment areas (p=0.02 overall, p= 0.11 for males,
and p = 0.05 for females). (Because of lack of studies
on rural sector, significance tests examine differences
between rural and mixed urban-rural areas).
2005: Mean (standard deviation) of schizophrenia by
urbanicity
Urban 4.70(7.23), rural 4.31(7.21), mixed 6.42(6.40).
Mixed urban/rural estimates compared to other rates
f=1.23, p= 0.20. Urban versus rural estimate f=0.95,
p= 0.33.
No significant association between

urbanicity and psychosis,
depression or mania
Caution: possible over adjustment
for comorbidity
Level of evidence 3aResults are equivocal: first paper
found that rates of schizophrenia
were higher in urban areas, second
paper found no difference in rates
of schizophrenia between rural and
urban areas.
Authors suggest that the difference
between the review findings is that
the analysis in 2005 included more
rates from developing countries
than the 2004 analysis, which may
have confounded the rural-urban
gradient.
Caution: Does not describe how
studies defined urbanicity or
critically appraise studies
66
Citation
Adults
Allardyce 2001 UK
Caldwell 2004
Australia

measured
Mental health
outcome and how
measured
Results
Resident in rural area with a

population density of 60 people per
square mile or being resident in an
inner city area with a population
density of around 19,000 per square
mile
Service based
incident rate for
schizophrenia
Population of rural area around

147,000, population of urban area
120,000.
Does not report completeness of
case reporting
Standardised incidence ratio by comparing rural area

with the urban area
Total population* 1.63(1.35,1.98)
White only 1.12(0.86,1.43)
Level of evidence: 3b
Rural, remote and metropolitan areas:

classified by population density.
Grouped as metropolitan (Capital
cities, and urban central areas
>100,000 population), rural centre
(with urban centre populations of 10,
000 to 99.999), other rural/remote
(with urban centres <10,000).
Suicide: national
mortality data.
*adjusted for age, year, gender
Mental health
disorder measured
by the CIDI:
depression and
anxiety
Use of health
professionals for
mental health
problems.
Suicide data from 1997-2000;

does not report completeness of
data linkage.
Survey:
10641 males and females. 15%
of sample from rural centre, 18%
other rural/remote area, 67%
metropolitan area. Response rate
for survey on mental health 78%..
Suicide rates(95% CI) per 100,000 population, by sex,

age and area
Male
AgeMetropolitan Rural centre Other rural/remote
A 31.8(30.1,33.4) 40.4(35.5,45.4)* 51.7(46.1,57.3)*
B 30.4(29.0,31.7) 38.0(34.2,41.8)* 34.9(31.4,38.3)*
C 20.5(19.3,21.8) 29.5(24.8,32.1)* 28.3(25.0,31.6)*
D 22.1(20.6,23.5) 24.0(20.5,27.4) 27.7(24.2,31.1)*
Female
AgeMetropolitan Rural centre Other rural/remote
A 7.2(6.4,8.0) 8.0(5.8,10.2)
7.2(5.2,9.2)
B 7.9(7.2,8.6) 10.2(8.2,12.2)* 7.7(6.2,9.2)
C 6.8(6.1,7.5) 5.5(3.9,7.1)
6.4(4.9,7.9)
D 6.1(5.4,6.8) 4.8(3.4,6.2)
4.9(3.5,6.3)
Age A = 20-29 years, B= 30-44 years, C = 45-59
years, D = 60 plus years
* p=0.05
Proportion (%) of the population (weighted estimates
and 95% CIs) with various types of mental health
disorder
Metropolitan Rural centre Other rural/remote
Affective disorders
M 5.4(4.5,6.2) 6.9(4.9,9.0) 4.1(2.7,5.5)
F
9.3(8.4,10.3) 9.7(7.7,11.8) 8.4(6.7,10.1)
Anxiety disorder
M 7.2(6.2,8.1) 8.3(6.0,10.6) 5.4(3.8,7.1)
F 11.8(10.7,12.9) 14.2(11.8,19.7) 11.0(8.9,13.0)
Any mental health disorder
M 18.4(16.8,19.9) 18.9(15.6,22.1) 15.2(12.5,17.8)*
F 19.4(18.0,20.7) 21.2(18.3,24.1) 16.8(14.4,19.2)
* p=0.05
The incidence of schizophrenia in

the urban area was higher than that
in the rural area; the high incidence
of non Whites in the urban area
largely explains the rural/urban
difference.
Young men in rural and remote
areas have higher suicide rates than
their metropolitan counterparts.,
but did not have higher levels of
mental health disorders.
For women there were few
differences in rates of suicide and
mental health disorders between
rural, remote and metropolitan
areas.
67
Fraser 2005
Australia
Kennedy 1999 UK
Lehtinen 2003
Finland, Ireland,
Norway, UK
Levin 2005 UK
Rural restructuring: measured by net

population growth and decline
Population density: 1991 census with

annually adjusted data obtained from
ONS.
Urban = Large city and one medium

sized town. Rural = no centre of
population greater than 15,000
residents and at least 20% of
population employed within an
occupation directly related to
agriculture, forestry, or fishing.
Urban v rural. Defined by population

density and includes subcategories of
accessibility (defined by being within
30 minute drive time of a settlement
of 10,000 or more)
Anxiety and
depression:
Positive and
negative affect
scale (PANAS),
K10, SPHERE-12
(all referenced)
4 local government areas of

population growth and decline
(declining agricultural regions,
declining mining communities,
growing regional cities) across
rural Australia. Sample 1334.
Response rate by area ranged
from 31-55%.
Suicide: vital
statistics
Inner city: 32 London boroughs.

linkage.
Depression:
diagnostic
interview and BDI
Suicide: vital
statistics
12,705 females, aged 18- 64

years. Sample response rate
varied from 54% to 68% between
areas.
Whole of Scotland population

except Grampian area, approx
5,000,000.
Regression model of odd ratios for poor psychological

health in areas where there is a decline in population
PANAS
Positive affect
1.13(0.99,1.28)
Negative affect
1.12(0.98,1.28)
SPHERE
Psychological symptoms
1.20(1.07,1.35)
Somatic symptoms
1.25(1.12,1.40)
K10
1.15(1.02,1.29)
Regression controlled for gender, age, nationality,
household type and duration of residence
Population density versus suicide rate
Spearman r=0.76, CI 0.48, 0.90 n=32
Adjusted for age group
Depressive disorder in females OR (CI) living in urban

area by country
Finland
Ireland
1.13(0.45,2.82) 12.58(1.09,303.80)
Norway
UK
0.49(0.14,1.75) 6.02(1.57,23.15)
Analysis adjusted for separated/widowed, living alone,
unemployed, born abroad, practical help difficulty, no
confidence, life events, age.
RR of suicide, male
Accessible rural Remote town Remote rural
1^ 0.88(0.81,0.96)* 1.08(0.90,1.30) 1.18(1.01, 1.39)*
2^^ 0.99(0.92,1.06) 1.17(1.01,1.35)* 1.26(1.10,1.45)*
RR of suicide, female
Accessible rural Remote town Remote rural
1^ 0.82(0.75,0.90)* 1.04(0.86,1.27) 0.77(0.62,0.95)*
2^^ 0.90(0.821.00)* 1.13(0.92,1.39) 0.85(0.68,1.06)
^ Suicide = age + offset (exposed population), ^^ with
Carstairs index.(an indicator of area deprivation)
* p= <0.05

A declining rural population
increased the risk of poor mental
health.
Caution low response and differs
by area.

Suicide rates were highest in
boroughs with high population
densities and high deprivation.
Caution does not report
completeness of data linkage
In the UK and Ireland there was an
increased risk of depression in
urban women. The same
association was not found in
Finland or Norway.
Caution response rate varied
between sites; confidence for Irish
data is wide and probably
unreliable.
No clear association between level
of rural access and suicide,
although rurality had a greater
impact on male suicide
Caution does not report level of
completeness of data linkage.
68
Oliver 2003 USA
Otsu 2004 Japan
Parikh 1996 Canada
Peen 2004 The

Netherlands
Cities versus suburbs: characteristics

of metropolitan places including
population size, density, racial
composition, affluence, age and land
use.
Urbanisation: combined measure of

population density and economic
development.
Urban/rural: population density
Urbanisation by postal address

density.
Depression,: CESD and self report

of depression
Suicide
Mood disorders:
CIDI
All first
psychiatric
admission in 1991
Retrospective use of 1986 data

from Americans Changing Lives
Survey and the 1990 US census.
2,191 males and females.
Average age 53, 63% female,
over sampling of black ethnic
groups. No response rate
reported.
All 47 Japanese prefectures.

Median male population per
prefecture was 725,050 and
female 865,354
9953 male and female adults.

Urban and rural groups were
significantly different in
educational attainment, income,
marital status, employment and
age. 76% response rate
All psychiatric admissions in the

Netherlands in 1991. Male and
female. Completeness of linkage
not reported.
The effects of metropolitan place characteristics on the

emotional correlates of psychological well-being
Self-report Depression
CES-D
Place size
-.009(.011) -.032(.018)
Density
.015(.009) .028(.015)**
Median Hse income
.398(.138)** .698(.229)**
Median building age
.001(.002)
.002(.003)
% white
-.157(.087) -.248(.144)
% commuting
-.110(.085) -.241(.141)
(controlled for age, ethnicity, education, family
income, marital status, length of residence)
Male suicide mortality and urbanisation and economic
development, regression coefficient from regression
analysis by timepoint
1980 0.577 (p= <. 001), 1985 0.551 (p= <. 001), 1990
0.583 (p= <. 001).
Data for females not reported but states not significant.
12 month prevalence (weighted n with 95% CI) of

affective disorder by urban and rural strata
Urban
Rural
Any affective disorder 4.6(3.7,5.4) 3.6(2.6,4.4)
Depression
4.2(3.4,5.0) 3.2(2.3,4.0)
Dysthymia
0.9(0.5,1.3) 0.5(0.1,0.9)
Manic Episode
0.6(0.3,1.0) 0.4(0.1,0.7)
(No significant differences between prevalence for
urban and rural areas)
Logit models correlation between estimated and
observed risk of admission in rural group
Schizophrenia: -0.35*
Affective psychosis: -0.13*
Organic psychosis: -0.23*
Other psychosis: -0.14*
Neurotic and personality disorders: -0.18*
*P=<0.001.
Controlled for age, sex and marital status, number of
admissions.

Residents of denser places had a
higher rate of depression.
Caution: No response rate

reported. Minus added to level of
evidence as is retrospective.
There was a gradient in male
suicide mortality, with those living
in areas of higher population
density with economic
development, having a lower risk
of suicide. No association was
found between urbanisation and
suicide mortality for females.
Caution: some under reporting of
methods
Rural rates for depression, manic
episode and dysthymia were not
different from urban rates.
Caution groups significantly
different in sociodemographic
characteristics which were not
controlled for in the analyses.
People living in urbanised
municipalities had an increased risk
of psychiatric admission. However,
being unmarried was a greater risk
factor than urban residence.
Caution completeness of linkage
not reported
69
Propper 2005 UK
Urban: by census 1991 enumeration

districts nearest 500-800 persons in
the neighbourhood.
Mental health:
GHQ
8184 individuals in 4341

households; cross-sectionally and
longitudinally over 5 years .
Rohrer 2005. USA
Residence in rural, suburban or nonmetropolitan county of residence.

Urban defined as a central city county
containing 50,000 or more persons.
Suburban was defined as a
metropolitan county adjacent to an
urban county. All other counties were
defined as non-metropolitan.
Mental distressself-report by one

question via
telephone
interview
6,035 adults in Texas- random

selection. 59% of potential
sample completed survey.
Effect of urbanisation cross-sectionally

Regression coefficient 0.065 (ns)
Effect of urbanisation longitudinally
Regression coefficient 0.058 (ns)
Analyses controlled for gender, ethnicity, educational
attainment.
Logistic regression analysis: odds ratios of mental
distress
Suburban 1.37(1.06,1.77)
Non-metropolitan 0.86(0.62,1.18)
Urban 1.00.
Adjusted for age, ethnicity, gender, income, BMI,
education, marital status

Urbanisation was not statistically
associated with prevalence or
changes in mental ill health over a
5 year period.
Caution response rate not reported.
Rural population was not at greater
risk of mental distress than those in
urban areas: there was an increased
risk of mental distress for the
suburban population.
Caution: weak measure of mental
distress
Saunderson 1998
UK
Schelin 2000
Denmark.
Urban rural defined by population

density: density ascertained using
1991 census and districts were
grouped into quartiles
Population density: 3 regional groups

of (1) capital, (2) suburb of the capital
and provincial cities with more than
100,000 inhabitants and (3) rural
counties including towns with less
than 100,000 inhabitants
Suicide and
undetermined
deaths: vital
statistics for years
1989-1992.
Schizophrenia:
psychiatric central
register
Population of England and Wales.

No adjustments in analysis. Does
not state completeness of linkage
2441 Danish psychiatric patients.

Linkage of data not reported
(Cross-sectional study).
Standardised mortality ratios (CI) for suicides for

groups of districts inquartiles of increasing population
density
1 (sparse)
2
3
4 (dense)
Male
110(105,115) 99(95,103) 96(92,99) 99(96,102)*
Female
102(93,111) 94(87,101) 91(85,98) 109(103,114)
*Mantel test for trend p value <0.05
Rate ratios(RR) and 95% CI for schizophrenia
Age Maximum urbanised Medium urbanised
Males
0-19 3.99(2.97,5.38)
1.69(1.32,2.17)
20-29 2.16(1.79,2.60)
1.65(1.41,1.93)
30-39 3.69(2.72,5.01)
2.09(1.60,2.73)
40-49 3.61(1.97,6.60)
1.18(0.65,2.13)
50+ 1.87(0.92,3.82)
1.19(0.63,2.23)
Females
0-19 4.33(2.94,6.36)
1.09(0.73,1.62)
20-29 2.96(2.31,3.79)
1.33(1.04,1.71)
30-39 5.82(4.19,8.08)
1.55(1.11,2.18)
40-49 2.48(1.34,4.59)
1.11(0.66,1.86)
50+ 2.04(1.30,3.20)
1.17(0.75,1.81)
Reference group those least urbanised

Suicide was significantly higher in
more sparsely populated areas for
males, but not females.
Caution: analysis did not adjusted
for any confounders and does not
state completeness of data linkage.
Incidence of schizophrenia
increased in both sexes with
increasing urbanisation
Caution outcome was not adjusted
for any confounders, completeness
of data linkage not reported
70
Singh 2002 USA
Urban versus rural (Used US counties,

10 levels defined by population
density)
Suicide: national
mortality data
1970-1997.
Used data on all suicides recorded

in US between 1970-1997 by
county
data linkage.
Sturm 2004 USA
Turner Goins 1999

USA
Weich 2003 UK
Suburban sprawl: metropolitan sprawl

index (Ewing) 4 rating dimensions
reflecting residential density, land use
mix, degree of centring (development
in the regions core), street
accessibility.
Depression and
anxiety: CIDI
Population density within rural areas:

1- less than 500 residents, 2- 500 to
2,499 residents, 3- 2,500 to 4,999
residents and 5- 5,00 or more
residents.
Self rated mental

health and
depression using
Geriatric
Depression Scale.
UK electoral wards: population

density in quartiles (number of 25-64
years olds per square mile) and rural
and non-rural residential groups based
on the Office for National Statistics
1991 census classification (14
groups).
Common mental
disorder: GHQ
8686 Adults in 38 metropolitan

sites in USA. Two waves of a
survey (response rate 64%, 61%).
Use of second wave of survey is
restricted to new participants only
(therefore not follow-up data).
2,178 adults aged 60 yrs plus
(35% male, mean age 72 years.
representing a 2% sample of the
elderly population of the region.
8978 people aged 16-75 years,

74% response rate. Prevalence of
common mental disorder 25%
Relative risks of suicide in most rural group 19951997

Male
Female
15-24 yrs
1.76 (1.52, 2.04) 1.85(1.29, 2.64)
25-64 yrs
1.77(1.65,1.91) 1.22(1.03,1.45)
65 plus yrs
2.06(1.84,2.30) 1.04(0.75,1.44).
Adjusted for ethnic composition and divorce rate.
Also found that the rural-urban gradient increased
between 1970 and 1997 for men.
Regression analysis.
No results shown: states there was no statistically
significant association between the prevalence of
mental health disorders or the mental health inventory
scale and the suburban sprawl index after adjustments
for age, ethnicity, education, income, marital status,
family size employment and gender.
Regression coefficient for depressive symptoms
Dichotomised residence- less rural 0.45(t=-3.82) p
=<0.001.
Five levels of residence: towns = -0.57(t=-2.95)
p=<0.01.
Self rated mental health not significant.
Adjustments made for age, gender, ethnicity, marital
status, income, education and social support.
OR (95% CI) for associations between common
mental disorder
By rurality (R = rural, NR = non rural)
Employed
Unemployed
Inactive
R 1.00
3.29(1.83,5.91)* 1.00(0.79,1.47),
NR 1.01(0.84,1.22). 2.78(2.13,3.64), 1.33(1.06,1.66)*.
By population density quartiles (1st lowest)
Employed
unemployed
inactive
1st 1.00
2.42(1.57,3.74)* 1.22(0.94,1.57)
2nd 1.13(0.92,1.38) 3.43(2.27,5.18)* 1.29(0.99,1.68)
3rd 1.00(0.81,1.23) 3.08(2.11,4.48)* 1.38(1.06,1.80)*
Top 1.15(0.94,1.40) 2.86(1.96,4.17) 1.60(1.24,2.08)
Adjusted for age, gender, ethnicity, physical health
problems, over crowding, housing problems, low
income, car access, and social class. *p = <0.05.

Men in the most rural group had
almost twice the risk of suicide
compared with urban males. For
females, this association was only
observed for the youngest females
(15-24 years).
Caution completeness of data
linkage not reported.
No association between suburban
sprawl and mental health.

High population density was
associated with lower rates of
depressive symptoms, in an elderly
sample.
Caution unclear completeness of
data.
Associations between population
density and CMD were modest and
were only found in those who were
economically inactive. Variance in
the prevalence of CMD between
electoral wards was modest and
smaller than the variance between
individuals and neighbourhoods.
71
Walters 2004 UK
Population density using census data.

Four groups 1=lowest density quartile
(0-355 people/km), 2= intermediate
density (356-1069 people/km), 3
intermediate higher density (10702466 people/km), 4= highest density
(>2467 people/km).
Anxiety and
depression:
Geriatric
Depression Scale,
GHQ
13,349 males and females aged

over 75 years. Median age 80
(range 75 yrs to 102 yrs).
71% of eligible population took
part; non-responders were more
likely to be older and female
OR of poor mental health by neighbourhood

population density
Depression
Anxiety
Living in an area of higher
2nd lowest density 1.52(1.09,2.11) 1.28(0.88, 1.85)
residential density was associated
2nd Highest density 1.23(0.87,1.73)
1.03(0.69,1.55)
with depression and anxiety, in an
Highest density
1.61(1.20,2.17)
1.47(1.00,2.16) elderly sample.
Analysis controlled for age, gender, deprivation score,
living status, impaired cognition, current physical
symptoms, having difficulties in performing activities
of daily living, living alone and difficulty making ends
meet.
Wang 2004 Canada
Rural and urban areas: defined by
Major depression:
17, 244, males and females.
The prevalence of major depressive episodes in rural
population density and concentration
CIDI
Response rate not reported.
and urban areas
White
Non-immigrant
Residents in urban areas were more
Rural
Urban
Rural
Urban
likely to have a major depressive
3.8(0.58)
5.0(0.40)* 3.9(0.60)
5.0(0.41)**
disorder compared with residents in
*rural-urban comparison p<0.05, **rural-urban
rural areas.
comparison p=0.05
Analysis controlled for gender, age, marital status,
Caution response rate not reported.
income, immigrant status, employment, education, and
ethnic group.
72
Table 8 Urban birth and mental health

Citation
Adults
Agerbo 2001
Denmark
Eaton 2000
Denmark
Haukka 2001
Finland

measured
Mental health
outcome and how
measured
Results
Place of birth defined by 5 categories:

capital with more than 100,000
inhabitants, capital suburbs with more
than 100,000 inhabitants, provincial
city with more than 100,000
inhabitants, provincial town with
more than 10,000 inhabitants, and
rural areas (density level not defined)
Urban birth: Danish Medical Birth
Register.
Schizophrenia:
hospital admission
registers
Matched nested case-control.

191 cases and 17413 individually
matched controls.
Reports accurate linkage of the
three registers.
Risk ratio for place of birth

Capital 2.77(1.74,4.41), suburb of city 1.48(0.82,2.69),
provincial city 1.87(1.07,3.26), provincial town
1.52(0.93,2.50),rural area 1.00
Adjusted for age, time period, household crowding
family history of mental illness, and gender
Schizophrenia:
Danish
Psychiatric Case
Register
Born between 1973 and entered

psychiatric hospital before 1994.
data linkage.
OR regression birth place and psychosis

S
N
A
Rural 1.0
1.0
1.0
Town 1.89(1.11,3.24) 1.82(1.19,2.79) 0.85(0.47,1.56)
City 2.69(1.47,4.95) 1.53(0.87,2.70) 0.57(0.22,1.50)
Suburb 3.43(1.91,6.15) 3.56(2.26,5.59) 1.51(0.77,2.98)
Capital 4.34(2.45,7.69) 5.72(3.74,8.73) 1.08(0.48,2.42)
S= Schizophrenia, N- non-affective psychosis, A=
affective psychosis.
(Analysis adjusted for birth weight, gestational age,
mothers age, maternal pregnancy history, and year of
birth).
Urbanisation and schizophrenia. Poisson regression
model for incidence
Urbanisation - df 1, deviance =6, p=0.0113; interaction
between urbanisation and birth cohort - df 3, deviance
17, p=<0.0006)
Analysis adjusted for age, birth cohort, gender,
urbanisation and their significant interactions.
Urban birth from the population

register: defined as at least 95% of
inhabitants living in settlements where
the distance between neighbouring
houses was less than 200 metres and
the population exceeding 200.
Schizophrenia:
National hospital
discharge register
Four birth cohorts, born between

1950 and 1969 followed to 1991;
1950-54, 1955-59, 1960-64,
1965-69
Increasing gradient in risk for

schizophrenia with increased
population density of birth place.
Urban birth increased risk of

schizophrenia but not non-affective
or affective psychosis
Caution: Does not report
completeness of linkage.

Urban birth was a risk factor for
schizophrenia. For the oldest birth
cohort, the risk was higher among
the rural born, but for the other
cohorts, the risk was higher among
the urban born and the difference
between urban and rural born
increased in the youngest cohorts.
Caution: does not report
completeness of data linkage
73
Marcelis 1998 and

1999. The
Netherlands
1998: Urban birth defined by

population density.
1999: Urbanicity defined by birth
and/or adult residence in area with
highest population density.
Psychosis: from
the national
records for first
admissions.
1998: N= 42115, all live births

recorded between 1942-1978 in
all 646 Dutch municipalities,
followed up to early adulthood
(aged 32) between 1970-1992.
Completeness of linkage not
reported.
1999: 135,1637, adults born
between 1972-1978 followed
early adulthood (aged 23).
Pedersen 2001a and

2001b. Denmark
Van Os 2004
Denmark
2001a: Urban birth and urban

upbringing defined by population
density.
2001b. 276 municipalities of Denmark
defined by population density.
Urban birth: 5 categories capital,

capital suburb, large provincial town,
small provincial town, and rural.
2001a and 2001b:

Schizophrenia:
Danish
Psychiatric central
register
Schizophrenia
hospital admission
or outpatient
treatment using
central register
2001a. 1.89 million born in 1971

or later.
2001b. 2.66 million born between
1950 and 1993
1,020,063 males and females

born between 1950 and 1976;
followed up in 2001.
1998: Linear trend incidence rate ratio urban birth with

later schizophrenia
Schizophrenia 1.39 (1.36,1.42).
Affective psychosis 1.18(1.15,1.21)
Other psychosis 1.27(1.24,1.30)
1999: RR of level of urbanicity at time of birth and at
time of first admission on incidence of onset of
schizophrenia before age 24 per 1,000 live births
NbNR NbEr
EbNr
EbEr
1.00 0.79(0.46,1.36) 2.05(1.18,3.57) 1.67(0.44,1.95)
NbNR = non-urban birth, non-urban resident, NbEr =
non-urban birth, urban residence, EbNr= urban birth,
non-urban residence, EbEr= urban birth, urban
residence.
2001a: RR of schizophrenia according to log-linear
model for accumulated number of years lived in each
degree of urbanisation as a child (per 15 years)
Capital 2.75(2.31,3.28), capital suburb 1.69(1.43,1.99),
provincial city 1.71(1.41,2.06), provincial town
1.32(1.13,1.54), rural area 1.00.
(Analysis adjusted for age, and its interaction with
gender, calender year, mental illness in family and
residential relocation out of area).
2001b: RR of schizophrenia according to place of birth
Capital 2.02(1.77,2.30), capital suburb 1.54(1.31,1.81),
Provincial city 1.57(1.36,1.82), provincial town
1.26(1.11,1.42), rural area 1.00.
(Analysis adjusted for age and its interaction with
gender, calender year of diagnosis, mental illness in
family and season of birth).
Summary risk difference linear trend over 5 categories
of urbanisation
0.062% (95% CI 0.054, 0.071, p=<0.001).
There was an interaction between urbanicity and
family history of schizophrenia (2 = 6.47, df = 1, p=
<0.02).

1998:Urban birth was associated
with increased incidence of
schizophrenia
1999: Urban birth increased risk of
schizophrenia, regardless of area of
residence in adulthood. Urban
residence in adulthood did not
increase risk for those with urban
birth.
Caution: Neither paper made
adjustments for confounders
There was a gradient of risk for
schizophrenia with being born and
spending childhood in non-rural
areas.
Caution: does not report
completeness of linkage.
Positive gradient in the prevalence

of schizophrenia by level of
urbanicity of birth place:
Completeness of data linkage not
association increases with
reported.
increasing urbanicity of birth place.
74
Table 9. Urbanicity (not specifically or weakly defined) and mental health

Citation
Adults
Paykel 2003 UK
Citation
Adults
Verheij 1996
The Netherlands

measured
Mental health
outcome and how
measured
Results
Summary of evidence
Urban versus rural: judgement of

interviewer whether urban, rural or
semi-rural
Mental health:
CIS-R (score 12
or above)
9,777 male and female aged 1664. 92% white

6416 in urban area, 1003 in rural
area, 2323 in semi-rural area.
Response rate not reported.
OR logistic regression for psychiatric morbidity

Rural 1.00, semi-rural 1.14, urban 1.33. p=<0.05
(Analysis adjusted for age, gender, employment, life
event, social support, housing tenure, social class,
education, ethnicity, marital status)

measured
Mental health
outcome and how
measured
Results
Urbanicity- does not describe how

identified studies defined urbanicity
or ruralness
Mental health
variously
measured by
validated scales
Systematic search for literature

since 1985. Does not describe
type of study design or critically
appraise studies
Identified 9 studies. In 5 studies urbanicity was

associated with poor mental health, however other
factors such as socioeconomic factors and social
support were also related to increased prevalence of
poor mental health.
Urban residence was associated

with increased risk of poorer
mental health.
Caution: Subjective judgement on
urbanicity and does not state
response rate
Summary of evidence
Unable to apply a level of evidence

because of under reporting of the
study methods
Urbanicity was associated with
poor mental health along with
socioeconomic factors and social
support
Level of evidence not rated because of weakly defined predictor variables.
75
Table 10 Aspects of physical and built environment where a lack of research evidence was identified
Citation

measured
Morrison 2004, UK
Traffic calming scheme composed of

5 sets of speed cushions, 2 zebra
crossings and a parking bay in an
urban residential area.
Citation

measured
Eckert 2004
Australia
Accessibility and remoteness Index of

Australia . Defined as remoteness to
goods, services and opportunities for
social interaction. Locations are
converted to 12 groups ranging from
high accessibility to extreme
remoteness.
Matthies 2000
Germany
Having previously lived on polluted

soil mainly exposed to benzopyrene
(ground was former coking plant).
Moved away from site once
contamination was identified,
surveyed after 9 years.
Mental health
outcome and how
measured
Mental health: SF
36
Mental health
outcome and how
measured
Psychological
distress and
depression:
Kessler 10
Psychological
Distress Scale, the
SF-12 measure of
health status, selfreported mental
illness diagnosed
by a doctor in the
previous 12
months.
Self report of
stress related
physical
symptoms using
the Lazarus stress
model
Study design: before and after

study
Results
Random 750 households.

Response baseline 39%, followup 32%. 66% female at both
baseline and follow-up, sample
also older than target population.
Difference (95% CI) in SF36 mental health score

before and after traffic calming scheme (n=117)
Male 2.2(-5.2, 0.8). Female 0.8(-1.5,3.1)
Results
2545 participants, 64% response

rate. 1% Aboriginals. Residents
from the more accessible areas
tended to be more educated, less
likely to be married and more
likely to have a higher status
occupation
Age-sex standardised prevalence in % (95% CIs) of

mental health outcome measures and accessibility and
remoteness index of Australia category
Category Kessler
SF-12 depression Self report
1(high) 10.8(9.3,11.7) 13.7(11.5,15.8) 13.5(11.3,15.6)
2
8.5(6.2,10.8) 7.7(5.5,9.8)
10.7(8.2,13.3)
3
9.1(5.6,12.4) 10.8(7.2,14.5) 9.5(5.9,12.8)
4
11.1(8.8,13.3) 12.3(9.9,14.7) 9.6(7.4,11.7)
No association between traffic

calming scheme and subsequent
mental health.
The prevalence of psychological
distress, depression and self
reported mental illness did not vary
between cities and more remote
country areas.
Caution sample groups different in
socioeconomic characteristics and
analysis only controlled for age.
215 residents who lived on

contaminated ground compared
with a control group of 200
citizens living elsewhere in the
same city. Groups were
comparable in residential
structure. Regression analysis did
not included controls. Response
rates not reported
Regression analysis. Best predictors of stress

symptoms for contaminated ground group.
Multiple R R2 Beta T
Estimate of global danger .55 .30 .49 5.66 p<.001
Trust town council
.58
.34 -.25 2.80 p<.01
Analysis adjusted for age
Estimate of global danger defined as an estimation of
the danger before and during decontamination.

Stress symptoms were associated
with the perception of danger
associated with pollution.
Caution small sample, weak mental
health outcome and response rate
not reported
76
Miller 2005, USA
Omata 1995 Japan
Thomson 2003 UK
Urban hassles: published index of 32

items. These relating to environmental
conditions (smelly bus stops, empty
buildings), interpersonal
interactions/surveillance (pressured to
join gangs, being followed in stores
by sales people), safety concerns
(nervous about sirens or gunshots),
anticipatory victimisation (being
stopped and questioned by police,
asked to sell drugs).
Territory in domestic spaces:
questions asked on whether in your
house if there were any rooms that
you could arrange at your will or you
could express your personality well or
where you do not want others to enter
without permission.
Usage of rooms for private purposes.
Public swimming pool and leisure

provision
Mental health:
anxiety,
depression and
posttraumatic
stress disorder
measured by
Hopkins
Symptom
checklist and
Adolescent
Symptom
Inventory
Psychological
mal-adaption:
using 5 item scale
relating to feelings
of not wanting to
do anything,
feeling irritated,
vacant, trouble
sleeping, anxiety ,
headaches and
gastro-intestinal
symptoms,
Self report of
stress and mental
health
254 males and females, average

age 13.76 (SD 2.05) range 10-20
years. Majority African
Americans. Response rate not
reported
79 married women, mean age

46years. All lived in detached
houses and most had children.
Response rate 48%
One way analysis of variance. Mean mental health

scores by level of Hassles
Low
Moderate
High
A.7.07(1.82) 7.84(2.15) 9.82(3.61)*
D.12.51(2.79) 14.48(4.46) 18.40(6.25)*
P. 19.59(4.12) 22.30(5.98) 28.05(8.62)*
*p= <0.001.
A = anxiety, D = Depression, P= post-traumatic stress
disorder
Comparisons of the mean score for psychological

maladaptations:
subjects with controllable space 20.9,
subjects without controllable space = 24.7,
subjects with personalised space 21.4,
subjects without personalised space 21.9,
subjects with exclusive space 22.4,
subjects without exclusive space 21.2.
p value <.05
A higher level of urban hassles was

associated with poorer mental
health
Caution: does not report response
rate.
Having territorial space,

particularly controllable space was
associated with fewer
psychological maladaptions.
Having personalised or exclusive
spaces in the home was related to
psychological well-being
Caution low response rate, small
study and analysis did not adjust
for sociodemographic factors.
Level of evidence scales not
applicable as qualitative study.
Retrospective using 14 focus

Use of the swimming pool was directly linked to
groups of 81 individuals. Two
reports of relief of stress and isolation and improved
deprived areas (similar in
mental health.
socioeconomic characteristics)
A positive effect on mental health
compared with contrasting
of the availability and use of a local
experience of provision of public
public swimming pool.
swimming pool (opening and
closure).
77

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A systematic review on the effect of the built and

physical environment on mental health

Report prepared by Charlotte Clark, Bridget Candy and

APPENDIX 1. PREDICTORS: TERMS USED IN THE SEARCH STRATEGY DESCRIBING

FIGURES AND TABLES

Attention Deficit Hyperactivity Disorder

Expert group of advisers

Ben Cave Associates Ltd

* Members of the ELF HEL group

Searching for the evidence

1995, 1996, 1997 were incomplete collections.

Access to residential green or open spaces.

Grades of Recommendation scale (http://www.cebm.net/levels_of_evidence.asp#levels).

Table 1. Citation databases searched, years searched and number of citations

Number of citations identified

Figure 1: Project flow chart

Five citations unable to get full text.

Evidence for access to residential green or open spaces

3b= evidence from cross-sectional study.

Evidence for exposure to neighbourhood violence

Evidence for housing or neighbourhood quality and regeneration

Housing or neighbourhood regeneration

Evidence for housing tenure

3b= evidence from a cross-sectional study.

Evidence for neighbourhood disorder

Evidence for the chronic noise exposure domain

Evidence for spatial and population density

3b= evidence from a cross-sectional study

3b= evidence from a cross-sectional study

Evidence for urban birth

2b = evidence from a longitudinal cohort study

Limitations of the review

18. Ellaway A, Macintyre S, Kearns A. Perceptions of place and health in socially

crime, street violence, mugged, mugging, flooding, robbery, vandalism, assaults,

Predictor or innovation and how

Study design: cross-sectional

Level and direction of evidence

Naturalness. A scale of the residential

337 children living in small towns

Regression analysis (adjusted for SES (income-to

Level of evidence 3b-.

Study design: cross-sectional

Level and direction of evidence

Mental well being

564 households were invited to

Significant predictors of mental health (regression

Level of evidence 3b.

Predictor or innovation and how

Children with more nature near the

Having a view of nature improved

Kuo and Sullivan

Lewis and Booth

Apartments with trees and grassland

145 urban public housing female

Residential environment rated by

6456 adults. Response 54%.

Home features: including housing

2867 adults. 50% response rate.

Mean DSB scores

Level of evidence 3b.

Caution: low response, direct effect

Table 2. Exposure to street violence and mental health

Predictor or innovation and how