How urban and rural built environments influence the health attitudes and behaviors of people who use drugs

Research suggests that the built environment is associated with drug use. However, there is limited scholarship focusing on specific features of the built environment that influence drug use behaviors, experiences, and patterns and how risk factors for drug use are placed in distinctive urban and rural settings. Applying Neely and Samura's conceptual theory that describes space as contested, fluid and historical, interactional and relational, and defined by inequality and difference, we assessed data from semi-structured qualitative interviews conducted between 2019 and 2020 with consumers at syringe exchange programs (SEPs) in an urban location (New York City) and a rural location (southern Illinois). We aimed to contextualize how drug use manifests in each space. In total, 65 individuals, including 59 people who use drugs (PWUD) and six professionals who worked with PWUD, were interviewed. Findings illustrate that, in both the urban and rural setting, the built environment regulates the drug use milieu by mediating social reproduction, namely the degree of agency PWUD exert to acquire and use drugs where they desire. Processes of “stigma zoning,” defined as socio-spatial policing of boundaries of behavior deemed undesirable or deviant, impacted PWUD's socio-geographic mobility, social conditions, and resource access, and modulated PWUD's broader capacity and self-efficacy. Similar patterns of drug use, according to social and economic inequities chiefly related to housing instability, were further observed in both settings.     

Materialities in supported housing for people with mental health problems: a blurry picture of the tenants

Our daily lives and sense of self are partly formed by material surroundings that are often taken for granted. This materiality is also important for people with mental health problems living in supported housing with surroundings consisting of different healthcare services, neighbourhoods, buildings or furniture. In this study, we explored how understandings of tenants are expressed in the materialities of supported housing. We conducted ethnographic fieldwork in seven different supported accommodations in Norway and analysed the resultant field notes, interviews, photographs and documents using Situational Analysis. The analysis showed that supported housing materialities expressed a blurry picture comprising widening and narrowing understandings of tenants, both by others and by themselves. Widening understandings concerned how tenants were living their lives in their own ways in private rooms while maintaining a social life in common areas. Narrowing understandings pertained to understand the tenants based solely on their diagnosis and need for care and control in hospital-like buildings. The following discussion focusses on the ideas that underlie narrowing materialities and on the importance of striving for atmospheres that entail a sense of belonging.     

A home but how to connect with others? A qualitative meta‐synthesis of experiences of people with mental illness living in supported housing

Supported housing principles emphasise the importance of decent, stable and affordable housing, and the provision of individualised support to enable people experiencing mental illness to live in their preferred communities, and to recover. This study sought to synthesise qualitative research addressing the question: how does living in supported housing facilitate social connections and participation from the viewpoints of people living with mental illness? Three databases (CINAHL, PsycINFO, Medline) were systematically searched to identify 19 peer‐reviewed reports on 17 studies published during 2001–2016, in which the views and experiences of supported housing residents with mental illness were reported. Most studies were informed by grounded theory and used interview methods. Appraisal indicated the reports were of varying quality, but all met the inclusion criterion of reporting qualitative data relevant to the research question. Constant comparative methods were used to synthesise the reported data, and to identify themes across the studies. There were four overarching themes regarding the lived experience of supported housing for people with mental illness: (a) living in supported housing gave individuals privacy, a sense of control, stability and security; (b) stable housing supported residents’ confidence to rebuild an identity and meaning in life, (c) there is a delicate balance between appreciating privacy and dealing with loneliness, and (d) opportunities and support to reconnect with families, friends and community are valued. The meta‐synthesis findings highlight that supported housing residents face challenges of protecting their privacy and being lonely when on their own. Individualised support approaches need to attend to personal preferences for social participation and their varied meanings and significance. Further research is required to better understand how individualised forms of support can enable supported housing residents to connect with family, friends and community in their preferred ways.     

Home making and community building: Notes on empowerment and place

The authors warn that some supportive housing development is creating a new generation of quasi-institutional settings, and they believe that developing units of housing is not as important as enabling each person to create a personalized home. A variety of processes for cocreating environments and social settings are proposed that will result in empowerment-oriented supportive housing programs. Such efforts require new staff roles and innovative techniques. Anticipated outcomes include improved self-identity and self-esteem, increased social status and a sense of security, increased residential stability due to improved person/environment fit, and improved personal competence among residents.     

Taking STOX: developing a cross disciplinary methodology for systematic reviews of research on the built environment and the health of the public.

STUDY OBJECTIVE: To develop a cross disciplinary literature search methodology for conducting systematic reviews of all types of research investigating aspects of the built environment and the health of the public. DESIGN: The method was developed following a comprehensive search of literature in the area of housing and injuries, using 30 databases covering many disciplines including medicine, social science, architecture, science, engineering, environment, planning and psychology. The results of the database searches, including the type (or evidence) of research papers identified, were analysed to identify the most productive databases and improve the efficiency of the strategy. The revised strategy for literature searching was then applied to the area of neighbourhoods and mental health, and an analysis of the evidence type of references was carried out. In recognition of the large number and variety of observational studies, an expanded evidence type classification was developed for this purpose. MAIN RESULTS: From an analysis of 722 citations obtained by a housing and injuries search, an overlap of only 9% was found between medical and social science databases and only 1% between medical and built environment databases. A preliminary evidence type classification of those citations that could be assessed (from information in the abstracts and titles) suggested that the majority of intervention studies on housing and injuries are likely to be found in the medical and social science databases. A number of relevant observational studies (10% of all research studies) would have been missed, however, by excluding built environment and grey literature databases. In an area lacking in interventional research (housing/neighbourhoods and mental health) as many as 25% of all research studies would have been missed by ignoring the built environment and grey literature. CONCLUSIONS: When planning a systematic review of all types of evidence in a topic relating to the built environment and the health of the public, a range of bibliographical databases from various disciplines should be considered.     

Community Priorities for Healthy Eating in Older Adults

Community planners such as policymakers and health care and nutrition service providers can create an “age-friendly” environment to support healthy eating in older residents by addressing the highest priorities that enable older adults to improve their dietary intake through different food-related community settings. To identify and prioritize these factors that facilitate behavioral change (enablers) and behavioral settings important for older adult nutrition based on the social ecological model, nutrition and aging professionals (n?=?30) from two rural (West Virginia, Iowa) and two urban (Massachusetts, New York) city/county regions (communities) participated in an online or live focus group discussion and completed an analytic hierarchy process survey online. Overall, the most important perceived enablers were accessibility and cost, followed by transportation and social support, but their relative importance varied by community. Participants from all communities considered congregate meal sites and food banks among the most important behavioral settings. Participants from most communities considered food stores to be important and also highlighted other settings unique to the area, such as senior housing, neighborhood, and farmers’ markets. By targeting interventions to address the most notable enablers and behavioral settings specific to their community, planning groups can enhance their older residents’ ability to achieve optimal nutritional health.     

(Em)placing recovery: Sites of health and wellness for individuals with serious mental illness in supported housing

This study used photo-elicitation methodology to explore how the move from supervised to supported housing affects recovery and community connections for individuals living with serious mental illness (SMI) in four Canadian cities. Qualitative interviews conducted in 2015 revealed five themes: (1) the characteristics distinguishing home from housing; (2) the importance of amenities offered by supported housing; (3) the connections between accessibility, mobility, and wellbeing; (4) the role of certain places in facilitating aspects of recovery such as offering hope or facilitating social connectedness; and (5) the concrete and metaphorical impact of changing vantage points on identity (re)construction. Utilizing therapeutic landscapes as an analytical framework, and combining insights from the health geography, and mental health (MH) housing and recovery literatures, this study deepens current understanding of how everyday places—conceptualized as therapeutic landscapes—directly and indirectly support MH recovery for individuals with SMI. Implications for research on housing, and on the spatial aspects of recovery processes are discussed.     

Supported housing for adults with psychiatric disabilities: How tenants confront the problem of loneliness

The objective of this study was to examine the experience of loneliness among people with psychiatric disabilities after moving from custodial housing, including group homes, boarding homes, and family‐type residences to independent, supported apartments in the community. Qualitative research methods guided by a naturalistic/constructivist framework were used. Data collection occurred between May 2014 and July 2015 and consisted of individual semi‐structured interviews with 24 tenants residing in five supported housing sites across three Canadian provinces; interviews were also conducted with a designated family member for each tenant and with their service providers. Group interviews were conducted with housing workers in the five housing sites. The interviews were transcribed verbatim, codes generated and a thematic analysis undertaken using a constructivist approach. Results showed that for most tenants living in independent apartments with support loneliness was not a serious problem or was an issue that could be overcome. Most study participants viewed supported housing as preferable to custodial housing and as a normalising experience that facilitated community integration. While housing conditions, particularly those associated with congregate housing, sometimes helped attenuate loneliness among tenants, managing loneliness was primarily contingent on the ability of individuals to develop and maintain social connections, as well as on family involvement.     

User involvement in the development of a health promotion technology for older people: findings from the SWISH project

Successive English government policies about older people’s health and well‐being aim to improve health and quality of life by promoting independence. Improving access to information and services that can improve health and well‐being and reduce health risks is central to the modernisation of health and social care. Most recently, tailored and person‐centred approaches with a strong emphasis on promoting health and well‐being are central to policy, including the proposals for ‘Life Checks’ and the recent emphasis on commissioning ‘community well‐being’. We carried out a qualitative study to identify the key aspects of social situations that affect health and well‐being, from the perspectives of older people and professionals, to enrich and expand an existing health risk appraisal tool so that it could be used for self‐assessment of health and social well‐being. This tool, Health Risk Appraisal in Older people (HRAO), has been evaluated in different European settings, including English general practice. Focus groups were recruited from general practice, older people’s forums, social care and voluntary organisations in two London boroughs where the HRAO tool had previously been tested. The social factors determining health that were prioritised by older people and service providers and recommended for inclusion in the health risk appraisal tool were recent life events, housing and garden maintenance, transport, both public and private, financial management, carer status & needs, the local environment and social networks and social isolation. This study has identified key social determinants of health that could usefully be added to ‘Life Checks’ for older people and that could also inform the commissioning of community well‐being. Modified with the addition of social domains, the HRAO technology could be a suitable tool to achieve current policy objectives.     

Public Health, the APHA, and Urban Renewal

Joint efforts by fields of public health in the last decade have advocated use of the built environment to protect health. Past involvement by public health advocates in urban policy, however, has had mixed results. Although public health has significantly contributed to health improvements, its participation in urban renewal activities was problematic. Health advocates and the American Public Health Association produced guidelines that were widely used to declare inner-city areas blighted and provided a scientific justification for demolishing neighborhoods and displacing mostly poor and minority people. Furthermore, health departments failed to uphold their legal responsibility to ensure that relocated families received safe, affordable housing alternatives. These failures have important implications for future health-related work on the built environment and other core public health activities.THE PAST DECADE HAS SEEN a reemergence of efforts to connect public health and urban planning. Focusing on the health effects of the built environment, new research has shed light on the association between urban sprawl and obesity, the association between the physical form of neighborhoods and the physical activity levels of its inhabitants, and the role of housing in asthma. On the basis of this research, new programs are being developed, new building and design standards have been proposed, and there is new willingness to manipulate the built environment to promote and protect health. During this process, it will be important to remember the lessons of 20th-century program failures as public health seeks to intervene again in the built environment in this new century.     

Service delivery and community: social capital, service systems integration, and outcomes among homeless persons with severe mental illness

OBJECTIVES: This study evaluated the influence of features of community social environment and service system integration on service use, housing, and clinical outcomes among homeless people with serious mental illness. STUDY SETTING: A one-year observational outcome study was conducted of homeless people with serious mental illness at 18 sites. DATA SOURCES: Measures of community social environment (e.g., social capital) were based on local surveys and voting records. Housing affordability was assessed with housing survey data. Service system integration was assessed through interviews with key informants at each site to document interorganizational transactions. Standardized clinical measures were used to assess clinical and housing outcomes in face-to-face interviews. RESEARCH DESIGN: Structural equation modeling was used to determine the relationship between (1) characteristics of the social environment (social capital, housing affordability); (2) the level of integration of the service system for persons who are homeless in each community; (3) access to and use of services by individual clients; and (4) successful exit from homelessness or clinical improvement. PRINCIPAL FINDINGS: Social capital was associated with greater service systems integration, which was associated in turn with greater access to assistance from a public housing agency and to a greater probability of exiting from homelessness at 12 months. Housing affordability also predicted exit from homelessness. Neither environmental factors nor systems integration predicted outcomes for psychiatric problems, substance abuse, employment, physical health, or income support. CONCLUSION: Community social capital and service system integration are related through a series of direct and indirect pathways with better housing outcomes but not with superior clinical outcomes for homeless people with mental illness. Implications for designing improved service systems are discussed.     

Perceived occupational balance and well-being among people with mental illness living in two types of supported housing

Abstract

Background: People with psychiatric disabilities often struggle with maintaining a satisfying occupational balance. Knowledge about factors of relevance for occupational balance in this group is therefore vital for improving their support.

Aim: The aim was to describe perceptions of occupational balance among people with psychiatric disabilities living in supported housing (SH) or in own flat/house with housing support (OHS). Potential importance of housing context and socio-demographic, well-being and recovery factors for occupational balance was also explored.

Methods: Participants from SH (N?=?155) and OHS (N?=?111) responded to questionnaires about sociodemographic situation, well-being (self-rated health, life satisfaction and self-mastery), personal recovery and occupational balance (work, leisure, home chores, self-care and general balance assessed by SDO-OB).

Results: A majority in both groups reported being in balance regarding all five domains of occupational balance. The OHS group reported being more under-occupied for home chores and self-care. Self-mastery was the most important contributor in both groups in the domains of work, domestic chores and self-care. Day center attendance was vital for general occupational balance.

Conclusion: Both groups generally perceived occupational balance. Control over one’s life situation and possibilities for regularly participating in occupations outside the home environment should receive high priority in housing support.     

Young males' gendered sexuality in the era of HIV and AIDS in Limpopo Province, South Africa

This article is focused on young males' sexual identity and behaviors in rural South Africa. The study comprised 19 focus group discussions with adolescents aged 12 to 14 years. The informants depict male sexuality as biologically predetermined, where physical needs and practices such as circumcision legitimize early sexual debut. Furthermore, the construction of male sexual identity and power imbalances in relationships are already evident at an early age, and age and economics are pertinent factors affecting social relations. Violent behavior and sexual abuse are supported by constructed gender inequalities forming an often negative and nonsupportive environment for young people. We stress the importance of planned HIV and sexuality education for young adolescents with support structures that can help endorse individual actions and informed choices. This is especially important in resource-poor settings where young people are likely to be less empowered than is the case in more affluent settings.     

Health and housing conditions in public sector housing estates

This article reports some of the findings of a study of health and housing conditions ina sample of households from eight different types of council housing areas in Gateshead.Controlling for age, there were found to be marked and consistent differences in self-reported health between individuals from different areas. For all age groups up to 65 years old, those living in “bad” housing areas reported poorer health, more long-standing illness, more recent illness and more symptoms of respiratory disease and depression. The clearest associations between poor health and bad housing emerged for the generally fittest age-groups (the under 25 years). For the people over 65 years the position was reversed, with those in “good” housing areas reporting poorer health, with the exception of recent illness. This is argued to be the result of local authority lettings policy, which gives priority to re-housing the less-fit elderly.Those in “bad” housing areas were also more likely to report housing defects which affected their health and to feel that their health could be improved by a change in their housing.The study found that “bad” council housing areas did not necessarily conform to thestereotype of non-traditional construction, or high-rise flats. Some consisted of traditionally built houses, while there was a sizeable representation among the “good” housing of system-built high-rise flats. The “bad” housing areas were marked off more by their location, their poor environment and the low quality of their construction.     

Engagement and social interaction in dementia care settings. A call for occupational and social justice

As full citizens, people with dementia are entitled to engage in social and occupational activities in residential care settings. Limitation or deprivation of choice and experience of valued occupations has been described elsewhere as occupational injustice. This research frames the unmet needs of people with dementia for occupation and social interaction, as issues of human rights and citizenship. It identifies a gap in current measurement tools of engagement in residential settings and in response, presents the Assessment Tool for Occupational and Social Engagement (ATOSE) as an objective measure of engagement. It examines results from a study of five residential care settings in Ireland using the ATOSE which included 73 residents with dementia and/or enduring mental health diagnoses. Residents spent on average, 38% of their time engaged and 62% of their time not engaged while in their communal sitting rooms. The ATOSE observations supported the rights of residents as citizens to have low levels of engagement addressed. A critical gerontology lens is employed to discuss concepts of citizenship, occupational justice, and social justice in the context of this research project.     

Social Integration of People with Serious Mental Illness: Network Transactions and Satisfaction

Social integration involves a process through which an individual establishes and maintains meaningful interpersonal relationships characterized by mutual exchange with community members in nonclinical settings. Using self-report data from a probability sample (n = 252) of supportive independent housing residents, transactional (i.e., support exchanges) characteristics of social networks, paying particular attention to reciprocation of exchanges between residents and their network members, were analyzed. The study also examined the extent to which transactional characteristics are related to satisfaction with social relations. Findings indicated considerable reciprocity in social relationships. Controlling for sociodemographic variables and network structure characteristics, mutual exchanges of tangible and problem-solving support were positively associated with network satisfaction. Results suggest that supported socialization services aimed at network and resource development with this population could facilitate more frequent exchanges of tangible resources and problem-solving opportunities between consumers and network members, which, in turn, might promote social integration.     

The impact of built environment on mental health: A COVID-19 lockdown perspective

Tackling mental health has become a priority for governments around the world because it influences not only individuals but also the whole society. As people spend a majority of their time (i.e., around 90%) in buildings, it is pivotal to understand the relationship between built environment and mental health, particularly during COVID-19 when people have experienced recurrent local and national lockdowns. Despite the demonstration by previous research that the design of the built environment can affect mental health, it is not clear if the same influence pattern remains when a ‘black swan’ event (e.g., COVID-19) occurs. To this end, we performed logistic regression and hierarchical regression analyses to examine the relationship between built environment and mental health utilising a data sample from the United Kingdom (UK) residents during the COVID-19 lockdown while considering their social demographics. Our results show that compared with depression and anxiety, people were more likely to feel stressed during the lockdown period. Furthermore, general house type, home workspace, and neighbourhood environment and amenity were identified to have significantly contributed to their mental health status. With the ensuing implications, this study represents one of the first to inform policymakers and built environment design professionals of how built environment should be designed to accommodate features that could mitigate mental health problems in any future crisis. As such, it contributes to the body of knowledge of built environment planning by considering mental health during the COVID-19 lockdown.     

The built environment and mental health

The built environment has direct and indirect effects on mental health. Highrise housing is inimical to the psychological well-being of women with young children. Poor-quality housing appears to increase psychological distress, but methodological issues make it difficult, to draw clear conclusions. Mental health of psychiatric patients has been linked to design elements that affect their ability to regulate social interaction (e.g., furniture configuration, privacy). Alzheimer’s patients adjust better to small-scale, homier facilities that also have lower levels of stimulation. They are also better adjusted in buildings that accommodate physical wandering. Residential crowding, (number of people per room) and loud exterior noise sources (e.g., airports) elevate psychological distress but do not produce serious mental illness. Malodorous air pollutants heighten negative affect, and some toxins (e.g., lead, solvents) cause behavioral disturbances (e.g., self-regulatory ability, aggression). Insufficient daylight is reliably associated with increased depressive symptoms. Indirectly, the physical environment may influence mental health by altering psychosocial processes with known mental health sequelae. Personal control, socially supportive relationships, and restoration from stress and fatigue are all affected by properties of the built environment. More prospective, longitudinal studies and, where feasible, randomized experiments are needed to examine the potential role of the physical environment in mental health. Even more challenging is the task of developing underlying models of how the built environment can affect mental health. It is also likely that some individuals may be more vulnerable to mental health impacts of the built environment. Because exposure to poor environmental, conditions is not randomly distributed and tends to concentrate among the poor and ethnic minorities, we also need to focus more attention on the health implications of multiple environmental risk exposure.     

Damp housing and adult health: results from a lifestyle study in Worcester, England.

STUDY OBJECTIVE--To explore the relationship between damp housing and adult health using two separate measures of ill health and taking into account the confounding effects of health related lifestyles and social factors. DESIGN AND SETTING--Analysis of responses gathered in a cross sectional, postal questionnaire survey of a randomly selected sample of 5347 residents of Worcester. PARTICIPANTS--Altogether 2353 people aged 16 to 64 years responded to the survey (adjusted response 52%). RESULTS--Nine per cent of respondents lived in housing which they reported to be damp. Rates were highest among young women. People who lived in damp housing were more likely to report long standing illness, disability, or infirmity; the increased prevalence could not be attributed to any particular medical condition. Perceived ill health, as measured by the sleep, energy, and social isolation dimensions of the Nottingham Health Profile, was also more common in this group. These associations could not be explained by lifestyle factors; the relationship proved strongest among people in non-manual social classes living in owner occupied housing. The prevalence of ill health increased as the severity of dampness increased. CONCLUSION--Self reported damp housing and ill health in adults were strongly associated, most noticeably among people in non-manual social classes living in owner occupied housing. The association met many of the epidemiological criteria necessary for suggesting causality: alternative explanations are discussed.     

Housing change of chronic schizophrenic patients: a consequence of the revolving door

A study of 119 chronic schizophrenics discharged to the community revealed that by 1 year post release, 50% have changed their living arrangement at least once. Housing changes, which typically involved movement from one non-institutional living situation to another, followed rehospitalization episodes and appear to be a consequence of the revolving door phenomenon. By virtue of its impact on rehospitalization, interpersonal stress in the patient's living environment has an indirect effect on housing change. The remarkable frequency with which housing changes occur among the mentally ill in both sheltered care and non-institutional living settings deserves consideration in the planning of mental health and social welfare service for this constituency.