Urban renewal and health: The effects of the Neighbourhoods Law on health and health inequalities in Barcelona

Roshanak Mehdipanah
Supervisors:
Dr. Carme Borrell & Dr. Carles Muntaner
Universitat Pompeu Fabra & Agència de Salut Pública
URBAN RENEWAL & HEALTH:
The effects of the Neighbourhoods Law on
health and health inequalities in Barcelona

INTRODUCTION
JUSTIFICATION
OBJECTIVES
STUDY 1
STUDY 2
STUDY 3
DISCUSSION
CONCLUSION
RECOMMENDATIONS
DISSEMINATION

 Over 50% of the world’s population lives in urban areas.1
 Focus is back on cities and in specific the physical and social
makeup of their neighbourhoods and communities.
 For a neighbourhood to achieve health & health equity:
 Must provide access to basic goods,
 Encourage social integration,
 Promote good physical and psychological wellbeing,
 Be protective of the natural environment.
URBAN HEALTH & HEALTH EQUITY
1UN-HABITAT (2010) State of the world’s cities 2010/ 2011-cities for all: bridging the urban divide. United Nations Human Settlements Programme 4–17.

URBAN HEALTH
PHYSICAL
ENVIRONMENT

URBAN HEALTH &
PHYSICAL ENVIRONMENT

URBAN HEALTH
SOCIAL
ENVIRONMENT

URBAN HEALTH &
SOCIAL ENVIRONMENT

 Urban planning and health concerns date back
to the 19th century where overcrowding and
unsanitary conditions began as a result of
growing industrial cities.1
 Urban renewal’s (regeneration) goal is to
improve physical infrastructure, promote
social integration and increase economic gain
within an area intervened.2
 Urban renewal has evolved to also address
some of the social problems and promote
sustainability.3
URBAN PLANNING & RENEWAL
1 Barton H. (2005) “Introduction to the concept of healthy urban planning”. Found in Built Environment: Theme issues – Planning healthy towns & cities. WHO
Collaborating Centre for Healthy Cities and Urban Policy 30(4).
2 Spaans M. (2004) The implementation of urban regeneration projects in Europe: Global ambitions, local matters. J Urban Design, 9(3):335-349
3 Arbaci S. & Tapada T. (2013) Social inequality and urban regeneration in Barcelona city centre: reconsidering success. Eur Urban Reg Stud,19(3): 287-311.

 Specific projects have highlighted the link between
urban renewal projects, health and health inequalities:
 Increased accessibility to services and resources (healthy
food outlets) through transportation improvements.1
 The creation of green spaces leading to an increase in
physical activity.2
 Housing renewal resulting in a decrease of asthma among
children.3
URBAN RENEWAL, HEALTH &
HEALTH INEQUALITY
1 RydinY.et al. (2012) Shaping cities for health: complexity and the planning of urban environments in the 21st century. Lancet/UCL, London.
2 Mitchell R. & Popham F. (2008) Effects of exposure to natural environment on health inequalities: an observational population study. Lancet, 372: 1655-1660.
3 Howden-Chapman P (2008) Effects of improved home heating on asthma in community dwelling children : randomised controlled trial. BMJ;337

URBAN RENEWAL &
HEALTH FRAMEWORK
URBAN RENEWAL
PROGRAM
PHYSICAL
INFRASTRUCTURE
SOCIAL INTEGRATION
ECONOMIC GROWTH
LIVEABILITY
SOCIO-ECONOMIC
MAKEUP
POPULATION
TURNOVER
HEALTH
&
HEALTH
INEQUALITY
A conceptual framework of the link between urban renewal and health/health inequalities.
POLITICAL CONTEXT

 Urban renewal policies are complex because:
 Context in which the intervention is carried out in,
 Actual projects undertaken,
 Implementation of the policy,
 Variability in the outcomes.
 This complexity results in difficulties to do evaluations because:
 Limited availability and reliability of data related to intervention for
health and socioeconomic indicators,
 Heavy reliance on quantitative analysis,
 Dominated by method driven as opposed to theory driven.
 The inability to establish clear causal pathways makes the
applicability to other situations more difficult.
EVALUATION OF URBAN RENEWAL, HEALTH &
HEALTH INEQUALITIES

THE NEIGHBOURHOODS LAW
LLEI DE BARRIS
Goal: to improve neighbourhoods in Catalonia, Spain while addressing
social issues, especially in deprived areas.
 The initiative consists of partial funding
from the regional government to selected
municipals with urban renewal proposals.
 143 neighbourhoods across Catalonia
have participated in the initiative.
 Approximately 1.3billion euros invested.
City of Barcelona:
 15 of 73 neighbourhoods have participated.
 10% of Barcelona’s population (1.6million).
Source: Departament de Política Territorial i Obres Públiques (2009)

THE NEIGHBOURHOODS LAW
Public space
Rehabilitation
Equipment
New Technologies
Sustainability
Gender equality
Social programs
Accessibility
The Neighbourhoods Law expenditure of projects within each of the seven focus areas.
41.5%
11.3%
31.4%
1.4%
2.2%
2.1%
6.5%
5.7%
Source: Departament de Política Territorial i Obres Públiques (2009)

THE NEIGHBOURHOODS LAW &
HEALTH FRAMEWORK
A conceptual framework of the link between the Neighbourhoods Law and health/health inequalities.
N
E
I
G
H
B
O
U
R
H
O
O
D
S
L
A
W
PHYSICAL
INFRASTRUCTURE
SOCIAL
INTEGRATION
ECONOMIC
GROWTH
LIVEABILITY
SOCIO-ECONOMIC
MAKE UP
POPULATION TURNOVER
HEALTH
&
HEALTH
INEQUALITY
PUBLIC SPACES
NEW TECHNOLOGY
GREEN
SUSTAINABILITY
REGENERATION
EQUIPMENT
INSTALLATION
GENDER EQUALITY
SOCIAL PROGRAM
EMPLOYMENT IN
NEIGHBOURHOODS
HEALTH IN
NEIGHBOURHOODS
POLITICAL CONTEXT

THE NEIGHBOURHOODS LAW &
HEALTH FRAMEWORK
A conceptual framework of the link between the Neighbourhoods Law and health/health inequalities.
N
E
I
G
H
B
O
U
R
H
O
O
D
S
L
A
W
POPULATION TURNOVER
HEALTH
&
HEALTH
INEQUALITY
PUBLIC SPACES
NEW TECHNOLOGY
GREEN
SUSTAINABILITY
REGENERATION
EQUIPMENT
INSTALLATION
GENDER EQUALITY
SOCIAL PROGRAM
EMPLOYMENT IN
NEIGHBOURHOODS
HEALTH IN
NEIGHBOURHOODS
POLITICAL CONTEXT
Traffic safety
Walkability
Aesthetics
Security
Employment
Education
Social cohesion
PHYSICAL
INFRASTRUCTURE
SOCIAL
INTEGRATION
ECONOMIC
GROWTH

JUSTIFICATION
 Urban renewal policies are becoming priorities for cities but
continue to not consider health and health inequality.
 There is evidence of positive links between initiatives and
health, but it remains limited.
 Furthermore, evidence on health inequalities remains sparse
mainly due to complexities discussed.
 Our study is the first in Spain and among the first in Europe to
use a mixed-methods approach to study this relationship.
 Such studies are needed to raise the importance of including
health and health inequality in the planning, implementation
and evaluation of urban renewal programs.

OBJECTIVES
GENERAL OBJECTIVE
 To study the effects of an urban renewal policy, the
Neighbourhoods Law, on health and health inequalities.
SPECIFIC OBJECTIVES
 To evaluate the perceptions of neighbours towards the effects of
recent changes in their neighbourhoods on their wellbeing. (Study 1)
 To evaluate the effects of the Neighbourhoods Law on the health
and social class inequalities in health of residents in intervened
neighbourhoods. (Study 2)
 To explore how urban renewal programs are linked to health and
health inequality and discuss some of the complexities. (Study 3)

RESEARCH APPROACH
QUANTITATIVE COMPONENT
QUALITATIVE COMPONENT
THEORY-DRIVEN APPROACH

STUDY 1
OBJECTIVE
 To evaluate the perceptions of neighbours towards the effects of
recent changes in their neighbourhoods, including the
Neighbourhoods Law, on their wellbeing from two Barcelona
neighbourhoods using Concept Mapping methodology.

STUDY 1. METHODS
 Concept Mapping is a non-traditional qualitative method
that provides a conceptual framework that depicts how a
group or a population perceives a particular situation.1
 Six steps carried out in three sessions with participants.
BRAINSTORMING
STRUCTURING OF IDEAS INTERPRETATION OF
MAPS
Step 1: Preparation
Step 2: Generation of statements
Step 3: Structuring of statements
Step 4: Representation of maps
Step 5: Interpretation of maps
Step 6: Utilization of maps
1 Trochim , W. (1989) An introduction to concept mapping for planning and evaluation. Special Issues of Eval Program Plan 12, 1-16.

STUDY 1. METHODS
ROQUETES
SANTA CATERINA Y
SANT PERE
“One change that has occurred within my neighbourhood in recent
years that has affected my family’s or my wellbeing is…”
Group 1: Neighbourhood
Association & Community Center
(N=14)
Group 2: Senior Day Center (N=12)
Group 3: Youth Center (N=19)

STUDY 1. RESULTS
Average cluster rating map of the importance of changes perceived by participants in the Casc Antic day center.
Decrease of economic activity
Abandoned areas
Sense of insecurity
Accessibility by car
Cleaning and repair of streets
Neighbourhood
relations
Reform of buildings
and plazas
Public events and spaces
Community and senior centers
Cluster Layer
Layer Value
1 2.99 to 3.22
2 3.22 to 3.44
3 3.44 to 3.67
4 3.67 to 3.89
5 3.89 to 4.12

STUDY 1. RESULTS
Cluster: Reform of buildings and plazas
ABSOLUTE
VALUE
POSITIVE
VALUE
NEGATIVE
VALUE
The installation of elevators in some residential
buildings.
4.29 4.29 0
The replacement of sheds for new apartments. 4 3.14 0.86
The improved liveability throughout the
neighbourhood.
3.86 2.57 1.29
The reform of the Community Center. 3.71 3.71 0
The repair of some building facades. 3.71 3.71 0
The re-urbanization of sidewalks and streets. 3.71 3.29 0.43
The reform and re-opening of the Santa Caterina
market.
3.57 3.43 0.14
The reform of the central plaza, Pou de la Figuera. 2.71 1.71 1
The replacement of old benches with new single-
person benches.
2.29 1.14 1.14
AVERAGE 3.51 3.03 0.49
MEDIAN 3.71 3.29 0.29
Reform of buildings
and plazas
Statements within the cluster, reform of buildings and plazas with corresponding rating values and effect

STUDY 1. RESULTS
Abandoned areas
Sense of insecurity
Neighbourhood
relations
Reform of buildings
and plazas
Somewhat negative
Very negative
Very positive
Somewhat positive
Average cluster rating map of the importance and effects of changes perceived by participants in the Casc Antic day center.

STUDY 1. RESULTS
Abandoned areas
Sense of insecurity
Neighbourhood
relations
Reform of buildings
and plazas
POPULATION &
SOCIAL CHANGE
URBAN RENEWAL
PROJECTS
Somewhat negative
Very negative
Very positive
Somewhat positive
Average cluster rating map of the importance and effects of changes perceived by participants in the Casc Antic day center.

STUDY 2
OBJECTIVE
 To evaluate the effects of the Neighbourhoods Law on the
health of residents (women and men) of intervened
neighbourhoods in the city of Barcelona and on the social class
inequalities in health within these neighbourhoods.

STUDY 2. METHODS
 Pre- (2001, 2006) and Post- (2011)
intervention periods.
 A comparison group of non-intervened
neigbourhoods with similar socio-economic
indicators based on Census 2001.
 Data from Barcelona Health Surveys with
population being over the age of 15.
 Poor self-rated health and mental health
prevalence were described for each sex by
neighbourhood group and survey year.
 Poisson Regression robust models were
used to estimate prevalence ratios and
their 95% CI, introducing the interaction
between survey year and group.
Comparison neighbourhoods
Intervened neighbourhoods

0%
5%
10%
15%
20%
25%
30%
2006 2011
WOMEN
0%
5%
10%
15%
20%
25%
30%
2006 2011
MEN
STUDY 2. RESULTS
1.25 (0.69 - 2.27)
1.93* (1.23 - 3.01)
0.95 (0.69 - 1.31)
0.86 (0.58 - 1.27)
Trends in age-standardised prevalence of poor mental health by neighbourhood groups.
Intervened Comparison
*p<0.05 **p<0.01 ***p<0.001. Numbers shown correspond to Prevalence Ratios calculated using 2006 as reference year

0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
2006 2011
WOMEN
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
2006 2011
MEN
STUDY 2. RESULTS
0.74*(0.56 - 0.97)
1.07 (0.85 - 1.35)
0.53*** (0.36 - 0.78)
1.04 (0.77 - 1.41)
Intervened
Trends in age-standardised prevalence of poor self-rated health by neighbourhood groups.
Comparison

0%
10%
20%
30%
40%
50%
60%
2006 2011
WOMEN - COMPARISON
STUDY 2. RESULTS
Manual ManualNon-manual Non-manual
Trends in age-standardised prevalence of poor self-rated health by neighbourhood group and social class.
0.72* (0.53 - 0.97)
0%
10%
20%
30%
40%
50%
60%
2006 2011
WOMEN - INTERVENED

STUDY 2. RESULTS
Manual ManualNon-manual Non-manual
Trends in age-standardised prevalence of poor self-rated health by neighbourhood group and social class.
0%
10%
20%
30%
40%
50%
60%
2006 2011
MEN - COMPARISON
0%
10%
20%
30%
40%
50%
60%
2006 2011
MEN - INTERVENED
0.45*** (0.29 - 0.69)

STUDY 3. OBJECTIVES
Article 3. Exploring complex causal pathways between urban renewal,
health and health inequality using a theory -driven approach. R.
Mehdipanah, A. Manzano, C. Borrell, D. Malmusi, M. Rodríguez-Sanz,
J. Greenhalgh, C. Muntaner, R. Pawson. Social Science & Medicine
(Under 2nd review).
OBJECTIVE
 To explore how urban renewal programs are linked to health
and health inequality and discuss some of the complexities
associated with these causal pathways using a theory -driven
approach.

STUDY 3. METHODS
 Theory-driven approach allows the development of links
between the program, its outcomes and the context in which it
was carried out in.1
 Requires a full understanding of the program and its goals while
having a constant consideration of the contextual settings in
which they are implemented.2,3
 Flexible in methods used and encourages both quantitative and
qualitative data as long as they serve to confirm, refine or
dismiss the mechanisms studied.2
 In the case of this study, we took a realist evaluation approach.
1Chen H.T. (2012) Theory-driven evaluation: Conceptual framework, application and advancement. Evaluation von Programmen und Projektenfüreine Kultur
2Pawson, R. & Sridharan, S. (2010). “Theory-driven evaluation of public health programmes”. In Killoran A., Kelly M.P. (Ed) Evidence-Based Public Health:
effectiveness and efficiency, Oxford University Press, Oxford UK.
3Donaldson S. et al. (2003) Theory-driven evaluation in action: lessons from a $20 million statewide Work and Health Initiative. Eval Program Plan, 26, 355-366.

STUDY 3. RESULTS
Two proposed causal pathways linking urban renewal to health & health inequality.
1
2

STUDY 3. RESULTS
1
Urban renewal programs increase
access and availability of resources
and opportunities for neighbours.

STUDY 3. RESULTS
2
Health and health inequalities will improve
if neighbours use and adapt to the
changes produced by the intervention.

STUDY 3. RESULTS
Open Spaces: Areas that allow residents to
participate in public spaces, promote
social interaction and are accessible by all
compared to private areas.
 Public spaces linked to health and
health inequalities:
 Increased opportunity for physical
activity.1
 Circulatory disease mortality lower in
populations that have access to such
public spaces.2
 Features within these open spaces can
increase social interaction.3
1 Rydin Y et al. (2012) Shaping cities for health: complexity and the planning of urban environments in the 21st century. Lancet/UCL, London.
2 Mitchell R. &Popham F. (2008) Effects of exposure to natural environment on health inequalities: an observational population study. Lancet, 372: 1655-1660.
3 Borja J. & Muxi Z. (2001) Espai Públic: Ciutat I Ciutadania. Diputació de Barcelona, Barcelona.
4 Kearns A. et al. (2009) Regeneration and health: Conceptualising the connection. J Urb Regen Ren 3(1): 56-76.

STUDY 3. RESULTS
Causal pathways for the renewal of public open spaces – Pou de la Figuera
MECHANISMS
OUTCOMES
CONTEXT
INTERVENTION
Social Interaction
Safety & Security
Accessibility
Children’s playground
Soccer & Basketball courts
Community garden
Benches around plaza
Planted trees
Changes in Health
+/-
Health Inequality
Population
composition
History

GENERAL FINDINGS
 The Neighbourhoods Law has had positive effects on the health
and health inequalities of residents.
 Neighbours perceived the majority of the Neighbourhoods Law’s
interventions as positive and important for their wellbeing.
 Poor self-rated health improved in neighbourhoods intervened
for both men and women especially in the manual classes
compared to those not intervened.
 Poor mental health remained constant in both men and women
while it increased in the non-intervened group.
 Urban renewal programs increase resources and create
opportunities in a neighbourhood, but neighbours must use and
adapt to these changes in order to benefit optimally.

DISCUSSION
 What do these results mean?
 Whose health does urban renewal programs affect?
 How do urban renewal programs affect health and
health inequalities?
 Why do urban renewal programs affect health and
health inequalities?

WHOSE?
 In the first four years the Neighbourhoods Law was estimated
to affect approximately 10% of the population.1
 Results from both quantitative and qualitative studies and
existing evidence indicate that not all neighbours have
benefitted equally:
 Interventions can be population specific.
1Departament de Política Territorial I Obres Públiques – DPTOP (2009) La Llei de barris: Una aposta collectiva per la cohesió social. Generalitat de

WHOSE?
AGE
 Younger populations focus more on employment services, activities, play
areas.
 Older populations focus more on accessibility, social spaces and safety.
GENDER
 Both women’s and men’s health outcomes improved.
SOCIAL CLASS
 Manual social class generally benefitted more than the non-manual social
class.

WHOSE?
POPULATION TURNOVER
 The Neighbourhoods Law, did not contain a housing renewal
component.1
 Risk of displacement by the law was addressed through the promotion
and protection of social housing in the areas intervened.
 In the Catalonia context, a large proportions of owners versus renters
with deeper roots in neighbourhoods.2
 In our quantitative study, we saw no significant differences in
populations with more than 5 years living in the neighbourhood and
with total population.
 However, displacement can become an issue with the effects of the
current economic crisis.
1Kearns A. & Mason P. (2013) Defining and Measuring Displacement: Is relocation from restructure neighbourhoods always unwelcome and disruptive?
Housing Studies, 28(2): 177-204
2Nel·lo O. (2011) The five challenges of urban rehabilitation. The Catalan experience. Urban Research & Practice. 4(3): 308-325

HOW?
One change that has affected my wellbeing is…
 Each reply forms a hypothesis of how the Neighbourhoods Law
affected the wellbeing of residents:
 In Roquetes, the installation of outdoor escalators and
elevators was recognized as important and positive for
neighbours’ wellbeing.
 The removal of a physical barrier.
 The improvement of accessibility to resources.

HOW?
POPULATION & SOCIAL CHANGE
URBAN RENEWAL PROJECTS
SOCIAL ENVIRONMENT

HOW?
SOCIAL ENVIRONMENT
LIVEABILITY
SOCIO-ECONOMIC
MAKEUP

WHY?
• Economic means.
• Lifestyle preferences.

WHY?
PLACE-BOUND
Individual characteristics:
• Age
• Gender
• Socio-economic position
• Health status

WHY?
USE & ADAPTATION:
 Neighbours can increase the effects of urban renewal.
 The presence of neighbourhood associations in program planning and evaluation can
empower neighbours to make decisions on the status of their neighbourhoods. 1,2
 Such groups can impact the wellbeing of residents by addressing issues with
production and distribution of specific resources throughout the neighbourhood that
may be otherwise.1
 Roquetes is a good example of this the strong involvement and participation of
neighbours throughout the entire process.
1Matheson A., et al. (2009) Complexity, evaluation and the effectiveness of community-based interventions to reduce health inequalities. Health Prom J. 20:221-226
2Pasarin et al. (2010) Community health: integration of primary care and public health competencies. SESPAS report 2010. Gaceta 24(S1): 23-27,

STRENGTHS & LIMITATIONS
Strengths
 Mixed-methods approach to study the effects of a complex urban
renewal intervention and its effects on health and health
inequalities.
 Study serves as a strong example of how structural policies can
affect health and health inequalities despite incorporating these
outcomes in the planning and implementation of these laws.
Limitations
 Census tract boundary changes between the pre and post periods
in order to accommodate for population growth and political
reasoning.
 Heavy reliance on the Barcelona Health Surveys where samples
are representative of the general population but often size did
not permit for subpopulation analysis.

GENERAL CONCLUSIONS
 The majority of projects within the Neighbourhoods Law were perceived
as positive and important to the wellbeing of neighbours.
 On the contrary, population and social changes in these
neighbourhoods were largely observed as negative and important.
 The incorporation of neighbours’ perspectives is critical for
understanding better the compositional and contextual factors in a
neighbourhood.
 The division found in the maps of the concept mapping, provided
support for the concepts of liveability and population turnover found in
the conceptual framework.

GENERAL CONCLUSIONS
 In both women and men, self-rated health improved in the
neighbourhoods intervened by the Neighbourhoods Law, especially
those within the manual social classes, compared to non-intervened
neighbourhoods with similar socio-demographic characteristics.
 Similar results as above were seen for the mental health status of
women in the intervened neighbourhoods.
 The Neighbourhoods Law appears to moderate further increases in
poor mental health observed in men from the comparison group.
 Although urban renewal programs may improve opportunities and
resources in a neighbourhood, residents must use and adapt to these
changes in order to benefit optimally.
 A focus on theory is needed to explore potential causal pathways
linking urban renewal to health outcomes.

 Health and health inequality outcomes should be included in the
evaluations of urban renewal programs conducted.
 A thorough understanding of contextual and compositional factors
in which the intervention was carried out is essential in order to
understand the influence it may have on the outcomes attained.
 In the case of the Neighbourhoods Law, information from this
dissertation can be used to lobby political groups to allow for the
continuation of such interventions.
 Furthermore, future urban renewal policies should take into account
potential effects on health and health inequality at both the
planning and evaluation phases resulting in the need for
intersectoral work.
RECOMMENDATIONS

THANK YOU
CARME BORRELL & CARLES MUNTANER
MAICA RODRIGUEZ-SANZ & DAVIDE MALMUSI
ALL THE CO-AUTHORS
SESIS
SALUT ALS BARRIS & SALUT COMUNITARI
UNIVERSITY OF LEEDS, UK
ROQUETES PLA COMUNITARI & TON I GUIDA C.C.
CENTRE DE DIA CASC ANTIC & PALAU ALOS
CROMA
ENRIC CREMADES & ORIOL NEL·LO
THE NEIGHBOURS OF ROQUETES & S.CATERINA

Urban renewal and health: The effects of the Neighbourhoods Law on health and health inequalities in Barcelona

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