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7. GREENER SCOTLAND

ACTION ON PHYSICAL ENVIRONMENTS TO REDUCE HEALTH INEQUALITIES

Introduction

1. This paper examines two of the Task Force's key principles:

• To improve the whole range of circumstances and environments that offer opportunities to improve people's life circumstances and hence their health.

• To reduce people's exposure to factors in the physical and social environment that cause stress, are damaging to health and wellbeing, and lead to health inequalities.

2. As in Professor Sally Macintyre's briefing for the Task Force, health inequalities would be wider today if it were not for a number of equity-enhancing policies on the physical environment over the past decades, including neighbourhood regeneration, housing improvements and control of the environment via clean air acts etc. Some of the policies Sally reported as more likely to be effective in reducing inequalities in health include:

• Structural changes in the environment eg area-wide traffic calming schemes, separation of pedestrians and vehicles.

• Legislative and regulatory controls, e.g. house building standards.

• Improving accessibility of services, e.g. through better transport links, affordable healthy food.

3. This paper explores action in these and related policy areas. While there are undoubted general benefits to health from such activity, it is difficult in many cases to identify what specific action, over and above current policies and programmes, will help to reduce health inequalities. The paper also looks at the importance of how environmental policies are implemented which will help to make them more effective in addressing health inequalities.

Environmental justice

4. The term "environmental justice" was first used in the USA in the late 1970s. It described the aspiration of more meaningful community involvement in environmental decision-making, together with a reduction in, and a more equitable distribution of, environmental burdens.

5. A 2004 research review by the Sustainable Development Research Network on environment and social justice concluded that:

• Problems of environmental injustice affect many of the most deprived communities and socially excluded groups.

• Both poor local environmental quality and differential access to environmental goods and services have a detrimental effect on the quality of life experienced by members of those communities and groups.

• In some cases, not only are deprived and excluded communities disproportionately exposed to an environmental risk, they are also disproportionately vulnerable to its effects.

6. The core relationship between environmental justice and health inequalities is founded on the premise that where there is a "stacking up" of "environmental bads", combined with an absence of "environmental goods", ill health and reduced quality of life result, and that this is evidence of an "environmental injustice". Therefore, tackling health inequalities should take account of the co-incidence of poor health outcomes and poor environmental quality, and consider those local environments as part of the solution to the health problems.

7. More is required in order to allow the Scottish public fuller involvement in environmental decision-making. This is based on the expectation that, when the public have visible and viable routes for involvement, their sense of exclusion and hopelessness will be reduced, with consequential secondary positive health outcomes.

8. Action on environmental justice should include the following:

• The UK Government Office for Science Foresight report Tackling Obesities 2007 suggests that people living in more deprived communities may suffer the health impacts of living in less walkable, more degraded environments; and that the health risks of being obese may be compounded by other health impacts associated with deprived environments. There could be a win-win outcome from improving environments and access to healthy food in terms of regeneration, better health, health and social inclusion.

• Quality of neighbourhood improvements - tackling problems locally and addressing local environmental 'bads' will lead to improvements in the local environment, and safer, healthier communities. Scottish evidence indicates that those who report the highest levels of local environmental 'bads' are also more likely to be anxious, depressed and in a poor state of health. They are less likely to 'take a walk', and more likely to smoke. The latter two activities point to behaviours closely related to key health inequalities (obesity, cardio-vascular disease, diabetes). This evidence suggests that low level 'street incivilities' are connected to (if not the cause of) important health inequalities, and as such, these environmental conditions should be addressed as part of achieving better health outcomes for groups at risk.

• In terms of mental health, the same Scottish study found that people reporting experience of living with high levels of environmental 'bads' were also less trusting of others and more fearful of being a victim of crime.

• The absence of 'environmental goods' emerged in this Scottish study as a key factor in the health outcomes explored. The absence of green, safe or pleasant places to walk or play is strongly correlated with how happy people feel about living in their area, whereas the presence of large infrastructural 'bads' is not.

• Neighbourhoods and communities that experience traffic congestion and high levels of urban traffic are susceptible to health inequalities in terms of air pollution and pedestrian accidents (see Transport and Air quality sections below).

• Waste infrastructure - moving away from over-dependence on landfill which can have a significant negative impact upon some communities. The evidence about physical health impacts from landfill or incineration is contested, but it is generally accepted that proximity to waste infrastructure is not conducive to good health and wellbeing, at both individual and community level.

9. On public involvement in environmental decision-making:

• The reform of the planning system embodies key elements of encouragement for the public to be involved in the planning system, but Scottish evidence suggests that the public is generally not able to easily access information about their local environment.

• Better, more effective access to and signposting of environmental decision-making information would encourage a higher level of public participation, and engender a better sense of individual and community wellbeing in such communities.

10. Activities already underway in the reform of the planning system, in the development of a new National Waste Plan for Scotland, and the forthcoming Flooding Bill already anticipate key improvements in localities experiencing both environmental 'bads' and absence of 'goods'. It is essential that health criteria are embedded in assessments for major initiatives in these areas, to allow a co-ordinated approach to policy development, and critically, to the gathering of evaluative data from which we can learn. It is especially important to embed consideration of the negative health impacts of 'street level incivilities' in local community planning activities.

11. Government will invest in further 'mapping' research and data gathering of environmental 'goods' and 'bads' research across Scotland, and work on integrating evidence and policy across the health and environment portfolios.

12. Government will also explore the possibility of a national portal for accessible environmental information for the public, guidelines and standards to inform a hierarchy of information, a network of environmental information providers and explicit promotion of these improvements to the public.

Health and equity impact assessment

13. The Task Force has already discussed the need for a whole range of public policies to be assessed for their impact on health and to demonstrate how they are contributing to reducing health inequalities. The Better Health, Better Care action plan, published in December 2007, said that Government would support this by the development and application of an integrated process for such assessments.

14. Better Health, Better Care also said that local decisions about service change and investment across the NHS should be more routinely informed by health impact assessment, with a view to extending this approach to the activities of all community planning partners.

Greenspace

15. Greenspace can be defined as "any vegetated land or water within or adjoining an urban area", including natural greenspaces; green corridors; amenity grasslands; parks and gardens; and countryside that people can access from their homes.

16. It is widely recognised that there is an association between health and access to greenspaces. Not only is the presence of greenspace believed to be conducive to good health, but the absence of greenspace is understood to be bad for health, in terms of both physical and mental health outcomes. So significant health inequalities may be associated with lack of access to greenspace, particularly in conditions such as cardio-vascular disease, obesity, diabetes and mental health. Where people at risk of these health conditions do not have access to greenspace, they are at a disadvantage. Evidence in Scotland indicates that it is the most deprived areas that enjoy least access (and least use of) high quality greenspace nearby.

17. While it is widely recognised that there is an association between health and access to high quality greenspaces, the role of such spaces in addressing Scotland's health inequalities is less explicitly mapped. This is an area of significant current research activity; evidence of causal links is not yet well scientifically established, but such links are strongly anticipated to exist among health and environment scientists. This emerging field is currently assessing the level of evidence available in relation to greenspace, and there is a strong argument that 'the precautionary principle' should be exercised to protect, maintain and encourage the creation of urban greenspaces.

18. The Scottish Government recognises the importance of greenspace and has a commitment to the provision of an environment which contributes towards well-designed, sustainable places with access to amenities and services, recognising the importance of the quality of the environment, nature and greenspace in promoting mental health and wellbeing.

19. Children who have better access to safe green and open places are more likely to be more physically active and less likely to be overweight, than those living in neighbourhoods with reduced access to such facilities. Therefore, children at risk of health inequalities require accessible greenspace as part of their pathway to good health.

20. Access to greenspace is also associated with greater longevity in older people.

21. Recent research suggests that health differences between urban and rural residents can be partly explained by the amount of 'green' in their direct living environments. It is not principally the quantity of greenspace available, but the quality of greenspace that makes a difference in encouraging use of such spaces. Active promotion of greenspace use is also required, especially in areas where there is lower use of accessible greenspace, and where other health inequalities prevail.

22. Policies that promote local creation of greenspaces offer opportunities to build social (and health) capital through local involvement, volunteering and physical activities embodied in the greenspace (such as gardening, landscaping). The Forestry Commission's Wood In and Around Towns initiative is already successful in reaching areas of multiple deprivation.

23. The Task Force can use its emerging understanding of the links between deprivation, stress and health inequalities to suggest that how future policies aim to improve provision of greenspace is as important as the policies themselves. There needs to be full engagement of individuals, families and communities most at risk of poor health in services and decisions and clear ownership of the issues involved, as set out in the Task Force's November principles. We also need to evaluate progress and success more carefully, paying particular attention to whether action really serves to reduce inequalities in health in specific communities and areas.

Transport

24. A recent briefing paper by the Glasgow Centre for Population Health considered how transport could reduce health inequalities and concluded that "transport strategies have a vital role to play in improving social inclusion and accessibility through investment in good public transport systems and instituting measures that encourage walking and cycling".

25. The Scottish National Transport Strategy (2006) includes action in some areas where transport could contribute to health improvement, for example, to improve the quality, accessibility and affordability of public transport.

26. Inactivity is a major risk factor in cardio-vascular disease and cancer. Encouraging a shift from car travel to public transport, cycling and walking is a key aspect of increasing rates of daily physical activity. Public transport users are more active than car drivers/passengers as they walk/cycle to and from transit points. Both the National Transport Strategy and the Government's Physical Activity Strategy aim to increase the proportion of short journeys made on foot and on bikes to improve individual health and also to reduce carbon emissions and improve air quality.

27. Research undertaken in 2006, Promoting Active Lifestyles - Good Ideas for Transport and Health Practitioners is aimed primarily at NHS Health Promotion teams, local transport planning officers, community planning partnerships and outdoor access officers. It includes examples of the type of work that is going on around Scotland to promote active lifestyles. For example, Active Referral in Linlithgow was set up to find out whether health-related travel awareness material would be more effective if it was delivered to the public via a reliable third party such as a GP, rather than through the traditional transport sector. Government is also looking more generally at how physical activity can be promoted effectively through primary care, including 'exercise on referral' approaches.

28. Increasing the accessibility of services can improve people's life chances and reduce social exclusion. Having reliable, safe and affordable public transport can often be critical, for example for those with limited employment options. This means considering transport implications when re-designing services or planning/building new facilities. The Bus Action Plan, which follows through on one aspect of the National Transport Strategy, highlights the need for a more holistic and partnership approach to integrating land use planning and transport planning. Better integration and planning frameworks will help ensure that the links are made between walking and pathways and the bus network when building new houses, hospitals, shopping centres or schools.

29. Other specific actions which are being taken forward include: completing the National Cycle Network and associated 'short links' that encourage commuting to work and travel to school by bike or on foot; supporting travel planning to ensure that all local authorities, major hospitals and health facilities have operational travel plans by April 2008; and working to increase the number of children and adults cycling to school and more generally. The challenge here is to scale up and replicate small projects that seem to work well in deprived communities: for example, Try-cycling run after-school bike clubs in Craigmillar, Edinburgh; and the Bike Station in Edinburgh are taking forward a small project that teaches young people in deprived areas how to build their own bikes.

30. There are links between the neighbourhood people live in and the rate of road accident casualties. People of all age groups experiencing social exclusion generally suffer higher casualty rates. Accident rates are higher in areas where there are higher levels of lone parents and pensioners, fewer economically active adults and lower levels of car ownership. Death in road accidents is related to socio-economic background. Children in the lowest socio-economic groups are as much as four times as likely to be killed and up to six times more likely to be injured, than those from more affluent areas.

31. Road Safety Scotland ( RSS) supplies road safety educational resources to every school in Scotland, while the Children's Traffic Club in Scotland ( CTCS) offers free road safety training to all 3 year old children. RSS has also supported local campaigns to try and increase uptake of CTCS in deprived areas.

32. Good Practice Guidance on developing community based road safety initiatives was published in 2002. The guidance provides practical advice on what local communities and public agencies can do to address some of the main threats to personal safety from traffic and road user behaviour. Most importantly, it targets those areas and people most at risk.

33. The National Transport Strategy states that the Scottish Government will support action targeting children from disadvantaged areas who are at greater risk of injury in road accidents.

Whole Community Approaches

34. The Government is planning a number of whole community developments and demonstration projects in the near future. For example, sustainable travel demonstration towns, in partnership with COSLA, which will focus on active travel, building in health outcomes from the outset. There are also plans for a whole community approach, mirroring successful developments in France to reduce childhood obesity. Other developments will support the creation of sustainable places as exemplars of good practice in planning and building, to help drive up the quality of new developments in the future. Work is underway within the Sustainable Places aspect of the Government's Greener Scotland theme, to make sure that the objectives of these local demonstrations are consistent and integrated, so far as possible. From the Task Force's perspective, it will be particularly helpful if these whole community approaches explore whether it is possible to reduce or avert the development of health inequalities. That will require health and health inequalities outcomes to be evaluated from the start.

Air Quality

35. There is a proven clear link between air pollutants and human health. This is primarily for particulate matter (PM) smaller than 10 µm which is able to enter the respiratory system. Cardio-vascular disease and asthma have been linked to high levels of PM10 in the air, hence an EU Air Quality Directive which sets limits for a range of air pollutants across member States and an air quality strategy for the UK which sets objectives for the same set of pollutants local authorities have a responsibility to meet these objectives. In Scotland there are tighter objectives than the rest of the UK for PM10 and benzene, as generally air quality is better here.

36. Scotland has particularly high rates of the population affected by cardiovascular disease and asthma. Given that PM10 is linked to both these diseases it would be beneficial to explore the contribution that air quality has on health outcomes.

37. Research conducted by SNIFFER (2006) into social deprivation and air quality did not find a relationship between the two for Scotland. Both the most deprived and least deprived areas experienced the same levels of air quality. The explanation lies in the distribution of different communities in city centres. Air quality is closely related to traffic, and certain city-centre areas of affluence also experience high traffic pollution. A reduction in traffic, and particularly in car use would improve air quality considerably and be likely to deliver health benefits.

38. The Scottish Government is funding a Scottish air quality database which will (by 2009) have almost all the air quality data monitored across Scotland in one website and produce both national and regional trend data. This will help support studies into human health impacts of air pollution.

Housing

39. Officials have reviewed evidence on the links between housing quality improvements and health inequalities. There are consistent correlations between poor housing and ill health, especially mental health and wellbeing. It is more difficult, however, to prove that poor housing actually causes ill health. In addition, neighbourhood characteristics, e.g. crime in the local area may be a further contributory factor to housing conditions having a negative impact on health.

40. Studies evaluating area regeneration housing improvements report both beneficial and adverse health effects. There may be improvements in mental health. When people are relocated, a different social environment can provide educational and employment opportunities that are beneficial to health. There may also, however, be adverse effects such as loss of social networks and stress.

41. It is clear that there are complex interactions between factors such as poverty and lifestyle characteristics that determine the relationship between housing and health. It is very difficult to untangle causal relationships between housing conditions and incidence of health problems. This therefore makes it hard to see what specific action, over and above current policies and programmes in the housing field, would help reduce health inequalities.

42. We can say, nevertheless, that more general action on poverty, employment and physical and social environments will interact with housing improvement positively and should serve to improve people's health and reduce health inequalities, if action on housing is sufficiently targeted.

43.COSLA's paper for the Task Force on the role of local authorities in reducing health inequalities sets out some of the general housing and environmental policies through which local government can contribute to positive impacts on health, within this complex overall picture.

44. More will be learnt about the impact of moves to better quality social housing and neighbourhood transformation from two current Scottish research studies. SHARP (Scottish Health, Housing and Regeneration Project) is a longitudinal study of the health and wellbeing impacts of moving into new, general purpose social housing provided by Registered Social Landlords (housing associations) across Scotland. The project is scheduled to be completed this year. It reports slight improvements in people's health after a move and some positive wellbeing and lifestyle changes, eg smoking cessation, improved diet. However, the overall scale of the improvements is very small. The Go Well project in Glasgow is a longitudinal study running for 10 years from 2006. It is investigating the effects on individuals and families of neighbourhood transformation and of people's moves within or beyond the city. The baseline survey indicated that the physical, social and service environments to be provided in transformation areas should be capable of enhancing the psycho-social benefits people derive from their homes and the neighbourhoods where they live. Both these studies should give significant insights into the ways in which housing and neighbourhood change could bring about improvements in health and wellbeing.

45. The Task Force's emerging thinking about design of public services will apply to the provision of housing services as it does to many other services. For staff, this is likely to mean:

• understanding is required of the interaction between stress, deprivation and people's specific housing needs and the way in which they present those needs.

• staff require to respond effectively to people with complex problems that span the responsibilities of many organisations.

• management should support cross-agency working to help clients to deal with the whole spectrum of problems, including housing issues.

• all housing services need to engage clients fully in decisions that affect them.

Conclusions

46. This paper has addressed some of the most significant factors in the physical environment that seem likely to have an impact on health inequalities. Other aspects such as drinking water quality and soils and health have also been examined briefly. However, it is difficult to map health consequences, and inequalities in particular and to identify action that will have any significant impacts on health inequalities other than in small local populations. These areas have not, therefore, been covered in detail here.

47. In general, there is disappointingly little evidence for specific effective action on physical environments that would achieve measurable reductions in health inequalities in Scotland. There is, however, understanding of complex interactions between individual health and physical and social environment characteristics. This should be useful in informing joined up national and local activity.

March 2008

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