Study protocolProtocol for a mixed methods study investigating the impact of investment in housing , regeneration and neighbourhood renewal on the health and wellbeing of residents : the GoWell programme

Background: There is little robust evidence to test the policy assumption that housing-led area regeneration strategies will contribute to health improvement and reduce social inequalities in health. The GoWell Programme has been designed to measure effects on health and wellbeing of multi-faceted regeneration interventions on residents of disadvantaged neighbourhoods in the city of Glasgow, Scotland. Methods/Design: This mixed methods study focused (initially) on 14 disadvantaged neighbourhoods experiencing regeneration. These were grouped by intervention into 5 categories for comparison. GoWell includes a preintervention householder survey (n = 6008) and three follow-up repeat-cross sectional surveys held at two or three year intervals (the main focus of this protocol) conducted alongside a nested longitudinal study of residents from 6 of those areas. Self-reported responses from face-to-face questionnaires are analysed along with various routinely produced ecological data and documentary sources to build a picture of the changes taking place, their cost and impacts on residents and communities. Qualitative methods include interviews and focus groups of residents, housing managers and other stakeholders exploring issues such as the neighbourhood context, potential pathways from regeneration to health, community engagement and empowerment. Discussion: Urban regeneration programmes are 'natural experiments. ' They are complex interventions that may impact upon social determinants of population health and wellbeing. Measuring the effects of such interventions is notoriously challenging. GoWell compares the health and wellbeing effects of different approaches to regeneration, generates theory on pathways from regeneration to health and explores the attitudes and responses of residents and other stakeholders to neighbourhood change. Background Regeneration and health The World Health Organisation (WHO) states that housing characteristics, including the interlinked dimensions of household, dwelling, community and neighbourhood environment, have the capacity to affect individual health status through physical, mental or social mechanisms [1]. As poor health is associated with poorer living circumstances, there is a policy expectation that area regeneration and housing improvement strategies will contribute to health improvement and reduced social inequalities in health [2-4]. We have designed a study to test this hypothesis. Evidence from systematic reviews There is limited evidence on the health impacts of housing improvement and regeneration. For example, a systematic review of the health impacts of housing * Correspondence: m.egan@sphsu.mrc. ac.uk 1 Medical Research Council/Chief Scientist Office Social & Public Health Sciences Unit, 4 Lilybank Gardens, Glasgow, UK Full list of author information is available at the end of the article Egan et al. BMC Medical Research Methodology 2010, 10:41 http://www.biomedcentral. com/1471-2288/10/41 Page 2 of 12 improvement has found that improvements in respiratory, general and mental health have been observed following home warmth improvement measures, but these health improvements varied across studies [5]. Some of the reviewed studies reported that housing improvement was associated with positive impacts on socioeconomic determinants of health. An earlier systematic review found some evidence that housing improvements led to rent increases a possible mechanism for adverse outcomes to low budget households with inadequate welfare protection [6]. Evidence on the health impacts of housing interventions that included neighbourhood improvements was found to be inconsistent or unclear. Despite several systematic reviews, we are aware of little or no robust evidence on the positive and negative health effects of broader, multi-component housing-led area based regeneration. Other 'evidence gaps' include long term effects of housing improvement and area regeneration, the social patterning of effects (i.e. effects on health inequalities), the comparative effects of rehousing and housing improvement, and the mechanisms by which different interventions or combinations of interventions might lead to positive health outcomes [5,7,8]. GoWell The Glasgow Community Health and Wellbeing (GoWell) Research and Learning Programme has been designed to provide such evidence. GoWell focuses on a large, multi-faceted programme of housing investment and area regeneration across the city of Glasgow (Scotland). These interventions can be described as 'natural experiments. ' At an early stage in the planning process, regeneration planners identified high level goals that included improvements in residents' health and health behaviours, and reduced health inequalities. This contributed to the development of GoWell (GoWell is the name of the study, not the regeneration programme). GoWell is a research and learning programme that aims to investigate the impact of investment in housing, regeneration and neighbourhood renewal on the health and wellbeing of individuals, families and communities over a ten-year period. The Programme aims to establish the nature and extent of these impacts and the processes that have brought them about, to learn about the relative effectiveness of different approaches, and to inform policy and practice. It is a multi-component study with a comparative design. Although focused on regeneration in Glasgow, we aim to produce findings that are transferable to other regeneration settings. This paper summarises GoWell's methods, focusing particularly on its Community Health and Wellbeing Survey, and discusses some of its strengths and limitations. Methods/Design Summary GoWell may be described as an observational study of a complex intervention. It is a mixed methods study that includes both quantitative and qualitative methods. Comparison areas (all relatively deprived) are incorporated into GoWell's design so we can compare the effects of different approaches to regeneration in different areas of the city. These regeneration activities are planned and delivered by a variety of stakeholders rather than by the researchers. GoWell has been designed to regularly produce findings on short term impacts to inform ongoing planning and delivery of the interventions being evaluated (i.e. formative evaluation), and more broadly transferable evidence of effects including short, medium and long term outcomes. (i.e. summative evaluation) [9]. Setting Glasgow is the largest city in Scotland and contains high concentrations of poverty, disadvantage and ill health [10,11]. Area based health inequalities are stark: for example life expectancy in the most disadvantaged areas of Glasgow has been estimated to be at least 15 years shorter than in the least disadvantaged areas [12-14]. Glasgow's urban landscape includes features familiar to many European cities. Many of its residents live in flats rather than houses, and most have either no garden or share a garden. Even some of the more popular inner-city gardened estates contain buildings that look like large semi-detached houses but actually contain 4 single-entry flats with shared gardens (called 'four-in-a-block' flats). Glasgow's socially disadvantaged areas include large postwar peripheral estates (made up of 'low-rise' tenement flats, houses and, to a lesser extent, 'high-rise' multi-storey flats); inner-city mass housing estates (mostly postwar multi-storey flats with some tenement flats); innercity gardened estates (houses and 'four-in-a-blocks' mostly dating from the 1930s); and old neighbourhoods dominated by 19th and early 20th century tenement flats. There are also affluent neighbourhoods in the suburbs and inner-city with housing types that include houses, tenements and recently built multi-storey developments. Interventions In 2003, over 80,000 socially rented homes in the city transferred from public ownership to a newly created not-for-profit organisation called Glasgow Housing Association (GHA), following a tenants' referendum. GHA became the largest provider of social housing in the city alongside a number of smaller providers (collectively known as 'Registered Social Landlords' or RSLs). The stock transfer paved the way for a city-wide regeneration investment programme spearheaded by GHA but involvEgan et al. BMC Medical Research Methodology 2010, 10:41 http://www.biomedcentral. com/1471-2288/10/41 Page 3 of 12 ing other RSLs and partner organisations from other sectors. Key elements of the programme include: • Housing improvement: includes internal and external refurbishment based on surveyor's assessments of each property. Social rented homes receive the bulk of this investment, which is driven by a government requirement that all social housing meets the Scottish Housing Quality Standard by 2015 [15]. • New builds: building new homes, including socially rented and private sector homes in green and brown field sites. Plans include more owner occupied homes in areas dominated in the past by socially rented property (referred to as tenure diversification), especially in regeneration areas. • Transformational regeneration: a neighbourhoodwide approach to regeneration planning (rather than improvements planned on a home-by-home basis) involving several or all of the following: relocation of residents, demolitions, new builds, housing improvement, tenure diversification, improvements to the physical neighbourhood environment, new/improved amenities and services, and community interventions. Typically, a Transformational Regeneration Area (TRA) would initially comprise between 1000-2000 households. • Local regeneration: similar to transformational regeneration but targeting smaller pockets of disadvantage situated in larger neighbourhoods. • Community interventions (sometimes called 'wider actions'): include employment and training initiatives, activities for young people, improved play areas, support for vulnerable people, addiction suppo