The thematic objective for this topic is called Promoting Social Inclusion and Combating Poverty. Economic and Urban Regeneration is now one of the investment priorities. The pathway applies to this investment priority.

The figure below shows the causal pathway by which urban issues affect health. Structural Fund spending for urban regeneration can influence different parts of this pathway. Possible approaches and actions for Structural Funds to improve health gains are shown in the blue box.

Click on any topic in the boxes to learn more.

 

 

 
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Understanding the policy context

Inclusive growth is one of the three priorities of the Europe 2020 Strategy – and its targets for 2020 include reducing the number of people at risk of poverty or social exclusion by 20 million. The European platform against poverty and social exclusion, one of the flagship initiatives under the Strategy, identifies health inequalities within Member States as a key concern. The proposed new Cohesion Policy regulations will require that at least 20% of European Social Fund resources is allocated to social inclusion and combating poverty.

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Developing projects

The causal pathway for water shows that efforts to improve social inclusion and combat poverty are an important driver of health gains in socio-economic development.   

 

The Approaches to Consider page shows a few good practice examples of projects that illustrate the positive impacts of social inclusion (including urban regeneration) on health gains.

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Developing Operational Programmes

There are a number of ways in which Structural Funds investment in social inclusion can affect public health. These include:

 

  • Improvements in the immediate environment in which people live, so as to reduce environment-related health risks and facilitate and promote physical activity
  • Enhance urban connectivity
  • Enhance access to local public facilities and spaces for recreation and social interaction
  • Improvements in safety and safety perception

 

The Approaches to Consider page provides examples of some of the linkages between health and social inclusion that can be considered within the Operational Programmes, and links to good examples from the project case studies and actual programme documents.

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Urbanisation

For the first time in history more than 50 % of the world’s population live in urban areas. By 2050, about 70 % of people are likely to be urban, compared with less than 30 % in 1950 (European Environment Agency, 2010: 15-18).

The European Region is becoming increasingly urbanized: by 2004, 80% of the population in high-income countries and 64% in medium- and low-income countries in the Region lived in urban areas (World Health Organization Regional Office for Europe, 2006: 13).

Cities concentrate investment and employment opportunities, promoting economic growth and increasing productivity. They provide higher-income jobs, as well as greater access to goods, services and facilities and improved health, literacy and quality of life.

Urban development offers unique chances for improvement in the quality of life and environmental protection if it is governed effectively. It offers major opportunities to reduce energy demand and minimise pressures on surrounding lands and natural resources, as a consequence of the concentrated form and efficiencies of scale in cities. However, poor governance can exacerbate two main environmental problems: poverty and increased affluence.

From (European Environment Agency, 2010: 15-18)

There are four main categories of problems that characterize rural areas in the EU and determine the risk of poverty and social exclusion:

  • demography: referring to out-migration, exodus and urbanization, counter urbanization and returning migrations and the ageing population;
  • remoteness: relating to lack of access to infrastructure and basic services;
  • education: general lack of preschool facilities, difficulties in accessing primary and secondary schools, inadequate strategies for grouping schools and lower quality of education;
  • the labour market: lower employment rates, persistent long-term unemployment, greater numbers of seasonal workers and low pensions, and also inadequate labour market institutions, mismatches between jobs and skills and lack of accessibility to workplaces.

Rural poverty influences, and is influenced by, demographic changes such as migration and ageing. Out-migration is a frequent means of achieving social mobility for many young people from disadvantaged families in rural areas. In western EU countries, there is a continuing trend of urbanization from more remote (poorer) rural areas to urban and accessible rural areas. Rural-to-urban and rural-to-abroad migration is under way in eastern countries of the European Region, with the latter particularly affecting young people.

From (World Health Organization Regional Office for Europe, 2010: 4)citing (European Commission, 2008)

Governments are withdrawing support from their agricultural sectors in favour of manufacturing and service sectors, and are overseeing the decline of peasant agriculture and a rise in agribusiness.

This development model encourages the relocation of agricultural production away from fertile, food-producing lands to allow urban expansion, and moves food production to regions rich in biodiversity and forests.

The model undermines the economic viability and physical sustainability of rural towns and villages.

The consequent rise of rural poverty, in turn, exacerbates the growth of cities, while the diminution in agricultural production encourages food imports and associated environmental problems.

From (Dixon et al., 2008: 5)

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Education

[ed note: Link to & text from Education Pathway – text to be provided]

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Equity: Distribution of wealth

Regions and urban areas that receive regeneration investment have low GDP and low levels of economic prosperity compared to national and EU averages. Regeneration investment will attempt to improve economic prosperity and reduce inequalities in the distribution of income.  

There are wide inequalities in the distribution of income among the population of the EU-27 between Member States, within Member States and for particular population groups.

In 2007 the 20 % of the population with the highest equivalised disposable income received five times as much income as the 20 % of the population with the lowest equivalised disposable income. This ratio varied considerably across the Member States, from 3.3 in Slovenia and 3.4 in Sweden, through 6.0 or more in Greece, Latvia and Portugal, to highs of 6.9 in Bulgaria and 7.8 in Romania.

Wide income inequalities were not confined to those countries with low GDP per capita. The distribution of income was noticeably more equitable in Slovakia and the Czech Republic, by way of example, than it was in the United Kingdom or Italy.

The average living standard in the EU is generally lower in rural than in urban areas (as expressed by gross domestic product (GDP) per head). In 19 of the 27 EU Member States, people in thinly populated areas are more at risk of poverty or social exclusion is higher than people in densely populated areas (29.8% compared to 22.2% in densely populated areas: data from 2008).

Different groups in society are more or less vulnerable to poverty: the unemployed (43% in EU-27 in 2007) and retired people (17% in EU-27 in 2007) are at particular risk of poverty.

From (Eurostat & European Commission, 2010: 320-321;World Health Organization Regional Office for Europe, 2010: 4)

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Equity: Gender

Gender is included as a pressure as, globally, it is a major determinant of disadvantage. Many households are headed by women, who usually have a lower status than men, and must earn money and care for their family in deplorable living and working conditions (Kjellstrom & Mercado, 2008: 562). There are close links between gender, education and governance and it is thus an important factor to consider when planning Structural Fund investments in regeneration.

The percentage of female-headed households varies from 20% in Greece and Portugal up to 42% in Denmark and Finland with the highest being 44% in Slovenia.

Much of the responsibility for long-term care continues to fall on families, and it is largely women who continue to meet the majority of society’s caring needs. Being a carer typically involves looking after children, or someone with a long-term physical or mental health disability, or with problems related to old age. The range of tasks performed and the time given to caring will vary. Women are more likely to be carers than men, both within the same household and outside the household. For example, a study in 2000 found that between 15% and 80% of carers in Germany are women.

From (European Institute of Women's Health, 2006: 6).

Gender is included as a pressure as, globally, it is a major determinant of disadvantage. Many households are headed by women, who usually have a lower status than men, and must earn money and care for their family in deplorable living and working conditions (Kjellstrom & Mercado, 2008: 562). There are close links between gender, education and governance and it is thus an important factor to consider when planning Structural Fund investments in regeneration.

The percentage of female-headed households varies from 20% in Greece and Portugal up to 42% in Denmark and Finland with the highest being 44% in Slovenia.

Much of the responsibility for long-term care continues to fall on families, and it is largely women who continue to meet the majority of society’s caring needs. Being a carer typically involves looking after children, or someone with a long-term physical or mental health disability, or with problems related to old age. The range of tasks performed and the time given to caring will vary. Women are more likely to be carers than men, both within the same household and outside the household. For example, a study in 2000 found that between 15% and 80% of carers in Germany are women.

From (European Institute of Women's Health, 2006: 6).

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Equity: Marginalised communities

Social cohesion among and between communities is a driver for European policy and the experience of migrants, and other marginalised groups, is important for the marginalised groups themselves and for wider society.

Discrimination, intolerance and stigma create barriers to health service access, and increase the health effects experienced by minority groups (Kjellstrom et al., 2008: 10).

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Governance

In the context of the current economic crisis the European Commission notes that countries with established governance arrangements and practices benefited from the engagement and mobilisation of stakeholders. Social partners played a key role in designing and implementing short term labour market measures to maintain people in jobs. Local authorities and NGOs across Europe had to meet increased demand for social benefits and services while often seeing their own revenue squeezed. Cooperation and coordination among these actors was a valuable asset (European Commission, 2010: 13).

Governance plays a central role in delivering health equity: society requires a strong public sector and strengthened governance (Commission on the Social Determinants of Health, 2008: 2). This is define as legitimacy, space, and support for:

  • civil society;
  • an accountable private sector; and
  • people across society to agree public interests and reinvest in the value of collective action.

It is difficult to ensure that members of a society have an equal capacity to participate, and that lay participants from local communities are on an equal footing with stakeholders from statutory agencies and private industry. While attention may be paid to issues that are most important for disadvantaged, or marginalised, minority communities, there is a risk that these issues will continue to be viewed in terms set by the elite or dominant groups.

Regeneration which benefits the majority of the population, in the ‘mainstream’ of society, may also cause ‘displacement’ of excluded groups, moving them to the edge or out of the community, to their further disadvantage.

From (Cave, Molyneux, & Coutts, 2004: 10)

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Land-take

The expansion of residential areas and construction sites is the main cause of the increase in the amount of urban land at the European level. As a result, agricultural zones and, to a lesser extent, forests and semi-natural and natural areas, are disappearing in favour of the development of artificial surfaces such as concrete or tarmac.

Across Europe, artificial land-cover increased by over 3% from 2000 to 2006. As urban sprawl has become diffuse, as a result more than one-quarter of EU territory is affected by urban areas.In addition to the loss of agricultural land, urban sprawl affects biodiversity since it decreases habitats, the living space of a number of species, and fragments the landscapes that support and connect them.

From (European Environment Agency, 2011).

Urban growth and sprawl will have indirect effects on health: it can reduce access to green and open land and thus opportunities for physical activity; and the reduction of arable land could affect food production and price. The loss of green areas may reduce natural capacities to absorb water during floods; and the growth of built-up areas will increase the “heat-island effect”: both these factors can have negative impacts on health.

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Migration

Rural poverty both influences, and is influenced by, demographic changes such as migration and ageing.

Out-migration is a frequent means of achieving social mobility for many young people from disadvantaged families in rural areas.

  • In western EU countries, there is a continuing trend of urbanization from more remote (poorer) rural areas to urban and accessible rural areas.
  • Rural-to-urban and rural-to-abroad migration is under way in eastern countries of the European Region: young people in particular are affected by rural-to-abroad migration.

From (World Health Organization Regional Office for Europe, 2010: 4)citing (European Commission, 2008).

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Built environment

At a city level across Europe living, working, shopping and leisure activities increasingly take place in different areas. This results in a greater demand for motorized mobility and reduced opportunities for activity in the neighbourhood (World Health Organization Regional Office for Europe, 2006: 13).

Opportunities for physical activity as a routine part of everyday life are decreasing and many social trends increasingly support sedentary behaviour.

Physical activity is strongly influenced by the design of cities through the density of residences, the mix of land uses, the degree to which streets are connected and the ability to walk from place to place, and the provision of and access to local public facilities and spaces for recreation and play (Commission on the Social Determinants of Health, 2008: 62)

[ed note: link to other pathways: waste; water; transport; soc infrastructure]

 

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Employment

A key issue for regeneration investments is to ensure that they benefit people from the areas on which they are targeted. This is a concern especially for employment opportunities.

One risk is that regeneration investments mainly create low paid, insecure, secondary sector, non-standard forms of employment rather than long-term jobs.

A further problem is that new jobs created by regeneration initiatives are often filled by workers from other parts of the city or rural area, rather than local populations in areas targeted for regeneration.

For example, a longitudinal study measured the health and economic changes experienced by residents in Johnson County, Tennessee, USA (Glenn, Beck, & Burkett, 1998). After a period of economic recession, the local economy improved but long term, non-migrating residents did not benefit from the regeneration. Instead, they experienced a significant decrease in average household income and in physical and mental health.

 [ed note: link to employment]

From (Cave, Molyneux, & Coutts, 2004: 45)

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Social capital

‘When trust and social networks flourish, individuals, firms, neighbourhoods, and even nations prosper’(Putnam, 2000: 319).

Social capital and the civic community is a basic prerequisite for a well-functioning democracy and a prosperous society. It eases co-operation and the attainment of collective common goals (van Schaik, 2002: 5).

Social capital operates at all levels in society: while it maintains and creates integration social capital can define groups and so it can maintain segregation.

A US survey found that individuals who report high levels of trust of others in the community benefit from living in places where other people shared that opinion (Subramanian, Kim, & Kawachi, 2002). The higher the level of trust reported within the community, the lower was the probability that trusting individuals would report poor self-rated health.

Social capital at the macro level is shaped by institutions, policies and cultures,. At local levels it is the density of social networks or patterns of civic engagement (Coutts et al., 2007).

Van Oorschot et al propose eight indicator scales for social capital (2006: 164): trustworthiness, political engagement, trust in institutions, trust in other people, passive and active participation in voluntary organizations, friends networking and family networking.

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Social resilience

This refers to the capacity to prevent; to cope; and/or to mitigate are important in maintaining social well-being (Spiegel et al., 2001). It is important for physical and for mental wellbeing.

Policies can increase wellbeing by concentrating on capability rather than merely on income and wealth. It is not just a question of the money or goods people have, but what these enable them to do.

Improvements in public infrastructure such as education, training and transport can raise wellbeing without any change in individual income.

From (Bartley, 2006: 7).

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Access to food

Obesity is a major and growing health concern, particularly among socially disadvantaged groups in many cities throughout the world.

The shift in population levels of weight towards obesity is related to the ‘nutrition transition’ – the increasing consumption of fats, sweeteners, energy-dense foods, and highly processed foods.

This, together with marked reductions in energy expenditure (ie physical activity), is believed to have contributed to the global obesity epidemic. The nutrition transition tends to begin in cities. This is due to a variety of factors including, accessibility and costs of healthy foods vs convenience foods, and acceptability of bulk purchases and ‘supersized’ portions.

From (Commission on the Social Determinants of Health, 2008: 62)

The affordability of city food supplies is a major consideration, given that urban residents purchase most of their food, as opposed to growing it, and the poorest in a country also spend disproportionately more of their income on food, up to 70% in some countries.

However, if the most affordable food is of poor nutritional worth, then nutritional improvements will not be served by lower prices on processed foods alone.

From (Dixon et al., 2008: 28)

Expenditure on food is often cut in favour of other bills: a survey across Eastern Europe (including countries that are not members of the European Union) reports that households have used a variety of methods to cope with the crisis. About 70% of households affected by the crisis report cutting back on spending on staple foods and health as a result of the crisis, a much higher proportion than in western Europe (European Bank of Reconstruction and Development, 2011: 4).

A final observation links food access and food safety to household, and to wider environmental, conditions: even if foods are in good phyto-sanitary order when they leave the vendor, household conditions are critical for the maintenance of food safety. Services like electricity and hygienic supplies of water, plus household items like refrigerators, and transport to and from shops, are imperative if food safety is to carry through the supply chain (Dixon et al., 2008: 27).

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Building/housing conditions

A recent WHO report examines in detail the following housing-related health effects (Braubach, Jacobs, & Ormandy, 2011):

  • damp and mould and asthma onset in children;
  • crowding and tuberculosis;
  • indoor cold and mortality;
  • traffic noise exposure and ischaemic heart disease;
  • indoor radon and lung cancer;
  • exposure to residential second-hand tobacco smoke and lower respiratory infections, asthma, heart disease and lung cancer;
  • lead in housing;
  • carbon monoxide poisoning;
  • formaldehyde and respiratory symptoms in children;
  • indoor smoke from solid fuel use; and
  • housing quality and mental health.

Poverty, poor housing, and poor health are usually linked, and this means that it is difficult to measure health gains from improvements to housing conditions alone.

Interventions most likely to lead to measurable health improvements are those that target groups in most need where the potential to benefit is greatest, i.e. residents in the poorest housing who are also most vulnerable to the detrimental health effects of poor housing (Thomson, 2011: 190-191).

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Knowledge of lifestyle risk factors

Health literacy refers to people’s ability to seek, understand and use information about healthcare and healthy lifestyles to promote and maintain good health.

Health literacy is dependent on basic literacy and plays a crucial role in enhancing or reducing individual vulnerability to health problems (Kjellstrom et al., 2008: 10).

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Neighbourhood conditions

Where people live affects their health and chances of leading flourishing lives. Communities and neighbourhoods that ensure access to basic goods, that are socially cohesive, that are designed to promote good physical and psychological wellbeing, and that are protective of the natural environment are essential for health equity. From (Commission on the Social Determinants of Health, 2008: 60).

The immediate environment in which people live also strongly influences their ability to be physically active. People living in deprived neighbourhoods are less likely to have easy access to the places that encourage exercise, such as safe streets and sidewalks, parks, paths and community gardens. In addition, they often face disproportionate safety risks related to traffic and the real or perceived risk of crime (World Health Organization Regional Office for Europe, 2006: 13;2007b: 7).

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Social infrastructure

Where people live and the daily conditions of their lives have a strong influence on health and health inequalities. Access to quality housing, services, green spaces, employment opportunities, transport and shops and exposure to crime, traffic and other health risks affect income, safety and behaviours that influence health.

There is substantial evidence of a social gradient in the quality of neighbourhoods. Poorer people are more likely to live in more deprived neighbourhoods. The more deprived the neighbourhood, the more likely it is to have social and environmental characteristics presenting risks to health.

From (Marmot et al., 2010: 78)

Challenges to health system performance in rural and disadvantaged areas can include:

  • a lack of qualified health workers;
  • greater distance to major hospitals;
  • lesser access to specialized services and pharmacies, health promotion and prevention activities;
  • financial barriers linked to lower incomes and insurance coverage, as well as higher costs for transportation and associated lodging;
  • lesser effective emergency care services;
  • lower quality infrastructure; and
  • potentially greater demands on health workers.

People belonging to minority groups are more likely to live in deprived rural or urban neighbourhoods. Discrimination, intolerance and stigma create barriers to health service access, and increase the health effects experienced by minority groups.

From (Kjellstrom et al., 2008: 10).

Adapted from (World Health Organization Regional Office for Europe, 2010: 2)

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Supportive relationships

Supportive relationships are very important for good mental health: supportive relationships include social support, social networks and social cohesion.

The Eurobarometer survey (European Opinion Research Group, 2003)showed the variations across the EU in the extent to which people recognize support for activity in their local areas. For example, 90% of people in the Netherlands agreed that “local sport clubs and other providers offer many opportunities for physical activity”, compared to 45% in Portugal and 54% in Italy (World Health Organization Regional Office for Europe, 2006: 13).

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Violence

More often it is the factors related to poverty, rather than poverty itself, which increase the risk for violence. Poor housing, lack of education, unemployment, and other poverty-related conditions are linked to youth violence placing some young people at heightened risk of being influenced by delinquent peers and participation in criminal activities. The rate at which people enter into poverty – losing resources that were previously available – and the differential way in which they experience poverty (that is, their relative deprivation within a particular setting rather than their absolute level of poverty) are also important (World Health Organization, 2002: 244).

Violence can be physical; sexual; or psychological in nature or it may involve deprivation or neglect. It can be:

  • self-directed including suicidal behaviour or self-abuse;
  • interpersonal including violence against family or partners and in the community against acquaintances or strangers; and
  • collective.

The World Health Organization defines violence as:

The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.

From (World Health Organization, 2002: 6-7)

Women are, by virtue of their sex, exposed to serious forms of ill-treatment, such as physical violence, rape, forced marriage or genital and sexual mutilation. Failure by state authorities to take effective measures to protect women against violence may amount to a violation of human rights. It also represents a serious obstacle to equality between women and men.

From (Directorate General of Human Rights and Legal Affairs, 2009)

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Incidence of violence

Rates of violent death vary across countries; national income levels are a key factor.

Violence exacts both a human and an economic toll on nations, costing the equivalent of billions of Euros each year in health care, legal costs, absenteeism from work and lost productivity. It is difficult to calculate the precise burden of all types of violence on health care systems, or their effects on economic productivity. The available evidence shows that victims of domestic and sexual violence have more health problems, significantly higher health care costs and more frequent visits to emergency departments throughout their lives than those without a history of abuse. The same is true for victims of childhood abuse and neglect. These costs contribute substantially to annual health care expenditures.

From (World Health Organization, 2002: 10-12).

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Injury

Injuries are a major European public health problem, representing the fourth major cause of death in the EU (after cardiovascular diseases, cancer and respiratory diseases).

Annually in the EU 60 million people – or 12% of the EU27 population - seek medical treatment for an injury. This corresponds to 50 million hospital days annually and a prevalence of more than 3 million disabled people to date. No numbers exist so far for the indirect and human costs of injuries (Angermann et al., 2007: 14-17). The statistics show an enormous economic and public health toll that differs between Member States. For example:

·         transport – 50,000 road fatalities in the EU per year - ranging from 4 per 100,000 inhabitants in Malta to 22 in Lithuania;

·         work place safety – 6,000 occupational fatalities in the EU; and

·         home and leisure – more than 100,000 fatalities in the EU.

In children, adolescents and young adults, accidents and injuries are the number one killer. Every year over 250,000 people in the EU27 Member States lose their lives as a result of an accident or due to violence. Annually, more than 60 million people receive medical treatment for an injury, from which an estimated 7 million are admitted to hospital. Two-thirds of all injuries occur in home and leisure environments - a trend that is unfortunately on the increase across Europe.

From (DG SANCO, 2006)

The leading mechanisms of death from unintentional injury in children are all amenable to investments for urban and rural regeneration. They are:

·         road traffic crashes;

·         drowning;

·         poisoning;

·         thermal injuries; and

·         falls.

The burden always falls heaviest on the most disadvantaged children and on those countries undergoing the greatest socioeconomic change. Death rates from unintentional injury among children vary by as much as nine times by socioeconomic stratum in some countries. Migrant children have 3-4 times the death rates from injuries than native populations (MacKay & Vincenten, 2009: 67). This unequal distribution of injuries threatens to further widen the gap in inequality in health between and within countries and it causes social injustice (World Health Organization Regional Office for Europe, 2008: xii).

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Mental health

Poverty threatens mental health in urban and in rural areas.

Poor housing conditions, overcrowding, noise pollution, unemployment, poverty, crime and fear of crime and cultural dislocation can cause or exacerbate a range of mental health problems, including anxiety, depression, insomnia and substance abuse. Overall rates of mental health service use are generally lower amongst the disadvantaged. Low mental health literacy and stigma may reduce the ability of people with depression to use treatment services effectively.

From (World Health Organization, 2010: 116)

Mental health is a growing component of the global burden of disease, and depression is responsible for the greatest burden attributed to non-fatal outcomes, accounting for 12% of total years lived with disability worldwide.

A growing body of evidence shows urban predisposition to mental health problems. For example, community-based studies of mental health in developing countries show that 12%–51% of urban adults suffer from some form of depression (Kjellstrom & Mercado, 2008: 557).

People migrate for many different reasons and a detailed analysis of the needs of migrants would not place all in migrants in a single category. That said, migrants are at high risk of poverty (Lelkes & Zólyomi, 2011)and mental health risk in some immigrant groups in Europe is high. It manifests itself through: high rates of schizophrenia; suicide; alcohol and drug abuse; access of psychiatric facilities; and risk of anxiety and depression (Carta et al., 2005). Migrants, and their children, face poor access to and experience of health services (Chauvin, Parizot, & Simonniot, 2009).

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Non-communicable diseases

Europe today has a high prevalence of non-communicable diseases such as

  • cardiovascular diseases (CVD);
  • cancer;
  • diabetes;
  • cardiovascular diseases;
  • obesity disorders; and
  • musculoskeletal disorders.

CVD affect the heart and surrounding blood vessels and can take many forms, such as high blood pressure, coronary artery disease, heart disease and stroke. CVD are the largest cause of death in the EU and account for approximately 40% of deaths or 2 million deaths per year.

These non-communicable diseases can be attributed to the interaction of genetic, environmental and lifestyle factors.

The lifestyle factors include:

  • tobacco use;
  • nutrition and physical activity;
  • alcohol consumption; and
  • psychosocial stress.

From (DG SANCO, 2011a;2011b)

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Obesity

The proportion of the population that is overweight has increased considerably in most Member States over the last decade, resulting in approximately half the EU population being overweight or obese.

In 2003 the highest rates were recorded in the United Kingdom (61.0 %, England only) and Germany (59.7 %) (9), while Italy and France were the only Member States to report less than 40 % of their population as either overweight or obese From (Eurostat & European Commission, 2010: 232).

Findings from the 2002 Eurobarometer study suggest that two thirds of the adult population in European Union (EU) countries are insufficiently physically active to achieve optimal health benefits (World Health Organization Regional Office for Europe, 2007a: 6-7).

Physical activity is generally defined as any bodily movement produced by skeletal muscles that results in energy expenditure above resting level (World Health Organization Regional Office for Europe, 2007a: 6-7).

The economic consequences of physical inactivity have been shown to be substantial in terms of health care costs, but even greater in indirect costs. These include the value of economic output lost because of illness, disease-related work disabilities and premature death.

The cost in monetary terms is estimated to be €910 million a year for a population of 10 million where half the population is too inactive to enjoy health benefits from regular physical activity.

It is calculated that 3.1 million extra days of sick leave each year are attributable to physical inactivity in a population of 5.5 million people.

From (World Health Organization Regional Office for Europe, 2007a: 9)

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Self-rated health, satisfaction and well-being

The level of satisfaction that people express in communities, neighbourhoods and wider society is important. It is affected by many factors and, thus as an indicator of wellbeing, it applies across many sectors. It is an accurate predictor of health outcomes and, unlike other health outcomes, it can be directly affected by regeneration investment.

A country-level survey of people across Eastern Europe looked at people’s overall sense of well-being and optimism, their views on markets, democracy and the role of the government, and their attitudes towards particular population groups. The survey looked also at comparators in western Europe: it found that few countries in Eastern Europe come close to the levels of satisfaction in western Europe. On a scale of life satisfaction four of the top five were western European countries. Income was not the sole determinant of life satisfaction as Hungary was second to last while one of the poorest countries, Tajikistan, ranking third.

Self-reported health status was found to have a particularly strong impact on a person’s life satisfaction: someone who described themselves as being in very bad health was significantly lower on the satisfaction scale relative to a very healthy person.

From (European Bank of Reconstruction and Development, 2011: 20-21).

Within the EU-27, some 29.1 % of men and 33.4 % of women (aged 18 or more) said they had a long-standing illness or health problem.

In each Member State, the proportion of women that reported that they had such a long-standing problem was higher than the corresponding proportion for men although in the United Kingdom the proportion of men was less than 1 percentage point lower than that for women.

This difference between the sexes rose to over 9 percentage points in Latvia and Slovakia.

Overall, the highest proportions of people reporting long-standing illnesses or health problems were in Finland and Estonia, where the proportions for both men and women were around two fifths, while the lowest proportions were recorded in Romania, Italy and Greece.

(Eurostat & European Commission, 2010: 233)

People who are engaged in local activities, who meet friends or relatives regularly, and who help others are more likely to report higher levels of happiness or life satisfaction. The relationship is positive, albeit somewhat modest: other personal characteristics also play a major role in wellbeing. Income, employment status - but also health, marital status, age and a number of other factors - influence the level of subjective well-being. All in all, social contacts, helping others or being engaged in voluntary organizations are activities that are positively correlated with well-being (European Commission & Eurostat, 2009: 24-26).