Within the last decade the dearth of robust evidence demonstrating the impact of area-based regeneration on health and health inequalities has been widely lamented, (e.g. Wanless 2004, Rhodes et al. 2005, Kearnset al. 2009), meaning that policy makers have been unable to draw firm conclusions as to how area-based initiatives impact on residents’ health. This lack of evidence has been attributed to many factors. For example, Mackenbach (2003) posited that many policies and interventions targeting health inequalities have simply not been evaluated, and those that were suffered in that they were not evaluated adequately. Similarly Rhodes et al. (2005) pointed to three
27 central deficiencies in past evaluations: (1) A limited understanding of the theory of change buttressing the policy action; (2) inadequate methods; (3) a focus on process and outputs as opposed to a focus on key outcome measures. As a result, calls have been made to introduce quasi- experimental designs, natural experiments and (if possible) randomised controlled trials to more rigorously asses the health and other impacts of regeneration interventions (e.g. Wanless 2004; Petticrew et al. 2004; Rhodeset al. 2005; Thomson et al. 2006,2007; Thomson 2007). There are well- documented difficulties associated with attempts to rigorously evaluate area regeneration practices. For example, Petticrew et al. (2005) stated that area-based regeneration is amongst a group of public health interventions (along with new roads and new housing) that are theorised to affect health inequalities but are often not amenable to randomisation for practical and political reasons. For example, practical difficulties would arise if a researcher has no control over how a government area regeneration programme is rolled-out, and it would be politically problematic and ethically dubious for a local authority to attempt to withhold a possibly beneficial intervention from a control group.
However, there are prominent examples from the USA where randomisation has been used to do exactly this. For example, the Moving to Opportunity programme which began in 1994 was a randomized, controlled trial in which families from public housing in high-poverty neighborhoods were moved into private housing in near-poor or non- poor neighborhoods, with a subset remaining in public housing (Leventhal & Brooks-Gunn 2003). Families in disadvantaged areas were randomised using a lottery system which assigned them to one of three groups: an experimental group who received a Section 8 voucher (a voucher that provides rent subsidies to purchase approved housing in the private market (Leventhal & Brooks-Gunn 2003)) and mobility counselling, but who had to move to a low poverty neighbourhood; a Section 8 group who received the voucher only, and had no restriction on where they moved to; and a control group who did not receive a voucher or any other assistance (Kearns et al. 2009). This approach has its critics for denying assistance to individuals who may benefit from the intervention (e.g. Bryson et al. 2002), however all participants in the MTO programme provided informed consent (Feins et al. 1996) and thus were well aware that they may not receive assistance.
In the UK, approaches to evaluating the impact of regeneration interventions by randomising residents to treatment and control groups have not been pursued by policy makers designing the large holistic programmes that have been rolled out since the 1990s. Petticrew et al. (2005) have thus argued that in the case of these initiatives, researchers can partially “fill the gaps” in knowledge by exploiting opportunities offered by natural experiments. Similarly Des Jarlais et al. (2004)
28 concluded that non-randomised evaluation designs such as quasi-experimental designs, non- randomised trials and natural experiments should be employed as they can “provide a more integrated picture of the existing evidence and could help to strengthen public health practice”.
Nevertheless, difficulties in designing quasi-experimental or natural experiments remain. For example, the conclusions offered by Cotterill et al’s (2008) study, which is geared towards evaluating the health impacts of the New Deal for Communities (NDC) regeneration initiative using a quasi- experimental design, state that the evaluation of regeneration initiatives is “extremely challenging” due to the fact that these initiatives “represent complex multi-faceted community-based interventions that are operationalised within dynamic systems subject to many competing influences”. In addition, Thomson et al. (2008) stated that conducting community-based quasi- experimental evaluations that are powered to detect small impacts among individuals over long periods are neither straightforward from a pragmatic point of view nor cheap. They too pointed to issues of being unable to control the timing of interventions and problems of increasing attrition in deprived communities likely to be targeted by area-based interventions. Furthermore, Thomson et al. (2008:934) stated that even an evaluation which achieves 100% response and incorporates a ten- year (or longer) follow-up may still be unable to generate the desired evidence due to the introduction of confounding factors:
“Even in the short term, impacts are likely to occur in conjunction with other changes which may or may not be associated with the intervention. Extended follow-up inevitably introduces further multiple confounding due to other changes over time, be they at an individual area or societal level; and intensive longitudinal tracking of individuals may themselves have to be quite interventionist, and thus, introduce an additional confounder which is difficult to control for.”
These examples, give an indication of the myriad difficulties surrounding the evaluation of the effects that area regeneration initiatives have on health and well-being. With this in mind, the following section will present an overview of a selection of these UK-based studies sequentially in order to shed light on the current progress of research concerned with evaluating the effects of area regeneration programmes on health and well-being outcomes. All but two of the studies selected for discussion have been published after Hilary Thomson et al’s (2006) widely cited systematic review of the impacts of area regeneration on health, which found little evidence of a positive impact of national urban regeneration investment on socio-economic or health outcomes. The studies that I include which were published before 2006 are by Huxley and colleagues (2004) and Huxley (2005), which are part of a group of publications from an evaluation of the impact of the SRB programme on mental health. These studies appear not to have been found in the literature search conducted by Thomson et al. (2006). The selected studies focus on large UK-based area regeneration programmes
29 that had an economic, social and physical focus using a variety of methodological approaches. The seven studies chosen are from the UK only in order to maximise relevance to the current evaluation for the following reasons. Firstly, the programmes considered in the studies chosen for discussion are of the holistic types that have been developed in the UK since the early 1990s, such as the SARP. These differ from other programmes such as the above mentioned Moving to Opportunity programme and other programmes from the USA such as HOPE VI (Popkin et al. 2004) which focus on housing renewal. Thus, the British holistic programmes have, in addition to housing issues, adopted a focus on tackling health issues (through health promotion for example) and employability via training courses. Furthermore, these British programmes did not facilitate the evaluation process by randomising residents to treatment and control groups at the outset of the intervention. Thus the researchers evaluating these UK-based programmes had to negotiate the same issues that I will tackle in this study in terms of how to best evaluate a programme that had already started without the gold standard evaluation approach of randomisation. The studies included here adopted diverse methodological strategies to conduct evaluations such as employing quasi-experimental techniques to evaluate the impact of the programmes in order to obtain a degree of generalizability, or instead conducted qualitative research in regeneration areas, or alternatively combined quasi-experimental work with qualitative research in a single study, which has been advocated by the likes of Petticrew et al. (2005). I will therefore evaluate these studies in the following section with the aim of learning lessons that will help to develop the evaluation strategy used in this study.
Section 2.5 Contemporary approaches to evaluating the impacts of area regeneration on