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Int. J. Environment and Pollution, Vol. 30, Nos. 3/4, 2007

Residential conditions and their impact on residential


environment satisfaction and health: results of the
WHO large analysis and review of European housing
and health status (LARES) study
Matthias Braubach
WHO Regional Office for Europe,
European Centre for Environment and Health, Bonn, Germany
E-mail: mbr@ecehbonn.euro.who.int
Abstract: Recent research into urban patterns and residential conditions has
shown that neighbourhood conditions are associated with both residential
environment satisfaction, and health and well-being. Multivariate analyses
performed on the LARES database confirmed that various environmental
characteristics (noise, lack of recreational areas, perception of fear, low
maintenance, etc.) show significant associations with residential environment
satisfaction. An increased likelihood for sleep disturbance is identified for
noise exposure, lack of recreational areas and the perception of fear,
while depression is related to noise exposure and safety perceptions.
Cardiovascular symptoms only showed a significant association with the
perception of safety.
Keywords: housing and health; residential environment; residential
satisfaction; sleep; depression; cardiovascular symptoms; neighbourhoods;
urban planning.
Reference to this paper should be made as follows: Braubach, M. (2007)
Residential conditions and their impact on residential environment satisfaction
and health: results of the WHO large analysis and review of European housing
and health status (LARES) study, Int. J. Environment and Pollution, Vol. 30,
Nos. 3/4, pp.384403.
Biographical notes: Matthias Braubach holds a Degree in Geography
(focusing on urban and environmental issues) and a Master in Public Health.
He works for the WHO Regional Office for Europe (European Centre for
Environment and Health, Bonn office) as a Technical Officer for Housing and
Health. He works on the health relevance of the residential environment, the
housing challenge for ageing societies, the health effects of housing insulation,
and the development of a burden of disease assessment for inadequate housing
conditions. Since July 2006, he is the head of the housing and health program.

Copyright 2007 Inderscience Enterprises Ltd.

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Introduction: urban settings, housing environments and well-being

The considerable differences in the health status of populations that exist within cities
may partially be explained by the environmental conditions provided in the different
neighbourhoods. Empirical research has shown that within cities and neighbourhoods,
health differences can be extreme (e.g., Cohen et al., 2003; Macintyre et al., 2003;
Stafford and Marmot, 2003; Mackenbach and Howden-Chapman, 2002). It has been
argued that
individual or household level socio-economic factors can explain most of
these area differences in health. On the other hand, other studies hypothesise
that ecological or environmental effects on health exist, independent of
individual or household level factors. (Chandola, 2001 p.105)

One of the main concerns in current research on the relationship between neighbourhood
quality and health effects is therefore, to identify the association between the quality and
perception of physical and social characteristics of the residential area and the health
status of residents (Wilson et al., 2004). Various research projects and publications show
that next to the housing quality, the impact of the residential environment is a relevant
health determinant (Ellaway et al., 2001; van Poll, 1997). In addition to the mere physical
and architectural quality, the neighbourhood is also affected by social and community
level parameters such as social cohesion or safety. The common use of public spaces
leads to social and functional conflicts and thereby brings a new dimension into the
residential environment that is fundamentally different from the residential experience
within ones four walls, where no compromises and negotiations with neighbours are
required.
The approach of the LARES survey and the general WHO approach to housing and
health is based on four dimensions of housing:

the home as a refuge and safe haven

the building as the physical shelter

the neighbourhood/community as the social climate surrounding the residential place

the immediate housing and residential environment as the physical infrastructure of


the residential place.

The LARES survey intentionally defines the surrounding areas around the house as a part
of the residential experience. As well, it includes data on the subjectively perceived social
and psychological dimension of the residential environment and does not limit data
collection to information on the physical surrounding, exclusively.
Assuming that individual health and well-being is the result of the interaction
between
a

the characteristics of physical and psychosocial environments

the subjective perceptions and evaluations of these surroundings by the individual


(see Figure 1), both objective and subjective factors are shaping the residential
satisfaction (Amerigo and Aragones, 1997) and affect the health of the residents of a
given area.

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M. Braubach

Figure 1

Objective and subjective factors for health and well-being

The same objective level of noise or air pollution can either be interpreted by a resident
as a normal consequence of urban life thereby indirectly accepting it or as a limiting
factor for the health related quality of life that has to be counteracted. In the latter case,
inadequate residential settings may represent a pathogenic residential health context that
may be expressed in the residents through stress, mental imbalance or direct and indirect
health effects.
Although urban planning processes are and always have been strongly informed
by public health arguments (WHO Regional Office for Europe, 1999), a variety of
stressors and health risks still exists in residential environments. The closeness of people
and the complexity of urban living make cities a place of constant negotiation of living
conditions. In addition, it has been found that architects and building professionals show
less interest in evaluating the performance of their urban buildings and neighbourhoods
than in the development of new (Brown, 2003), implying that there is still space for
improvement.
It is a challenge to create residential environments that support the health and
wellbeing of the residents and provide high levels of satisfaction (van Kamp et al., 2003;
Amerigo and Aragones, 1997; Sime, 1986). Residential environments may have their
strongest impacts on children and sick or disabled persons, who spend most of their time
in the neighbourhood, and are more vulnerable to health threats within that setting. It has
been acknowledged by many public health researchers that environmental prevention
should receive increased attention (Stokols et al., 2003; WHO Regional Office for
Europe, 1986) instead of relying on health care systems. In this context, the increased
interest in the health relevance of the place raises the question as to whether healthy
residential settings can support and maintain the health status of healthy people and
prevent ill health (Bistrup, 1991).
The development of healthy residential settings would be an ideal way to implement
the objectives of public health, which have been defined as (a) the reduction of social
and health inequalities (b) the striving for health sustaining environments (McMichael
and Beaglehole, 2000, p.495).

Residential quality and health: empirical findings

Recent work carried out by researchers such as Ellaway and Macintyre (2000),
Cattell (2001), Dunn (2002), Stafford and Marmot (2003), Evans (2003) and Latkin and
Curry (2003) provided mounting evidence that the health status of residents is affected by
the quality of the residential conditions and the built environment. This influence is based
on two mechanisms: Firstly, improved residential quality and reduced residential
stressors directly lead to lower exposure to pathogenic factors. Secondly, improved

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residential quality and attractiveness of neighbourhoods increase the residential


satisfaction of the residents and provide a more positive interpretation and evaluation of
neighbourhood life and living conditions, while residential problems that cannot be
escaped from, provide dissatisfaction and frustration.
It seems natural that the first mechanism will have a direct bearing on the physical
health of residents, although the latter pathway may be more relevant for social and
mental health.
Despite the diversity of areas, and the uniqueness of local problems, there are five
general types of features of local areas that appear to have a direct or indirect influence
on health, and are of relevance for any neighbourhood (Macintyre and Ellaway, 2000).
These overarching features are

physical characteristics of the shared environment

healthy environments in general, referring to the conditions at, and the functionality
of, home, work, school or recreational settings

services provided to support the daily life of residents

sociocultural features of neighbourhoods

the reputation of the neighbourhood.

These five points indicate that residential neighbourhood quality covers a whole range of
aspects, including physical and social characteristics as well as subjective dimensions.
Neighbourhood effects on health and well-being have received increasing interest in
recent years and various research projects have attempted to identify the health impact of
contextual and/or environmental factors. Urban and residential health research therefore
mostly deals with the mental and social effects of the physical and built environments
(Evans, 2003; Jackson, 2003; Twiss, 2003). In urban planning and landscape architecture,
numerous publications also emphasise the meaning and importance of public and social
places (Thompson, 2002), green and open spaces, and vegetation in urban settings
(Attwell, 2000; Botkin and Beveridge, 1997). Urban ecology is a major field within urban
planning, and concepts such as the urban green structure aim at improving the liveability
of cities (Jensen et al., 2000; WHO Regional Office for Europe, 1997), including
ecological as well as urban and recreational functions. Urban design discusses issues of
accessibility and participation while trying to make cities integrative spaces for all groups
of society (Imrie, 2000). Evidence from various studies indicates that the view of natural
scenery positively affects mental capacity and physiological indicators such as mood
states and stress hormones (Kaplan, 1995; Ulrich, 1991). Next to the effects on health,
residential satisfaction studies and projects on the neighbourhood quality have been able
to link almost all physical and social aspects of neighbourhoods to the residents
subjective assessment of the quality and the satisfaction with the residential environment
(Trkoglu, 1997; Anderson and Weidemann, 1997). It is therefore likely that residential
environment satisfaction is closely related to health related quality of life, but so far this
has only been tested in relation to the mobility of residents (Kahlmeier et al., 2001).

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The availability and quality of green open spaces and places for physical
exercise has been associated with the rising epidemic of obesity (Hume et al., 2005;
de Bourdeaudhuij et al., 2003; Emery et al., 2003; Giles-Corti and Donovan, 2003), as
well as the perception of safety and the conditions of playgrounds etc. In addition to
the decreased use of neighbourhood amenities in unsafe and deteriorating areas, the
perception of insecurity has been identified as a health threat per se (Latkin and
Curry, 2003; Austin et al., 2002; Green et al., 2002, Chandola, 2001) that is capable of
strongly affecting the life of residents and impacting their mental balance.
Environmental pollution present in the neighbourhood through litter, bad smells
and fumes, and animal excrements (Ellaway et al., 2001; van Poll, 1997) limits not only
the aesthetic value of the neighbourhood and its usability, it also threatens physical
and mental health by posing the risk of allergies, respiratory effects, and general
discomfort and irritation. Noise exposure, probably the largest reason for environmental
pollution in urban settings, is increasing in most European cities (Sharp, 2002) and
has been linked with sleep disturbance, emotional and hormonal effects and increased
risk of cardiovascular effects (Stansfeld and Matheson, 2003; Lercher et al., 2002;
Babisch, 2001). Studies on children also found cognitive and social effects of night noise
exposure, e.g., expressed by an impaired ability for learning in school (Maschke et al.,
2001; Stansfeld et al., 2000).
The location and the general structure of neighbourhoods are relevant factors
for exposure to traffic flows at the origin of noise as well as air pollution and
the inclusion of city quarters into public life and their proximity to public services
and amenities (Thomson et al., 2003). Furthermore, the exposure to traffic flows
also increases the necessity for security measures in order to avoid accidents
(Nakahara et al., 2004).
Stress and related health effects arise most often from a lack of one or several of
the necessary features of residential neighbourhoods (Halpern, 1995). Severe limitations
in the quality of life result from the collision of too many discordant expectations
towards residential environments, possibly leading to social tension and conflicts
(Thompson, 2002).

Analytical objectives and data selection

The analytical work presented here attempts to identify the impact of the residential
housing environment on (a) the satisfaction with the residential environment and (b) the
health status of residents, using the WHO LARES data set.
The survey was carried out in eight cities of Europe in 20022003 and constitutes
a database of 3373 households and 8519 individuals (further information at www.euro.
who.int/housing).
The analysis was based on a variety of characteristics of housing environment such
as greenery, playgrounds, security, and cleanliness/maintenance issues (taken from
the inhabitant questionnaire and the inspection sheet). Data on the building and
neighbourhood types, and their location, were taken from a housing inspection sheet,
while the residential environment satisfaction was obtained through an inhabitant
questionnaire. Data on noise exposure, mental health, sleep disturbance, and the
prevalence of diagnosed diseases such as cardiovascular symptoms were collected from a
health questionnaire. In addition, personal characteristics (age, gender, socioeconomic

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389

status (SES), functional limitations) were obtained through the health questionnaire
as well.
The database enables a variety of investigations linking the residential quality of
the housing environment with a number of health outcomes while adjusting for individual
characteristics of the residents. Although the results of this cross sectional study cannot
be interpreted as causal evidence, they are capable of providing important indications on
the existence and the strength of associations between the residential environment, and
the health status of the residents.

Methods

The results presented are based on multivariate logistic regression models. These models
use various residential environment characteristics as independent variables, which are
selected on the basis of a literature review on residential environments and health, and
the results of a correlation test using the Spearman rank correlation coefficient.
The chosen independent variables are related to the aspects identified as some of the most
relevant residential and urban stressors (see Table 1). For the analysis, all variables were
transferred into a dichotomous format.
Table 1

Independent variables used for analysis

Residential
environment category
Greenery, public
spaces, and play areas

Noise exposure
Public safety

Upkeep and
maintenance

Independent variable

Original variable format

Vegetation along streets

Binary variable (Yes No)

Play areas for children

3 point scale (Yes to some


extent No)

Place to sit and relax outside of


dwelling

Binary variable (Yes No)

Traffic noise

5 point scale (not at all extreme)

Surrounding area noise

5 point scale (not at all extreme)

Safety perception in residential area 3 point scale (Yes to some


at night
extent No)
Feeling of safety in the dwelling

5 point scale (strongly


agree strongly disagree)

Graffiti on residential buildings

4 point scale (No one or


two three to five six and more)

Litter and trash in residential


environment

5 point scale (Very dirty/littered


not at all dirty/littered)

As dependent outcome variables, residential environment satisfaction and three specific


health outcomes (sleep disturbance, depression, and cardiovascular symptoms) have been
selected (see Table 2).

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Table 2

Dependent variables used for analysis

Outcome variables

Dependent variable

Original variable format

Satisfaction

Residential environment
satisfaction

5 point scale (very good very


bad living area assessment)

Sleep

Sleep disturbance

Binary variable (Yes No)

Mental health

Depression screening tool


SALSA

Four aggregated binary variables


(Yes No) based on sleep,
motivation, self esteem and
appetite)

Circulatory system

Cardiovascular symptom index

Three aggregated binary variables


(Yes No) based on diagnosed
hypertension, heart attacks and
strokes

For each outcome variable, an individual regression model was computed. All regression
models included the variable city in order to control for the variation among the eight
cities included in the database. It was perceived as very important to make sure that
identified differences could not be attributed to city differences, and would have only
little relation to residential conditions.
To adjust for the confounding influences of known health determinants related to
individual characteristics, the four variables age group (child adult senior), gender
(male female), SES score (high low) and functional limitations (yes no) were
selected as potential confounding variables to be tested for.
Each regression model was run in two steps. With the first step, the direct impact of
the selected residential environment characteristics on the four selected outcome
variables was tested. The second step included also, the four confounder variables, testing
the stability of the associations found during the first step.

Results

Table 3 shows the results of four independent regression models using diverse outcomes
as the criterion variable. Each regression was done in two steps, with the first step
covering the residential environment characteristics only, and the second step covering
both the residential environment characteristics and the personal characteristics of the
residents.

5.1 Low residential environment satisfaction


The results for the model Low residential environment satisfaction (low RES) (Step 1)
indicate that all nine selected residential environment variables provide a significant
influence on the occurrence of low RES. The highest impact is identified for surrounding
area noise and play areas for children, while feeling of safety in the dwelling shows
the lowest association.

Residential conditions and their impact on residential environment


Table 3

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Logistic regression results: examining the impact of the residential environment on


residential environment satisfaction and health outcomes

392
Table 3

M. Braubach
Logistic regression results: examining the impact of the residential environment on
residential environment satisfaction and health outcomes (continued)

Residential conditions and their impact on residential environment


Table 3

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Logistic regression results: examining the impact of the residential environment on


residential environment satisfaction and health outcomes (continued)

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M. Braubach

The integration of individual characteristics (Step 2) does not lead to any relevant
change, as all residential environment variables remain significant. Furthermore, the odds
ratio (OR) values of low RES, change only very little for the individual residential
environment variables, and in seven out of nine cases it even slightly strengthens the
odds of low RES. The low impact of individual characteristics on RES is also visible in
the OR values for the individual characteristics, out of which only children provide a
significant association.
After inclusion of the individual characteristics, noise exposure is identified as
the largest cause of low RES: surrounding area noise shows, by far, the highest impact
of all variables (OR of 2.89), while traffic noise doubles the odds of a bad assessment of
the residential environment. The impact of play areas for children, however, remains
the second strongest influencing factor with an OR of 2.13. Litter and trash in residential
environment, providing an OR of 1.87, show that the aesthetic perception of
environmental pollution also has a significant impact on RES.

5.2 Sleep disturbance


Model 2, analysing the impact of the residential environment on sleep disturbance, is
naturally dominated by the impact of the residential environment especially the two
noise variables (traffic noise, surrounding area noise). In Step 1, all residential
environment variables except vegetation along streets and graffiti on residential
buildings show a significant association with reported sleep disturbance, but for three
variables only, there are strongly increased odds ratios (traffic noise and surrounding
area noise with ORs over 6; and feeling of safety in the dwelling with an OR of 2.53).
The full model, including personal characteristics (Step 2), shows a very modest
impact of the individual characteristics of the residents, and consequently does not
provide any relevant change to the impact of the residential environment on sleep
disturbance. All seven significant variables remain significant, and there are only
extremely small changes for the OR and CI values. This is especially valid for traffic
noise, which was identified as the most relevant predictor of sleep disturbance in Step 1,
and only shows an OR decrease from 6.52 to 6.42 after the inclusion of the confounders.
Similarly, surrounding area noise and feeling of safety in the dwelling remain much
more relevant than any of the other significant residential characteristics.
Compared to the strong influence of the environmental variables, there is almost
no significant impact of any personal characteristics except for age group, in which
adults are slightly more likely to suffer from sleep disturbance than the elderly (OR 1.23).
The results therefore clearly show that for reported sleep disturbance, the contextual
dimension is much more relevant than compositional factors.

5.3 Depression
The third model, assessing the impact of the residential environment on depression as an
indicator for mental health status, tries to focus in more detail on the mental health
dimension that was already uncovered by the analysis for sleep disturbance. Step 1
identifies four residential environment variables that are significantly associated with
depression: traffic noise, surrounding area noise, safety perception in residential area
at night and feeling of safety in the dwelling, with surrounding area noise being more

Residential conditions and their impact on residential environment

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relevant than traffic noise and feeling of safety in the dwelling being more relevant
than safety perception in residential areas at night.
Again, the integration of the confounding factors in Step 2 does not provide
any significant change in the interactions between the residential environment and
depression, and only slightly alters the OR and CI values of the residential environment
variables. Surrounding area noise (OR reduction from 2.15 to 2.13) and feeling of
safety in the dwelling (OR reduction from 2.3 to 2.11) therefore, remain the most
relevant environmental predictors for depression, while traffic noise (OR reduction
from 1.56 to 1.41) and safety perception in residential areas at night (OR reduction
from 1.42 to 1.3) also remain significant. All other residential environment variables are
not significant, although recreational factors (play areas for children and place to sit
and relax outside of dwelling) and litter and trash in residential environment show
increased ORs for depression that do not remain significant.
However, different from the model for sleep disturbance, all individual characteristics
provide a significant influence on depression especially age group (OR 0.34 for
children compared to elderly) and functional limitations (OR 2.6 for handicapped
persons). SES (OR 1.42) and gender (OR 0.59) show OR values that are weaker than
those of surrounding area noise or feeling of safety in dwelling, showing that the
impact of the residential environment conditions matches or even exceeds the impact of
SES on depression.

5.4 Cardiovascular symptoms


Finally, the last model for cardiovascular symptoms tried to assess the effect of
the residential environment on the circulatory system, based on research findings
(Sundquist et al., 2004; Diez Roux, 2001) that have shown the impact of neighbourhood
conditions on cardiovascular health. Step 1 identifies three significant residential
environment variables (vegetation along streets, traffic noise, and safety perception in
residential area at night), but the OR values are rather low (ranging from 1.24 to 1.34).
The integration of the individual characteristics in Step 2 changes the results to a
large extent. Safety perception in residential area at night (OR 1.22) is the only
contextual variable that remains significant in Step 2. Traffic noise, representing
the residential environment variable with the highest OR (1.24), is not significant
(CI 0.981.57). All other environmental variables show very little influence, as their ORs
range closely around 1 (0.951.09).
Vice versa, all individual characteristics provide a significant influence on
cardiovascular symptoms, although age group shows, by far, the largest OR variation.
Socioeconomic status (OR 1.48 for low SES) and gender (OR 0.85 for males) provide
relatively little influence on the prevalence of cardiovascular symptoms.

Discussion

The results of the first model, identifying the relevance of neighbourhood characteristics
for the satisfaction with the local environment, clearly showed that the general
assessment of the residential environment quality is strongly shaped by the individual
residential environment characteristics. While all residential environment variables
provided significantly increased OR for low RES, there was only one individual factor

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children (under age group) that also showed significant influence. It is likely that this
could be an artefact, as children did not make a vote themselves the assessment of the
household head who answered the inhabitant questionnaire was used as a proxy.
It is therefore possible that families with children may have a slightly more negative
assessment of their residential environments, which then leads to a biased result for
children. Such an assumption is easy to justify as one can easily imagine that households
with children may have specific expectations and requirements for their residential
environment and therefore more easily report negative assessments. A potential
indication for this is the OR of 2.13 for the lack of play areas for children, which is the
second highest OR after surrounding area noise.
Although noise is identified as a major cause for low RES, the variation between
traffic noise and surrounding area noise shows that neighbourhood noise source
may even have a stronger impact on residential well-being than traffic induced
noise possibly due to the fact that noise from the surrounding area may have some
social and emotional dimensions attached to it, which may alter the subjective annoyance
caused by it. As well, traffic noise usually decreases in the evening and on weekends,
while surrounding area noise may have its exposure peaks exactly in these hours.
Finally, a strong distinction is visible for the two safety variables: while a lack of
safety perception in residential area at night increases the chance of low RES at a highly
significant level (OR 2.03, CI 1.72-2.39), the perception of feeling of safety in the
dwelling (OR 1,29, CI 1.03-1.61) provides the lowest impact on the satisfaction rating.
This contrast shows the difference of the two concepts of safety in the home and safety
in the neighbourhood, and suggests that the residents are able to distinguish between
these concepts: if one variable out of the nine would have been expected to be not
significant, feeling of safety in the dwelling would have probably been the first
candidate. In parallel, one would expect that safety perception in residential area at
night should have quite some impact on the assessment of residential environment
satisfaction.
In summary, the results show that the residential environment characteristics selected
for this study do have a large impact on the overall perception of and satisfaction with the
residential environment. This is especially true when looking at the relative impact of the
residential environment variables in relation to the individual characteristics, which have
almost no influence at all. This suggests that satisfaction with the residential
environment, representing a most important basis for social cohesion and social security
in residential neighbourhoods, can be significantly influenced by environmental
conditions and urban planning policies. In this context, the results presented are in line
with previous research in relation to noise, maintenance and safety issues which have
been already defined as powerful indicators for residential quality.
The results of the impact of the residential environment on sleep disturbance
represent a clear proof of how contextual parameters can be the most dominant factors for
the expression of health effects. The more a specific health outcome is related to the
environmental conditions, the less relevant is the impact of the individual characteristics.
For sleep disturbance, only age has some measurable but limited impact, while gender,
functional limitations and especially SES known as one of the most influential
parameters provide no significant change of the results. The fact that those residents
who are exposed to noise are more than six times as likely to report disturbed sleep shows
that unsurprisingly noise exposure must be seen as one of the major public health
problems in urban settings. The significant associations with play areas for children,

Residential conditions and their impact on residential environment

397

place to sit and relax outside of dwelling and litter and trash in residential
environment show that noise exposure is most likely partially linked to the general
quality of the urban setting. Not enough space for recreational activities seems to be a
typical characteristic of noise exposed neighbourhoods a fact that, by itself, provides an
additional burden on the soundscape of a neighbourhood, especially in the case of a lack
of childrens playgrounds. However, these results also point out that urban planning can
considerably improve the degree of noise exposure, if noise is actively considered and
mitigated, and more space for noisy leisure activities is given in locations where no
resident is exposed.
On the other hand, the residential environment variables show that sleep disturbance
is not only an outcome of the direct noise exposure, but is also a psychosocial
phenomenon. The perception of safety, and especially the feeling of being protected
from the outside influences while at home, is strongly associated with sleep
disturbance independent of gender, age or SES. This finding provides further evidence
on the relevance of the mental status for health and well-being, and fits well with other
studies, showing that mental unrest is associated with insecurity of tenure or rent levels.
Any insecurity or doubt about being in control of the own home be it financially or
emotionally motivated does have an impact on the mental well-being of the residents.
Sleep disturbance may be one of the consequences of such compromised psychosocial
benefits of the home (Kearns et al., 2000).
The results of the model for depression further support the argument that bad housing
and inadequate residential environments can strongly affect the mental well-being of
residents. The fact that before and after the integration of the confounders the two
noise variables as well as the two safety variables are significantly associated with
depression shows that these factors have an independent and stable influence that,
compared to some of the individual characteristics, is rather strong. This shows that noise
and safety constraints are relevant aspects for depression, and provide another piece of
evidence for a psychosocial link between housing and health.
In this context, it is interesting to look in detail at the difference between the two
noise variables. Traffic noise, which in comparison to surrounding area noise
provided the higher OR for the prevalence of sleep disturbance, is much less relevant for
depression: it shows an increased OR of 1.41 only, while surrounding area noise
increases the likelihood for depression more than twofold (OR 2.13). The data therefore
suggests that noise sources may have a varying impact on different health outcomes, and
possibly the perception and the characteristics of the noise exposure explain the reaction.
Traffic noise may be easier to accept, as most likely, every resident has a personal
interest in functional traffic systems. Traffic noise may therefore be a major source for
sleeping problems, but could be less relevant for mental health effects as they are
evaluated as an unavoidable characteristic of urban living, and therefore subjectively
accepted and justified. Neighbourhood noise from other sources, such as playgrounds and
other outside areas, may have a more devastating effect on mental health, as the
perception of such unacceptable noise has a more emotional dimension and may also
contain some social characteristics. Such noise is often the reason for social conflicts,
even leading to legal cases. Due to this psychosocial dimension, it seems natural that the
effects of residential noise exposure are more strongly expressed in the mental health
domain.

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A different pattern, however, is visible for the safety parameters, for which feeling of
safety in the dwelling shows the higher relevance for both sleep disturbance and
depression. Here, the perception of safety in the residential area at night is less important.
A possible explanation would be that a resident has a variety of alternatives to avoid or
reduce the feeling of being exposed to threats in the residential area by his or her
behavioural choices (not going out at night, not going alone, taking a taxi, etc.). Such a
choice does not exist when being in a home that does not provide the feeling of total
security and protection from outside threats.
However, any interpretation of the results must keep in mind that the LARES
data is cross sectional. Therefore, it cannot be excluded that those residents suffering
from depression have a more negative assessment of their residential environment
(or tend to live in less healthy neighbourhoods due to some socioeconomic selection
mechanisms), which will inevitably result in statistical associations between the
residential environmental variables and depression.
Looking at the cardiovascular symptoms, the data clearly showed that they are mostly
independent from the residential environment parameters selected for the regression
models (only one of the contextual variables safety perception in residential area at
night- is significantly associated). As expected, age turned out to be the dominant
parameter that remains unchallenged by any other factor.
However, looking at the discussion on noise exposure and the increased risk for
heart attacks and infarcts, the OR of 1.24 (CI 0.981.57) for traffic noise is remarkable
as it corresponds to the findings provided by various other studies. Babisch (2001)
and Stansfeld and Matheson (2003) suggested that with noise exposure, there is a 20%
increased likelihood for heart attacks and myocardial infarction. Despite the fact that the
regression model did not provide a significant result in the LARES study, there is some
relevance in the fact that traffic noise shows the highest OR increase of all residential
environment variables. Based on the more detailed results not shown in this paper, there
is substantial reason for assuming that a larger sample size could have provided a similar
but significant result.
For cardiovascular symptoms, safety perception in residential area at night was the
only significant residential environment variable. For sleep disturbance and depression,
the feeling of safety in the dwelling was more influential. It has been argued above, that
the perception of security in the home may be more strongly associated with mental or
psychosocial health, while the perception of not being safe in the residential area based
on the results of the LARES survey could be more linked with physical health effects
such as cardiovascular symptoms.

Conclusion

Looking at the results of the analysis of the impact of the residential environment
characteristics on residential environment satisfaction and the selected health outcomes,
the multivariate analyses identified two key problems that showed the highest and most
consistent impact on the likelihood to be less satisfied with the residential environment,
or to suffer from the three analysed health outcomes. These two problem areas were
(a) noise exposure and (b) perceived safety. Both were significantly and strongly
associated with low residential environment satisfaction, sleep disturbance, and
depression. For cardiovascular symptoms, only perceived safety aspects were significant,

Residential conditions and their impact on residential environment

399

but the traffic noise variable provided an even higher OR just below the significance
level.
Less expressed but still relevant, a lack of play areas for children was strongly
associated with low residential environment satisfaction while in general, recreational
characteristics (play areas for children, place to sit and relax outside of dwelling) were
associated with sleep disturbance and provided slightly increased, but not significant,
OR values for depression (1.15 and 1.13 respectively). The last relevant residential
environment characteristic was litter and trash in residential environment, which was
significantly associated with low residential environment satisfaction and sleep
disturbance and provided a not significant OR of 1.22 for depression.
In concrete terms, the results support the argument that the quality of the residential
environment is significantly associated with the residential satisfaction as well as with a
variety of health outcomes and therefore has a direct impact on the well-being, health and
the health related quality of life of the residents. This finding, based on data from eight
European cities, corresponds to the results of other research on the health impact of
neighbourhood conditions (Howden-Chapman, 2004; Drukker et al., 2003; Dunn, 2002).
The study thereby suggests that the relationship between the selected contextual
residential environment factors on one side, and residential environment satisfaction and
the selected health outcomes on the other is valid for all cities. Based on the results
presented, it can thus be concluded that at least neighbourhoods have a small but
consistent impact on health status (Howden-Chapman, 2004, p.165), and it can be added
that a low rating of residential environment satisfaction is most likely a telltale sign for
health-related neighbourhood problems.
Although urban planning and neighbourhood development projects are often based on
a variety of health relevant objectives (WHO Regional Office for Europe, 1999), they
have yet to develop an improved understanding of how their practice relates to human
well-being and satisfaction (Dannenmaier, 1995). Physical features of neighbourhoods
(traffic system, density, recreational facilities, greenery, physical incivilities such as
trash), together with the social components (residential behaviours, social incivilities,
safety perception), can translate into physical as well as nonphysical effects that
shape residential satisfaction and health related quality of life of a residential area
(WHO Regional Office for Europe, 1999). In this context, it remains:
... one of the major challenges to bridge the divide between the
environmental quality/wellbeing/quality of life specialists and the players who
make urban policy and who shape our physical and social environments in
other words the engineers, planners, architects, service delivery specialists, etc.
(Brown, 2003, p.85).

Urban and neighbourhood planning has both the capacity and the mandate for
developing health supportive settings, and for promoting and supporting the health
status of individuals (WHO Regional Office for Europe, 1999, 2004). Well designed
neighbourhoods and residential environments are able to reduce or compensate health
relevant exposures to physical, social and mental challenges, with residential satisfaction
being a valuable indicator of the overall residential conditions. If adequately considered
and located, many neighbourhood features could improve the health related quality of life
of the residents, and represent a strong and preventive contribution to population health.

400

M. Braubach

Acknowledgements
The author would like to acknowledge the work and support of Xavier Bonnefoy
and Nathalie Rbbel at the WHO European Centre for Environment and Health, Bonn,
WHO Regional Office for Europe, in the context of the LARES survey, as well as the
comments and advice given by Philippa Howden-Chapman and Irene van Kamp during
the development of this paper.
The LARES survey was supported by Grant No. 328-1720/60 from BMGS
(German Federal Ministry of Health and Social Security). The support from the German
Ministry of Environment, Ministries of Health of Portugal, France and Lithuania, from all
participating municipalities, and from the Canton of Geneva is duly acknowledged.

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