Mental health impact assessment: population mental health in Englewood, Chicago, Illinois, USA

Abstract

In this paper, we describe a pilot mental health impact assessment (MHIA) undertaken by the Institute on Social Exclusion (ISE) at the Adler School of Professional Psychology. This pilot involved a multi-method approach that included literature reviews and direct engagement of community stakeholders. It resulted in a policy document that summarized the anticipated effects of a proposed amendment to Chicago's Vacant Buildings Ordinance on the collective mental health of people living in Englewood, a neighbourhood located on the city's southwest side. The Chicago City Council passed the proposed amendment in the summer of 2011.Working to advance health impact assessment (HIA) practice, the project aimed to assist Englewood residents by empowering them to participate in the systematic review of a proposed policy change that would impact their own community's mental health. Additionally, the pilot sought to ensure that any policy decision reflected an evidence-based understanding of its probable effects on the mental health of Englewood residents. Thus, these efforts were designed to narrow several health inequities as suggested by key indicators of community mental health.

Keywords:

• health impact assessment
• mental health impact assessment
• social determinants of mental health
• community mental health

Mental health impact assessment

Mental health impact assessment (MHIA) derives from the more commonly known health impact assessment (HIA). However, it is different from the typical HIA in that it focuses on the mental health implications of public decisions. Most HIAs limit their assessments to the anticipated impacts of public policies on physical health. Even when HIAs consider mental health outcomes, only limited conceptualizations are commonly discussed. Social impact assessments (SIAs) are sometimes employed as part of broader impact assessment processes or as supplemental reviews (UNEP 2002). Per best practice guidelines, SIAs address lifestyle, cultural, community, quality of life and health impacts, with mental health impacts included as subsets of one or more of these categories (UNEP 2002). MHIAs differ from SIAs in that mental health is the central focus of the assessment process. Thus, mental health outcomes such as depression, anxiety, symptoms of post-traumatic stress disorder (PTSD) and attention deficit/hyperactivity disorder (ADHD) and substance abuse are covered in the MHIA. We hypothesize that one reason that mental health has not been well integrated into HIA practice is due, in part, to the need for the specialized knowledge and skill set required to assess mental health impacts. For this reason, mental health clinicians are critical members of the multidisciplinary team conducting an MHIA. The integration of mental health considerations into HIA practice is a complex and challenging exercise. The relative lack of analytic focus on and active practice in population mental health also complicates efforts to integrate mental health considerations into HIA practice.

HIA best practice guidelines and project reports have argued the need for impact assessments to provide ‘human elements’, sometimes labelled as ‘social impacts’, that build upon the physiological focus of impact assessments (UNEP 2002,Glasson and Wood 2009, p. 284). Mental health is an integral component of overall health. As articulated by the World Health Organization (WHO), ‘there is no health without mental health’ (WHO 2010, p. 1). The International Association for Impact Assessment (IAIA) identifies a ‘comprehensive approach to health’ as one of its guiding principles for international best practices (Quigley et al. 2006, p. 3). This comprehensive approach emphasizes the importance of integrating mental health into HIA methodology (Quigley et al. 2006). Additionally, mental health plays a critical role in mediating the relationship between social conditions and physical health outcomes (Leventhal and Brooks-Gunn 2000, Stafford et al. 2007, Curry et al. 2008, Echeverria et al. 2008, Collins et al. 2009, Johnson et al. 2009, O'Campo et al. 2009, Raphael 2009, Roman et al. 2009, Geronimus et al. 2010, Mair et al. 2010, Matthews et al. 2010).

At the Institute on Social Exclusion (ISE) we set out to address the need for more substantial inclusion of mental health impacts within HIA practice by piloting an MHIA on a proposed amendment to Chicago, Illinois’ Vacant Buildings Ordinance. Vacant foreclosed houses often are used as sites for criminal activity, because they serve as convenient locations for drug activity, prostitution and violence. The amendment, if passed, would hold banks and other financial institutions legally and financially accountable for securing and maintaining the buildings on which they foreclose. This, in turn, would decrease the number of abandoned properties that could be used as sites for criminal activity.

Like many cities throughout the USA, Chicago has a large number of foreclosed properties. Foreclosures constitute a significant portion of properties on Chicago's vacant buildings index, with 18,320 properties reported as of September 2010 (Woodstock Institute 2011). Of these, 69.2% were associated with a foreclosure filed between 2006 and the first half of 2010 (Woodstock Institute 2011). There were also 1,896 ‘red flag’ properties on the city's vacant buildings index, indicating a foreclosure filing with no subsequent outcome (Woodstock Institute 2011). These red flag properties are of significant concern to city officials and to communities, particularly when they remain vacant for extended periods of time. Over 40% of these red flag properties have been in the foreclosure process for more than a year and a half, suggesting that loan servicers likely have decided not to complete foreclosure (Woodstock Institute 2011). Red flag foreclosures are disproportionately concentrated in Chicago's low-income African American communities, with over 71% of red flag properties located in these communities (Woodstock Institute 2011). In comparison, only 6.5% of red flag properties are located in primarily White/Caucasian communities in Chicago (Woodstock Institute 2011).

For the pilot MHIA, we focused on Englewood, a low-income, African American community. Englewood has the third-highest rate of foreclosure-associated vacant properties out of all 77 Chicago community areas (Woodstock Institute 2011). In 2010, there were 712 foreclosed properties listed in Englewood (Woodstock Institute 2011).

Englewood is beset by many of the social and economic problems common to low-income communities – high rates of crime and violence, underperforming schools, depressed housing stock, joblessness and few public services and amenities. It is also vulnerable to broader challenges such as racism, sexism and social exclusion. There is a robust body of empirical evidence linking such determinants to mental health outcomes such as anxiety, depression, ADHD, PTSD, alcohol and drug abuse and a range of other mood disorders and unhealthy behaviours (Almedom 2005, Baumeister et al. 2005, Scutella and Wooden 2008, Kloos and Shah 2009, Raphael 2009, Wilkinson and Pickett 2009, Congdon 2010, Maimon et al. 2010, WHO 2010).

The MHIA pilot

In summer 2010, the ISE piloted a ‘modified’ MHIA that included screening, scoping, assessment, recommendations and reporting activities consistent with the standard HIA practice model. As in many HIAs, however, monitoring and evaluation activities were more limited. The following describes the activities undertaken in each phase.

Screening took place from June through mid July. It was largely undertaken ‘in-house’ by ISE staff. However, it was significantly informed by an understanding of the community's major challenges and issues that had become clear over the course of a prior five-year working relationship among ISE staff and Englewood residents, service providers and community-based organizations. We screened proposals in such areas as labour (e.g. living wage, wage theft, paid sick leave), transportation (e.g. revisions in bus routes and rail transit lines), education (e.g. school closures, elimination of remedial education in city public colleges), public safety (e.g. sales of fire arms), criminal justice (e.g. required reporting of conviction records in employment applications, prison census adjustment) and housing (e.g. use of public funds for affordable housing).

We selected the proposed amendment to Chicago's Vacant Buildings Ordinance as the focus of the MHIA on the basis of a number of screening criteria including: relevance to the target community, potential for the proposal to impact the social determinants of mental health, a timeline sufficient to allow a prospective assessment of mental health impacts, breadth and magnitude of potential impacts, availability of data and information, access to key stakeholders and decision-makers and whether findings may actually lead to improvements in mental health outcomes. The proposal was sponsored by an alderman who represents the Englewood community on Chicago's City Council. A major element of the proposed amendment was the expansion of the definition of property ‘owner’ to include banks and other entities that initiate foreclosure proceedings on vacant properties (Chicago, Ill., Municipal Code Chapter 13–12–125 et seq.). Other critical elements of the amendment included: the imposition of higher fees and fines on owners of five or more properties that maintain vacant properties; the requirement that owners of five or more properties post a $10,000 bond for each vacant property; and the requirements that owners of five or more properties pay a 5% finder's fees to city residents who report building code violations. These key elements were intended to ensure that the city is paid quickly for the fees and fines it assesses; create incentives for residents to help identify violations of the Vacant Buildings Ordinance; and ensure more properties are registered, secured and maintained. Given the disproportionate number of vacant and foreclosed properties in the Englewood community, the proposed amendment possessed significant potential to impact the mental health and well-being of this community.

Scoping took place from mid July through August. During the scoping phase, we determined the key parameters of the MHIA including the key health determinants and mental health impacts of interest, the research plan (e.g. analytic methods, data sources), participant roles and a timeline. We also determined the key stakeholders and developed methods for engaging them in the MHIA process. During the scoping phase we developed a series of pathways models – based on a preliminary review of the literature – that highlighted the possible relationship between the proposed ordinance change and the mental health and well-being of the Englewood community. This is in accordance with best practice recommendations (Mindell et al. 2001).

The assessment phase involved additional literature reviews that strengthened the pathway models developed in the scoping phase and highlighted the relationship between the proposed amendment, the social determinants of mental health and mental health outcomes. The literature reviews employed a wide range of search terms including vacant housing, substance use, neighborhood violence, depression, anxiety, collective efficacy and social cohesion. Three pathway diagrams illustrate our hypothesized connection between the amendment and mental health in the targeted community. These pathway diagrams (Figures 1, 2, 3) are rooted in the three major tenets of the proposed amendment, which are imposition of increased fees and fines, institution of finder's fees and the requirement for a $10,000 bond. Each of these pathway diagrams linked a tenet of the proposed amendment to social determinants found within the Englewood community. These include safety, crime, violence, employment opportunity, local economic activity, public services, collective efficacy, civic engagement and trust. These pathways served as a useful tool during the reporting phase to easily inform policy-makers with research-based information on the potential mental health impacts of the proposed amendment.

Figure 1 Pathway diagram depicting the social determinants of mental health potentially impacted by the proposed amendment to the Vacant Buildings Ordinance. Notes: 1. Apgar et al. 2005, 2. Kruger et al. 2007, Yonas et al. 2007, 3. Apgar et al. 2005, Kruger et al. 2007, Curry et al. 2008, 4. Latkin and Curry 2003, Kruger et al. 2007, Curry et al. 2008, 5. Apgar et al. 2005, Yonas et al. 2007, Curry et al. 2008, 6. Taylor et al. 1997, Kruger et al. 2007, Curry et al. 2008, 7. Molnar et al. 2003, Freisthler et al. 2006, 8. Boyle and Hassett-Walker 2008, 9. Higgins and McCabe 2003, 10. Widom et al. 2007, 11. Downey and Van Willigen 2005, Kruger et al. 2007, Curry et al. 2008, 12. Mazza and Reynolds 1999

Figure 2 Pathway diagram depicting collective efficacy as social determinants of mental health mediating community mental health outcomes. Notes: 13. Sampson et al. 1997, 2002, Leventhal and Brooks-Gunn 2003, Sampson 2003, Sabol et al. 2004, Almgrem 2005, Odgers et al. 2009, Yonas et al. 2009, Mazerolle et al. 2010, 14. Kruger et al. 2007, Stafford et al. 2007, Curry et al. 2008, Johnson et al. 2009, Roman et al. 2009, 15. Leventhal and Brooks-Gunn 2003, Sampson 2003, Sabol et al. 2004, 16. Johnson et al. 2002, Stafford et al. 2007, Stockdale et al. 2007, Johnson et al. 2009, 17. Margolin and Gordis 2004, Stafford et al. 2007, Foster and Brooks-Gunn 2009, 18. Margolin and Gordis 2004, Johnson et al. 2009, 19. Kruger et al. 2007, Stafford et al. 2007, Stockdale et al. 2007, Johnson et al. 2009, 20. Johnson et al. 2002, Margolin and Gordis 2004, Kruger et al. 2007, Stafford et al. 2007, Stockdale et al. 2007, Curry et al. 2008, Foster and Brooks-Gunn 2009, Johnson et al. 2009, 21. Johnson et al. 2002, Margolin and Gordis 2004, Stafford et al. 2007, Stockdale et al. 2007, 22. Stafford et al. 2007, Stockdale et al. 2007, Johnson et al. 2009

Figure 3 Pathway diagram based on focus group feedback from the HIA workshop, hosted by the Adler School of Professional Psychology, 28–29 September 2010.

Community residents' participation in the impact assessment process is also a crucial element in the democratic principles of current HIA guidelines as well as an important condition for influencing policy decision-makers (Quigley et al. 2006, Devlin and Yap 2008). Thus, the assessment phase of the MHIA included active engagement of Englewood community residents. Input from community stakeholders took place during a two-day HIA workshop that occurred in September 2010. Facilitated by Human Impact Partners (HIP), an Oakland, CA-based organization that provides technical assistance in HIA practice, the workshop provided basic training to a broad stakeholder group interested in the proposed amendment. We used the opportunity for receiving technical assistance to generate community input into the MHIA process. Twenty-one individuals, including Englewood residents, service providers and staff of community-based organizations, participated in the workshop. Representatives of local housing, community development and legal advocacy groups also participated. Figure 3 reflects the information gathered during the workshop. This pathway demonstrates the participants' considered judgement of the ways in which the amendment would likely impact mental health and well-being in the Englewood community. A principal goal of this assessment activity was to engage residents and other key stakeholders in the review process to increase their understanding of the causal links between social conditions and mental health. Another goal was to promote residents' participation and sense of ownership in the overall impact assessment process. Recent reports on larger-scale impact assessments conducted in the European Union have underscored the critical need for this sort of community engagement for effective outcomes (d'Auria and Cinneide 2009).

The recommendations from the workshop resulted in a policy letter addressing the proposed amendment to the Vacant Buildings Ordinance. This letter included a review of the implications of the proposed amendment on indicators of community mental health. The policy letter constituted the major vehicle by which recommendations were reported to the public. Although a mayoral election slowed down the deliberative process, the ISE continued to monitor the proposed amendment's status throughout the winter and spring of 2011. In summer 2011, after the new mayor took office, efforts to push the amendment forward resumed. The ISE presented the policy letter and its findings to a joint session of the Chicago City Council Housing and Real Estate and Housing and Zoning committees. On 28 July 2011, the full City Council passed the amendment with a commendation from Chicago's Mayor (Cardona 2011, City of Chicago 2011, Olivo 2011). News on the amendment's passing, along with an explanation to residents about the amendment and their potential role in participating in the new terms, was published in city and neighbourhood news outlets (Cardona 2011, City of Chicago 2011, Olivo 2011).

The MHIA pilot served as an effective means by which to engage community and other stakeholders in a process to assess the mental health implications of a public decision. The MHIA constituted a ‘modified’ HIA in that the assessment process was limited to literature reviews complemented by a workshop in which stakeholder input was gathered. The recommendations put forth were a subset of an extensive list of caveats suggested by the stakeholders that participated in the workshop. Reporting was limited to a policy brief that was presented to the sponsoring alderman and the Chicago City Council, and resources – both time and funding – limited our capacity to conduct an evaluation. The pilot did, however, provide a useful and informative foundation for the more extensive, grant-funded MHIA that the ISE Team is currently undertaking.

Future directions and broader impacts for the international community

This pilot provided the groundwork for a comprehensive MHIA also related to the Englewood community. Funded by the Robert Wood Johnson Foundation and the W.K. Kellogg Foundation, we are currently (January 2011 through June 2012) conducting an MHIA on a proposed amendment to the U.S. Equal Employment Opportunity Commission (EEOC) Policy Guidance on the Consideration of Arrest Records in Employment Decisions (U.S. EEOC 1990). The selection of this amendment as the focus of the MHIA was based on a lengthy screening process that involved extensive input from the Englewood community. As of this writing, scoping of the project has been completed, and early phases of assessment have begun. This early work (e.g. preliminary reviews of the literature and engagement in public discussion with community stakeholders) supports the results of prior studies that the key social determinants of mental health are income, discrimination, social capital, neighbourhood and local economic conditions. These determinants may have profound impacts on indicators of mental health in the Englewood community, as evidenced by changes in the community's perception of social capital, its psychological sense of community and the collective efficacy embodied in its residents and organizations. These relationships are being documented in pathway diagrams that demonstrate hypothesized relationships between the proposed amendment of the EEOC Policy Guidance and the collective mental health and well-being of the Englewood community. Research protocols are being established and will include mixed methodologies including systemic literature reviews, community surveys, focus groups, guided town hall discussions and key informant interviews. The findings and recommendations that emerge from the research will be used to inform state-level deliberations on the use of arrest records in employment decisions, as well as the U.S. EEOC.

In following best practice recommendations in the HIA literature concerning the future of impact assessments in the USA, our present grant-funded project was preceded by the aforementioned MHIA pilot examining the usefulness of impact assessment in our particular community (Dannenberg et al. 2006). This served to both educate community partners and provide opportunities for them to shape the impact assessment process. The current grant-funded MHIA is also implementing recommendations from the international literature by including public input from community residents at the beginning of the process (Krieger et al. 2003, Devlin and Yap 2008, Bhatia et al. 2010).

Both MHIA projects provide potentially useful examples to the international impact assessment community of how mental health implications of policy decisions may be used in the scoping process and employed as an additional measure for social impact assessment. These MHIA projects also demonstrate mechanisms for implementing the IAIA International Best Practice Guidelines concerning democratic and comprehensive approaches at the outset of the project (Quigley et al. 2006). Our models are consistent with the recommendations from the World Health Organization's Commission on the Social Determinants of Health, as they focused on identifying and stressing the behavioural impacts of local housing and employment policies (WHO 2008).

In their 2003 article on assessing HIA from multidisciplinary and international perspectives, Krieger et al. called for enhanced recognition of societal determinants of health and ‘intersectoral responsibility’ through teams that extend beyond the public health field (p. 659). The MHIA projects described here build upon these recommendations to further the research and practice of HIA examining the roles of mental health, particularly depression, anxiety and substance abuse, on policies that may not have been originally considered to be impacting these facets of citizens' lives. This modification opens the door to building multidisciplinary teams that include residents of the local community and community advocates from the outset of the process along with members of the professional team. These projects revealed the efficacy of such teams in a myriad of ways. For example, the inclusion of mental health clinicians on our team brought about our hypothesis that the lack of more robust integration of mental health issues in HIA practice is due, in part, to differences in the units of analyses employed by HIA practice (wherein the dominant unit of analysis is population health) and mental health practice (wherein the dominant unit of analysis is individual health). Integrating mental health considerations into HIA practice will serve as an important foundation for continued development and advancement of HIA, not only in the USA, but also in the larger, international community.

Acknowledgements

Two community organizations worked closely with the ISE in the pilot MHIA, described above, and in implementing the current MHIA, as well. They are Teamwork Englewood and Imagine Englewood-IF. Public agency partners included the Chicago Department of Public Health and the Illinois Department of Public Health. Special thanks go to Adler School of Professional Psychology doctoral students Margaret Cornell and Jared Berger for their contributions to the MHIA pilot project.