Addressing health inequalities with nature in Oxgangs, Edinburgh

1. Health inequalities in Edinburgh.

Cities are regarded as centres of prosperity, employment opportunities, education access, healthcare services and culture (Glaeser, 2011), but access to these services are not evenly distributed amongst all city residents.

Conditions such as cardiovascular disease, high blood pressure, obesity and type-2 diabetes are experienced more frequently within cities (Pretty et al., 2016) as a result of higher incidences of sedentary lifestyles (Dye, 2008), time indoors and on screens (Bratman et al., 2019). However, these problems are particularly pervasive amongst communities from low-income areas (Twohig-Bennett and Jones, 2018).

Oxgangs’ history dates back to the 1950s to provide predominantly council housing for skilled workers in the city (Flint and Casey, 2008). A programme of redevelopment and regeneration oversaw the construction of new flats in 2006, which was regarded as successful by residents despite their continued awareness of constrained residency choices, job access and financial resources (Batty et al., 2011).

According to the Scottish Index of Multiple Deprivation (SIMD), Oxgangs ranks in the top 10% “most deprived” areas in Scotland, ranking within a range of 2-4 out of 10 for “Health Domain Rank.” Criteria which contribute to these health outcomes are income, employment, health, education level, housing type, crime rate and geographic access, all of which are low-ranking on the SIMD (see Figure 1).

NHS Health and Wellbeing Reports (2010;2016) further detail multiple health factors which combine to give an overview of an average Scottish resident’s life expectancy and health outcomes which vary across local authority areas. These factors include:

• Number of patients with a psychiatric hospitalisation
• Adults claiming incapacity benefit/severe disability allowance
• Working age population claiming Jobseeker's Allowance
• Out of work benefits/child tax credit income deprivation
• Crime rate
• Population living within 500 metres of a derelict site
• Number of patients hospitalised after a fall in the home (65+)

According to Oxgangs’ area profile, all of the above factors ranked as “significantly worse” compared to the Scottish national average. Oxgangs’ more negative community health outcomes are highlighted if compared to Morningside, Oxgangs’ adjacent suburb which is one of Edinburgh’s most affluent and high-value areas that ranks in the top 10% “least deprived” areas according to the SIMD (2021), which obtains a “Health Domain Rank” of 10/10.

South Edinburgh’s health inequalities are a consequence of the inequitable distribution of power, income, and wealth (Phelan, 1995). Money is ultimately what provides the means to access goods and services that support healthy living, such as nutritious diet, good housing, and leisure activities (Morris et al., 2010).

This highlights how systemic injustices cannot be overcome with state intervention alone. A grassroots intervention is required in order to help Oxgangs’ residents overcome the negative health outcomes they disproportionately experience, for an improved quality of life.

2. Nature-based solutions.

High quality parks and greenspaces are important urban assets because they enable local residents to obtain multiple physical and mental health benefits, if they are accessed on a regular basis (Sandifer et al., 2015). In terms of physical health, parks can encourage exercise such as walking, running or cycling. Promotion of gardening, volunteering or ecological restoration programmes can also support physiological and cardiovascular health if achieved on a regular basis for at least 30 minutes (Cox et al., 2017), and the positive well-being effects that are obtained from exercise are augmented if done in nature (Thompson-Coon et al., 2011).

Biodiverse spaces contribute ecosystem services that are vital for human health such as offering cooling properties to reduce urban heat island effects (Bowler et al., 2011) and the filtration of air pollution by virtue of vegetation presence which can reduce the quantity of harmful toxins inhaled and improve immune function (Barton et al., 2009).

In terms of mental health, greenspaces can enhance an individual’s life satisfaction and overall happiness because biodiversity and landscape produce restorative and calming benefits such as reduced stress and anxiety (Kaplan and Kaplan, 1989). Parks facilitate social contact, which is a reinforcing wellness factor and contributes to feelings of community cohesion (Cox et al., 2017). A sense of place can develop if regular access to a greenspace is encouraged and maintained, which can be empowering for individuals and the wider community (Kazmierczak, 2013).

The improvement of human health is considered the ultimate ecosystem service (Sandifer et al., 2015), which qualifies urban parks as “nature-based solutions” (NbS). NbS are defined by the IUCN as natural or modified ecosystems that address societal challenges effectively and adaptively, whilst simultaneously providing human well-being and biodiversity benefits (Cohen-Shacham et al., 2016). Connecting nature with public health offers a reciprocal and restorative relationship between health and environment which can align what is often a ‘conflicting urgency’ between sustainable development and social justice goals, as identified by Campbell (2013).

NbS are proven to help urban communities achieve goals such poverty alleviation and socio-economic development (Seddon et al., 2020), so are vital assets for the Oxgangs community, and deserve to be accessible and well utilised by all of its residents. Health inequalities are demonstrably narrower amongst people living in ‘low-income’ areas such as Oxgangs if they have regular and easy access to greenspace (Gascon et al., 2015; Marselle et al., 2020). DEFRA and Natural England (2017) estimate that the NHS could save £2.1 billion per year if everyone had equitable access to sufficient greenspace.

3. Access disparities.

Regular greenspace access is hypothetically achievable by many Oxgangs residents, since by virtue of their location, they are optimally situated nearby several semi-natural and high-quality greenspaces; Braidburn Valley Park, Hope Triangle Garden, Oxgangs Lochan and Colinton Mains Park, connected by the Braid Burn (see Figures 2, 3, 4 and 5).

All qualify as NbS because they are high quality and biodiverse spaces which foster and facilitate multiple physical and mental health benefits. It could be perceived that these are readily accessible for the community. However, a neighbourhood’s proximity to parks does not automatically correlate to their frequent access (Boyd et al., 2018), or doing so in a way that produces health benefits (Lin et al., 2014).

Socio-cultural barriers to greenspace access are common in ‘low-income’ areas (Mitchell and Popham, 2008) and explain why some residents do not access their local greenspaces as often as they should. It is important to note that not all of the following socio-cultural barriers will be experienced by Oxgangs’ residents, and some will be more common than others. They include:

• Limited awareness of opportunities to visit greenspace
• Lack of experience and confidence in being in a natural setting
• Lack of time
• Multiple, competing time pressures and interests
• Difficulties of accessibility if limited mobility/disabled

• Being out in a natural setting is not part of social expectations
• Feeling unwelcome or out of place
• Fear of bullying or presence of dogs
• Differences in the way the Oxgangs community perceives greenspace as a contributing factor to health
• Negative perceptions of safety; risk of antisocial behaviour, vandalism, litter, poor maintenance or lack of lighting

(from Public Health England, 2021)

4. Community recommendations.

Interaction with greenspaces needs to be increased and achieved in new and more meaningful ways by a greater percentage of Oxgangs’ residents, in order to achieve a transformative impact on their health outcomes and life quality (Ehnert et al., 2018).

In order to achieve this, I set out the following three community recommendations whereby local community actors and stakeholders can work together to implement and promote these health-enhancing nature-based initiatives over a long-term basis.

Recommendation 1 – Nature Prescriptions

Nature prescriptions are activities that are designed to help people connect with nature in personal, emotional and meaningful ways, in order to overcome or mitigate mental or physical health problems that typically stem from sedentary and indoor lifestyles (RSPB, 2018).

A leaflet and a calendar of nature-based activities (see Figures 6, 7 and 8) were developed by the NHS Scotland and the RSPB to signpost people to simple ways of connecting with nature that are specific to their local community, the urban context and season. Ideas include finding a favourite place in nature, listening to nearby birdsong, noticing the beauty of the surrounding landscape, getting to know a neighbourhood tree or helping local wildlife thrive (RSPB, 2018). Crucially, activities are accessible for all ages and mobility levels, flexible and free.

Its success in NHS Shetland resulted in its rolling out within 5 health-authority areas within Edinburgh by the Edinburgh and Lothians Health Foundation. Oxgangs’ proximity to many high-quality greenspaces positions it strongly as an area in which to implement the programme by the local Allermuir and Craiglockhart Health Centres.

They facilitate and encourage new ways for people to understand, engage and “notice” nature in a deeper and beneficial way (National Trust, 2021), which is vital for achieving health outcomes since the depth, length and type of experience matters greatly in determining true “connections” with nature and being able to obtain the array of physical and mental health benefits it plays host to (Myers, 2020).

It is important to point out here that nature prescriptions are a hybrid solution; they are geared toward the community, but inevitably include institutional actors (such as the NHS) for their implementation. Nonetheless, by virtue of being recommended by health professionals, nature prescriptions offer a legitimised consent pathway towards forms and frequencies of nature-engagement, which could be useful for individuals who may not have previously considered their take-up, especially in relation to overcoming personal health ailments.

In Oxgangs, nature-prescriptions calendars and leaflets can be printed and produced in multiple languages and formats to be more widely accessible for people with English as a second language or disabilities, and be widely distributed in local schools and community centres to enable their access by a wider pool of residents, so as to not require a pre-existing health condition for their take-up, or ensure health resources are not gate-kept by formal health institutions.

Community centres could facilitate regular drop-in support groups where participants can meet and share experiences, ideas and recommendations, hold each other accountable and foster a collaborative element to what are often individual activities, to further encourage and sustain their take-up. Groups can be split by demographics or shared interests.

Recommendation 2 – Community Gardening

Oxgangs and Triangle Community Centres are hubs of holistic group and individually focused activities that are centred on exercise, cooking, socialising and creative activities. These are examples of vital community and social infrastructure provision that enhance Oxgangs’ residents’ social and cultural capital (Seyfang and Smith, 2007).

These centres are thus fantastically suited to implementing a nature-based dimension to the activities they already run to reinforce their health benefits and connect nature with locally defined interests to help embed increased greenspace access within participants’ everyday lives (Jones et al., 2013). Framing activities in terms of fun, leisure, creativity and socialising instead of mental and physical illness prevention can contribute to their appeal (Rankin et al., 2006).

‘Facilitated access’, such as organised transport to the Oxgangs or Triangle Community Centres, followed by a supported led activity, could be successful in reaching underrepresented groups, such as those with disabilities, whose day-to-day mobility may disproportionately increase the actual or perceived barriers they face in reaching their local community centres and greenspaces.

Horticulture in the Triangle Community Garden particularly promotes social inclusion and community-building (Diamant and Waterhouse, 2010). Gardening imparts multiple mental and physical well-being benefits to practitioners, usually ascribed to being out in the fresh air, exercise, doing something meaningful and mindful, and doing so alongside others (Sempik, 2010), hence why it is frequently described as “therapeutic horticulture” (Thomas, 2014).

Vegetable and herb growing sessions are a simple way to enact a care-giving responsibility that produce mental health benefits (Kimmerer, 2012). If combined with cooking classes which use community garden-grown produce that is fresh and healthy, nourishing meals become available that positively impact the community’s nutrition, as well as offer the opportunity to socialise, and learn skills such as food hygiene and budgeting (Spence and van Teijlingen, 2005). Surplus meals can be stored in a Community Fridge for other residents.

Activities could expand from vegetable growing to sowing flowers, maintaining wildlife habitats, woodcraft or pottery, or educational and themed activities such as “pollinator-friendly” workshops that incorporate useful and infrastructural elements such as composting workshops or building bee towers out of recycling waste, ideas which can expand to people’s own gardens and further enhance social cohesion (Seyfang and Smith, 2007). Activities span the indoors and outdoors so are accessible irrespective of season, weather, age or mobility level.

Construction of sheds, planters, fences or raised beds could be done in partnership with the grassroots youth group ‘YouthBuild Edinburgh’ which teaches construction and employability skills; this could not only help improve the civic amenity of Oxgangs’ local community centre, gardens and wider greenspaces for its people, but also enhance their environmental benefit (Pincetl, 2010).

Activities could culminate in an organised themed community open day within Colinton Mains Park, to showcase and highlight the development and potential successes of community garden focused activities, demonstrate their empowering social value and motivate more community members to participate (Morris and O’Brien, 2011).

Recommendation 3 – Conservation Activities

Community centres could collaborate with grassroots organisations and NGOs to implement larger-scale and transformative projects including ecological restoration activities such as tree planting, conservation management and meadow seeding, to enhance the health and ecological benefits that can be derived from Oxgangs’ local greenspaces.

Recent research points to the tangible and verifiable health benefits that are derived from restoration activities (Mills et al., 2017; Speldewinde et al., 2015) as a result of its interconnected pathways towards nature engagement, socialising, physical activity and doing something meaningful for one’s community (Jennings and Gaither, 2015).

If adapted to the community’s interests, integration of expertise and knowledge from external grassroots organisations such as the Edinburgh and Lothians Greenspace Trust could provide unique experiences for residents such as wildlife counts and identification days along the Braid Burn river walkway or Oxgangs Lochan, or mindfulness sessions using accessible and inclusive language within favourite nature spots which can facilitate long-term mental health improvements (Shanahan et al., 2019).

An NbS programme that only considers expert scientist and policy maker voices would not achieve an environmentally just and sustainable project (Pincetl, 2010), but their involvement could assist with fundraising, training or pro-bono consulting, which could be required if new green infrastructure is to be successfully deployed and managed (Pincetl, 2010). When expert knowledge is shared and strengthened by community actors such as “Friends Of” groups or using a “local champion” framework for specific knowledge gatekeeping, a top-down knowledge-power imbalance can be overcome, which supports the longevity and sustainability of more complex and long-term projects (Pretty et al., 2016).

Volunteer work is enjoyable and imparts multiple health benefits and is often an essential component of environmental programmes due to budget constraints (Townsend, 2006). However, voluntary upkeep of project must not become costly or burdensome on local residents. Their benefit must be obvious to the whole community to avoid being seen as problematic (Pincetl, 2010). Recruiting and delegating responsibility for such tasks can be complicated, so voluntary work uptake cannot be immediately expected (Pincetl, 2010), but could begin with Friends of groups, grassroots organisations, schools, universities and church groups, who can plan, fundraise for and partake in an organised voluntary programme that can fit into their varying routines and schedules.

5. Participatory approach and governance

A participatory approach involving all local community actors is imperative in order to help Oxgangs’ residents shift how they perceive their local parks and nature, because they hold influence and play a crucial and public role within the Oxgangs community.

Actors include:

• Oxgangs Community Centre
• Triangle Community Centre and Garden
• Church groups
• Pentland Primary School
• Firrhill High School
• Firrhill Community Council
• Allermuir and Craiglockhart Health Centres
• Friends of Braidburn Valley Park

The World Health Organization (2016) suggests the following steps should be taken by actors, to ensure everyone can access and benefit equally from their local greenspaces:

• Develop a common understanding of equity amongst the stakeholders
• Define the objectives of the greenspace, in terms of equity
• Look at distribution of local benefits and resources, as well as disadvantages and deprivation levels
• Gather and use data on greenspace accessibility to be able to assess any potential changes to equity
• Involve the community from the start, especially during the planning phase and listen to what their needs are, to ensure benefits are realised and help with increasing feelings of ownership and responsibility

Collaboration means fellow actors can engage with as many individuals as possible from a diverse range of backgrounds, demographics and mobility levels, to collectively determine how new forms of nature interactions can be successfully implemented. New habits and ideas can be successfully integrated into individual lifestyles and work alongside residents’ multiple and varying commitments, which may require a transition to an entirely new way of thinking and doing (Barr et al., 2011).

Dialogue and communication is key, to ensure everyone remains on the same page and that the community is consulted with and supported throughout the planning and implementation stages, remain proactively involved, their ideas and needs are listened to, and that any issues are resolved as soon as possible (Berkman, 2000). This can help avoid social conflicts about how local greenspaces are used and by which community groups in future (World Health Organisation, 2016).

Collective strategizing, consulting, organising, planning and implementation of initiatives on a trial-and-error basis to measure their effectiveness, enjoyability, accessibility, longevity, and sustainability for residents across social, economic and environmental dimensions, will ensure long-term and tangible progress is made (Pincetl, 2010) in respect to overcoming unequal and negative health outcomes.

Actors are the bridge between the community and external information, organisations and charities who can assist with innovation and implementing change. By partnering and collaborating e across knowledge bases and specific community relationships, competencies and capacities can be shared (Horsford and Sampson, 2014) which can ensure appropriate expertise is relayed to community group leaders who can then transfer this to the community. Interdisciplinary communication between stakeholders also enables partnership and lobbying power for purposes such as pooling resources and applying for capital in the form of grants and bursaries in which to fund new greenspace projects and maintain operation of local nature-based programmes (Enhert et al., 2018).

6. Diversity and inclusion.

Access to Oxgangs’ parks must be understood through an intersectional lens, to ensure that socio-cultural barriers to greenspace access are overcome across all identity intersections, so that their psychological and cultural benefits are attained equally (Jennings and Gaither, 2015). Ethnicity, gender, sexuality and ability are factors which influence the parameters through which Oxgangs’ individuals perceive and interact with their greenspaces and fellow community. Approaching this within the community can be facilitated by organisations such as Equality Scotland (http://www.equalityscotland.com/).

7. Council.

The City of Edinburgh Council play an important role in the funding of and ensuring installation and maintenance of signage, lighting, walkways and transport routes (Lovell et al., 2020). However, it is essential that approaches towards increased nature engagement remain led by the community, to avoid vulnerability such as during periods of austerity and budget cuts (Pincetl, 2010), or risking ‘green gentrification’ if greenspace improvements are made which prioritise aesthetics and “liveability” over socio-cultural priorities (Cole et al., 2017).

8. Next steps.

Development of a collective and cohesive outcome plan is a useful way to begin action and implementation of a comprehensive greenspace-access strategy for the Oxgangs community and affect change (Staples, 2004). This can begin with regular meetings and community consultations within a community centre that involves all actors, to begin the participatory process towards addressing and mitigating the more negative health outcomes Oxgangs residents experience. A unique portfolio of desired outcomes and timescales can be created by each actor, who will have unique interests and understandings of community needs.

Each actor can contribute and collaborate on specific targets, goals and ideas. Future benefits, methods of use and potential problems can be identified and planned for, with a contingency plan created in case of issues such as funding cuts, volunteer and labour shortages, activity success/unpopularity, or weather disruptions. Stakeholder-specific responsibilities and action points ensure each actor engages with activities they are best suited to, motivated by, and most relevant to the community groups they are involved with on a day-to-day basis, who can create affordable goals that fall in line with their budgets, that can be pooled or remain separate. Areas of overlap and cross-overs of knowledge, labour and funding can be identified to develop the scale and ambition of some projects if desired.

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