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Cities
journal homepage: www.elsevier.com/locate/cities
Social consequences and mental health outcomes of living in high-rise
residential buildings and the influence of planning, urban design and
architectural decisions: A systematic review
Paula Barros
a,⁎,1
, Linda Ng Fat
b,1
, Leandro M.T. Garcia
c
, Anne Dorothée Slovic
d
,
Nikolas Thomopoulos
e
, Thiago Herick de Sá
f
, Pedro Morais
g
, Jennifer S. Mindell
b
a
Universidade Federal de Minas Gerais, Escola de Arquitetura, Departamento de Projetos, Rua Paraíba, 697, Savassi, Belo Horizonte, MG 30130-141, Brazil
b
Health and Social Survey Research Group, Research Department of Epidemiology and Public Health, UCL (University College London), 1-19 Torrington Place, London
WC1E 6BT, UK
c
School of Public Health, Oswaldo Cruz Foundation, Rua Leopoldo Bulhões, 1480, Rio de Janeiro, RJ 21041-210, Brazil
d
Department of Atmospheric Sciences, Institute of Astronomy, Geophysics and Atmospheric Sciences, University of São Paulo, Rua do Matão, 1226, São Paulo CEP 05508-
090, Brazil
e
Glaux, 95 Mortimer street, London, UK
f
Center for Epidemiological Research in Nutrition and Health, University of São Paulo, Av. Dr. Arnaldo, 715, Cerqueira Cesar, São Paulo, SP 03178-200, Brazil
g
Architecture and Urban Planning Department, Uni-BH University Center, Av. Professor Mário Werneck, 1685, Bloco A2, sala dos professors, Estoril, Belo Horizonte, MG
30575-180, Brazil
ARTICLE INFO
Keywords:
High-rise housing
Residential building
Mental health
Social well-being
Urban planning
Physical design
ABSTRACT
Different types of high-rise residential buildings have proliferated in different countries at least since the 1940s,
for a range of reasons. This paper aims to provide an overview of the current state of evidence on how planning,
urban design and architectural aspects of high-rise residential buildings may influence social well-being and
mental health. A systematic review following the PRISMA guidelines was conducted. Searches for peer-reviewed
papers were conducted in MEDLINE, Embase, PsycInfo, Scopus, SciELO, and Web of Science; 4100 papers were
assessed. 23 empirical studies published between 1971 and 2016 were included. The review found that house
type, floor level, as well as spaces intrinsic to high-rise residential buildings (e.g. shared stairwells) are associated
with social well-being and mental health. However, conceptual gaps and methodological inconsistencies still
characterise most of the research in this field. We expect that research about and policy attention to this subject
may intensify due to its strategic relevance in the face of global challenges such as increasing urbanization and
loneliness. This paper concludes by highlighting a number of recommendations for future research.
1. Introduction
Housing has long been associated with health. The World Health
Organization (WHO) has considered housing a determinant of health
from its formation in 1948 (Howden-Chapman, Roebbel, & Chisholm,
2017). Although there is not a consensual cross-disciplinary definition
for health, since the WHO's (2014, p.1) well-known definition of health
as “[…] a state of complete physical, mental and social well-being and
not merely the absence of disease of infirmity”, social well-being, also
known as social health, and mental health have been understood as
essential and inter-related aspects of health.
Different definitions and indicators of social well-being and mental
health permeate the literature because they tend to be conceptualized
according to research aims (Hashemi et al., 2016) and, on the other
hand, these are also culture-related. For the purposes of this review,
social well-being is defined as “the appraisal of one's circumstance and
functioning in society”(Keyes, 1998, p.122), and good mental health as
“[…] a state of well-being in which the individual realizes his or her
own abilities, can cope with the normal stresses of life, can work pro-
ductively and fruitfully, and is able to make a contribution to his or her
community”(WHO, 2007, p.1).
United Nations have directed efforts to promote social well-being
https://doi.org/10.1016/j.cities.2019.05.015
Received 30 May 2018; Received in revised form 16 April 2019; Accepted 9 May 2019
⁎
Corresponding author.
E-mail addresses: paula-barros@ufmg.br (P. Barros), l.ngfat@ucl.ac.uk (L. Ng Fat), leandromtg@gmail.com (L.M.T. Garcia), adslovic@usp.br (A.D. Slovic),
nt@glaux.eu (N. Thomopoulos), thiagoherickdesa@gmail.com (T.H. de Sá), pedro.morais@prof.unibh.br (P. Morais), j.mindell@ucl.ac.uk (J.S. Mindell).
1
Joint first authors.
and mental health because these highly neglected aspects of health are
critical to the achievement of WHO's 2030 Sustainable Development
Goals (United Nations, 2018). Although the health effects of living in
high-rise residential building are still to be fully understood, this house
type has been a common solution for accommodating population
growth across the globe. The report carried out by the Council on Tall
Buildings and Urban Habitat (CTBUH) in 2018 shows that there was a
464% increase in high-rise buildings with total height over 200 m in the
world from the year 2000 (CTBUH, 2019).
Like health, high-rise building, as health and its aspects, has no
internationally accepted definition (Al-Kodmany, 2018). This housing
type includes multi-story buildings that differ in many aspects such as
in their height, primary use (e.g. office, residential, mixed-use), archi-
tectural design, scale, meaning and market position. Rapid urbanization
and the need to control urban sprawl, whose cost is over 1 US$ trillion
annually (Litman, 2015), are not the only factors that have driven the
construction of high-rise residential buildings. Other forces include
increases in land prices, massive migration from rural to urban areas,
global competition, human aspiration, symbolism, and ego (Al-
Kodmany, 2018).
In addition to the increasing demand for designing and building
high-rise residential buildings, there has been an interest in retrofitting
those that have been associated with social isolation, crime, negative
image, poor indoor air quality, and other problems, as the case of
Amsterdam's Bilmermeer high-rise illustrates (Helleman & Wassenberg,
2004).
Mental health disorders have a bi-directional relationship with so-
cial well-being and accounted for 57% of disability-adjusted life years,
according to the Global Burden of Disease Study 2010 (Whiteford et al.,
2015). Awareness of that; the rapid growth in the height and numbers
of high-rises; the long life cycle of this building type, the demand for
upgrading aging high-rise residential buildings; the value of residential
spaces to people; and the longstanding associations of housing with
health call for a systematization of what is known about the inter-re-
lationships between high-rise residential building, social well-being and
mental health.
To our knowledge, however, no systematic review of the evidence
has been conducted on this topic, although other types of reviews have
been carried out on living environments, social well-being and/or
mental health (Blair et al., 2014;Clark et al., 2007;Diez & Mair, 2010;
Evans, 2003;Evans, Well, & Moch, 2003;Gong et al., 2016;Julien
et al., 2012;Mair, Diez Roux, & Galea, 2008;Mazumdar et al., 2017;
Moore et al., 2018;Mueller, 1981;Rautio et al., 2017;Renalds, Smith,
& Hale, 2010;Truong & Ma, 2006).
From all these earlier reviews, only one, a critical review carried out
15 years ago by Evans et al. (2003), focused on aspects of high-rise
residential buildings (house type, floor level and housing quality) and
mental health. Evans (2003) concluded that housing does influence
residents' mental health and discussed the importance of taking into
account moderating and mediating constructs as well as the role of
psychosocial processes, which for the purposes of this research are
under the umbrella of social well-being, as mediators variables (Fig. 1).
With these policy priorities and gap in research, the authors build
on past efforts (notably Evans et al., 2003) to provide an overview of
the current state of evidence on the inter-relationships between phy-
sical and spatial aspects of high-rise residential buildings, social well-
being and/or mental health. As part of an attempt to bring a range of
technical expertise and viewpoints, this review was conducted by a
team covering a wide range of disciplines, including architecture,
planning, urban design, economics, public health and epidemiology.
We hope that the findings of this review will: (i) help policy makers,
urban planners, urban designers, architects, landscape architects and
public health professionals to take evidence-based decisions that will
contribute towards the enhancement of social well-being and mental
health among those who live in high-rise residential buildings, and (ii)
promote high-quality research on a topic that is key to the quality of life
of a large proportion of the global population in cities.
2. Methods
2.1. Literature search
We performed a systematic review of studies investigating the in-
fluence of living in high-rise buildings on social consequences and/or
mental health outcomes (excluding psychotic illness), following the
PRISMA guidelines (Liberati et al., 2009). A systematic literature re-
view is an approach regularly used in the public health field as an at-
tempt to reduce biases in the process of compiling the available evi-
dence to respond to a specific research question. It therefore involves a
pre-specified, specific research question that results in an extensive
search of several databases using both free text and thesaurus terms,
combined using Boolean operators; selection of relevant studies based
on pre-specified eligibility criteria; extraction of relevant information
within each study under a pre-specified extraction protocol; and the
assessment of the quality and risk of bias of the available evidence
identified. Unlike scoping reviews, another common type of knowledge
synthesis, systematic reviews are not intended to map evidence on a
topic –e.g. housing, social connectedness, and mental health –so as to
identify main concepts, theories, sources, and knowledge gaps (Tricco
et al., 2018).
MEDLINE, Embase, PsycINFO, Scopus, SciELO, and Web of Science
were searched between August and October 2016. The full search
strategy for each database is available as Supplementary Material 1.We
searched in title, abstract, keywords, and subject descriptors using
combinations of terms in English related to: high-rise residential
buildings (e.g. high-rise, flat, apartment, social housing, collective
housing, housing, built environment, high density), plus social out-
comes/psychosocial processes (e.g. social support, community network,
social isolation, loneliness, social capital, social network, social inclu-
sion, social interaction, sense of community, cohesion), and/or mental
health (e.g. agoraphobia, depression, neurotic disorder, psychological
stress, anxiety, mood disorder, depressive disorder, mental health, well-
being). Duplicate records were removed using EndNote™7.7.1
(Thomson Reuters, Carlsbad, California, United States).
2.2. Study selection criteria and process
To be included, studies had to be carried out within urban areas; we
had no limits on geographic location. Participants had to be non-in-
stitutionalized people living in high-rise buildings, but no limits on any
demographic or social attribute were set. Initially we sought papers that
investigated all three variables in a single study, given their known
associations, but the lack of such reports led us to also investigate the
separate associations of high-rise residential building and social well-
being or mental health. Therefore, publication content had to include
associations between high-rise residential buildings and social well-
being and/or mental health. Papers that reported only on the associa-
tions between neighbourhoods containing high-rise buildings and social
well-being and/or mental health outcomes were excluded. No limits
were set for publication date, language, or study design. Theoretical
papers and reviews were not included.
We performed a two-phase selection process. First, we assessed
documents based on title and abstract. Then we retrieved and reviewed
the full text of filtered-in papers. All authors participated in both
phases, grouped in pairs from different disciplinary backgrounds to
minimise associated bias. In each phase, each pair received a share of
documents to assess; each member independently assessed full-text
articles to check their eligibility. Disagreements between the two re-
viewers about which studies to include were resolved by discussion
and, if not resolved, by involving a third reviewer. We retrieved 4945
records from the electronic database search, from which 4100 were
assessed after duplicates were excluded. 23 studies met the eligibility
P. Barros, et al.
criteria (Fig. 2).
2.3. Data extraction
We independently extracted data using a collection form pretested
through a pilot review on a sample of papers. A second reviewer revised
the data extraction, and a third reviewer resolved any disagreements.
For each study, we retrieved the following information: publication
attributes (title, authors, year of publication, and main scope of the
source); study objective, setting, and design; sample size and attributes
(both of buildings and people); data collection and analysis methods;
concepts and operationalisation regarding high-rise housing, social
Fig. 1. Factors that influence the inter-relationship between high-rise residential building and mental health.
Fig. 2. Flowchart of study selection.
Table 1
Quality assessment criteria.
Score Appropriateness of study design Definitions and operationalisation Quality of data
collection
a
Quality of analysis
b
Housing Mental health/social consequences
0 Unable to answer their research
question
No definition of ‘high-rise’No concepts or operationalisation
described
Poor or not described Poor or not
described
1 Cross-sectional Number of storeys OR other
attributes described
Concepts or operationalisation described Adequate Adequate
2 Longitudinal or randomised
assignment
Number of storeys AND other
attributes described
Validated scale used, if quantitative data Excellent Excellent
a
Assessed in relation to study type (e.g., quantitative, qualitative, observational, mixed methods, or review), considering factors such as: sampling design, sample
size, response rate, training of interviewer, use of validated survey tools for quantitative study; sampling design, training of interviewer, specified type of data
collection (e.g., interview, focus groups), procedures to limit bias for qualitative study; literature search terms and databases searched for review.
b
Assessed in relation to study type (e.g., quantitative, qualitative, observational, mixed methods, or review), considering factors such as: descriptive analyses only
or adjusting for potential confounding factors for quantitative study; use of formal analysis software or underlying theory for qualitative study.
P. Barros, et al.
effects, and/or mental health outcomes; findings; strengths and lim-
itations; and recommendations for future research, policy and design
practice.
Because of the range of study designs and disciplines included, we
created a quality assessment matrix for this review including (i) ap-
propriateness of study design to the research question, (ii) presence of
definitions and operationalization of high-rise residential buildings, and
social effects and/or mental health outcomes, (iii) quality of data col-
lection, and (iv) quality of analysis. One reviewer assigned to that paper
plus an experienced second reviewer (the same person for each study)
evaluated the quality of the studies, scoring each element from 0 to 2
according to the criteria presented in Table 1. Differences were dis-
cussed and an agreed score assigned. A quality score, ranging from 0 to
10, was generated by adding the scores for each element to create a
composite indicator. Characteristics and quality of the studies are pre-
sented in narrative form, and in total and relative frequencies. Table 2
shows the quality scores for each included study.
3. Characteristics and quality of articles selected
23 papers were included in this review. These studies discuss the
impacts of house type, floor level, and external/internal spaces intrinsic
of high-rise residential buildings on social well-being and/or mental
health. Table 3 and Supplementary Material 2 summarize character-
istics and key findings of the selected studies. Concerning the year of
publication, the earliest article was published in 1974. Ten papers were
published recently, from 2010 to 2016, suggesting an increasing in-
terest in this topic.
Most of the research was conducted across the Global North, in
high-income countries. The highest number of studies were carried out
in the United Kingdom (eight papers), followed by studies from the
United States (four papers), South Korea (two papers), Canada (two
papers), Netherlands (two papers), Japan (two papers), and Albania,
Brazil and Singapore (one apiece).
The mean quality score for the 23 papers was 6 (standard devia-
tion = 1; quality score ranging from 0 to 10). Nine had a score of 7 or
higher, and only four scored less than 5 (Table 2). Only one study used
a longitudinal or experimental design. Seven studies did not provide a
thorough description of the high-rise residential buildings, whereas
only one did not formally operationalise its outcomes (e.g. social well-
being and/or mental health outcomes).
Almost all papers were evaluated as adequate or excellent in terms
of quality of data collection (n= 20) and data analysis (n = 20). All
papers with a total score of 7 or higher received at least one point in
every criterion. The majority of the research designs lacked controls
(e.g. random assignment to building types) or information on con-
founders (e.g. socio-economic status).
In view of the relatively small number of studies that met the in-
clusion criteria for our systematic review, we did not exclude any study
on the grounds of quality but considered the reliability of overall evi-
dence in relation to the studies' quality. It should be noted that apart
from the study design, low scores primarily reflect the lack of in-
formation provided in the paper and are not necessarily a reflection of
the quality of the studies themselves.
4. The influence of physical and spatial aspects of high-rise
residential buildings on social well-being and mental health
4.1. Terminology
Our review is structured in the following categories: semi-public
spaces (e.g. shared entrances, private entrances); floor level (e.g.
ground floor); house type (e.g. high-rise residential building); and
streetscapes. The key findings related to each of these housing variables
are summarized within Table 3, which lists the included studies al-
phabetically. This section aims to clarify the terms employed in this
systematic review.
‘High-rise residential building’denotes a physical structure with at
least four storeys that necessarily, but not exclusively, contains a
number of private residences (also referred as apartments or flats)
reached via a shared entrance, stairwell and/or lifts. For the purposes of
this systematic review, this terminology also includes mixed-use re-
sidential high-rise developments. The upper floor level benchmark
varies across the included studies. Saito et al. (1993),Kearns et al.
(2012) and Hannay (1981) define the 15th, sixth and fifth storey and
above as upper floor levels, respectively. Kowaltowski et al. (2006)
compares the ground floor with the higher floor levels.
‘Semi-public spaces’embrace those shared spaces intrinsic to high-
Table 2
Quality assessment.
First author Year Global rating Appropriateness of
study design
Definitions and operationalisation Quality of data collection Quality of analysis
Housing Mental health/social outcomes
Gibson M 2011 8 2 1 1 2 2
ZaffJ 1998 8 1 2 2 1 2
Angrist S 1974 7 1 1 2 1 2
Ghosh S 2014 7 1 2 1 1 2
Kearns A 2015 7 1 1 1 2 2
Kearns A 2012 7 1 1 1 2 2
Knipschild P 1978 7 1 2 2 1 1
Pojani D 2015 7 1 1 1 2 2
Saito K 1993 7 1 1 2 1 2
Hannay D 1981 6 1 1 1 1 2
Hooper D 1979 6 2 0 1 2 1
Kitchen P 2012 6 1 0 1 2 2
Li X 1994 6 1 1 1 1 2
Masters N 1989 6 1 2 2 1 0
McCarthy P 1985 6 1 1 2 0 2
Asgarzadeh M 2014 5 1 1 1 0 2
Kowaltowski D 2006 5 1 1 1 1 1
Phoon W 1976 5 1 1 1 1 1
Quinn N 2010 5 1 0 1 2 1
Husaini B 1991 4 1 0 2 1 0
Lee J 2011 4 1 0 1 1 1
Jung E 2015 3 1 0 0 0 2
Korte C 1983 3 1 0 1 1 0
P. Barros, et al.
rise residential buildings or other house types (e.g. shared entrances,
private entrances). ‘Streetscape’is used to refer to all elements (e.g.
buildings, urban furniture, sidewalks) that define the appearance of a
street.
The overarching category ‘social well-being’includes a range of
social variables, such as: social contacts, anti-social behaviour, social
network, sense of belonging, sense of community, memberships, sense
of control, social cohesion, social capital and social support.
‘Mental health’embraces both affective outcomes (e.g. quality of
life, mood, loneliness) and mental illnesses (e.g. clinical neurosis, de-
pression, schizophrenia) that may be directly (or indirectly) influenced
positively or negatively by high-rise living. Although we occasionally
use terms that suggest causality, such as “consequences”,“outcomes”,
and “effects”most researchers have investigated “associations”or “re-
lationships”.
4.2. Semi-public spaces, social well-being and mental health
4.2.1. Results
Of all 23 included studies, two explored the associations between
semi-public spaces intrinsic to high-rise buildings and social well-being
(Phoon et al., 1976;Pojani & Buka, 2015)(Table 3). Pojani and Buka
(2015) found that narrow, dark staircases and elevators are spaces
likely to inhibit social interactions and, therefore, the expansion of
Table 3
Characteristics and main findings of the selected studies.
First author Year Country Context Exposure Social well-being Mental health
Angrist S 1974 US Deprived Living in high-rises vs. other housing types Fear (+)
Asgarzadeh M 2014 Japan x Views of high-rises
Views of sky and trees in front of high-rises
Oppressiveness (+)
Oppressiveness (−)
Ghosh S 2014 Canada Deprived Living in high-rises Sense of community (+)
Gibson M 2011 UK Deprived Living in high-rises vs. other housing types Sense of control (−) Well-being (−)
Communal spaces vs. private garden Sense of control (−)
Safety (−)
Privacy (−)
Antisocial behaviour (+)
Levels of sociability (−)
Well-being (−)
Quality of life (−)
Positive mood (−)
Shared vs. private entrances Sense of control (−)
Safety (−)
Privacy (−)
Quality of life (−)
Positive mood (−)
Stress (+)
Streetscape Anti-social behaviour (+)
Hannay D 1981 UK Deprived
⁎⁎
Living in high-rises vs. other housing types Mental symptoms (+)
Living upper floors vs. lower floors Mental symptoms (+)
Hooper D 1979 UK Varied Living in high-rises vs. other housing types Clinical neurosis (+)
Husaini B 1991 US Deprived
⁎⁎
Living in high-rises vs. other housing types Social support (−) Stress (+)
Depression (+)
Mental disorder (+)
Schizophrenia (+)
Simple phobia (+)
Jung E 2015 South Korea x Pedestrian-friendly streetscape Sense of community (+)
Kearns A 2012 UK Deprived Living in high-rises vs. other housing types Perception of anti-social behaviour (+)
Sense of community (−)
Cohesion (−)
Social contact (−)
Social support network (−)
Living upper floors vs. lower floors Social cohesion (+)
Social contact (+)
No social support (−)
Kearns A 2015 UK Deprived Living in high-rises vs. other housing types Loneliness (o)
Kitchen P 2012 Canada x Living in high-rises vs. other housing types Sense of belonging (−) Mental health (−)
Knipschild P 1978 The Netherlands Privileged
⁎⁎
Living in high-rises vs. other housing types Psychological problems (−)
Sedatives and hypnotics (−)
Psychosomatic problems (o)
Korte C 1983 The Netherlands x Living in high-rises Social support (−)
Kowaltowski D 2006 Brazil Deprived Living in high-rises vs. other housing types Sense of belonging (+)
Living upper floors vs. lower floors Sense of control (+)
Privacy (+)
Security (+)
Lee J 2011 South Korea Privileged Semi-public spaces in high-rises Quality of life (+)
Li X 1994 x Deprived Living in high-rises vs. other housing types Risk behaviours (o)
Masters N 1989 UK Deprived Living in high-rises vs. other housing types Depression (+)
McCarthy P 1985 UK Deprived Living in high-rises vs. other housing types Psychological distress (o)
Phoon W 1976 Singapore Deprived Living in high-rises Social contacts friends & relatives (−)
Corridors in high-rises Social contacts with neighbours (+)
Pojani D 2015 Albania Privileged Living in high-rises vs. other housing types Social cohesion (−)
Social network (−)
Dark and narrow staircases Social network (−)
Elevators Social network (−)
Quinn N 2010 Scotland Deprived Living in high-rises Social capital (+) Mental health (+)
Saito K 1993 Japan x Living upper floors vs. lower floors Psychological distress (o)
ZaffJ 1998 US Deprived Living in high-rises vs. other housing types Sense of community (−)
Membership (−)
** = Presumably.
X = No information.
o = No evidence of association; + = Positive association; −= Negative association.
P. Barros, et al.
social networks, while Phoon et al. (1976) reported that the large
majority of social contacts in high-rises take place in corridors.
Gibson et al. (2011) found associations between semi-public spaces
and a range of domains of social well-being which, in turn, were re-
ported to be linked to mental health outcomes (Table 3). These findings
reinforce the importance of exploring social well-being as a potentially
mediating variable between built environments and mental health.
Gibson et al. (2011) found that communal areas behind high-rises
are related to worse social effects (i.e. higher perception of antisocial
behaviour, lower sense of control) which, in turn, are linked to poorer
mental health outcomes than private gardens of houses. Likewise,
shared entrances were reported to be associated with lower sense of
control, safety and privacy, which, in turn, were associated with poorer
mental health than private entrances intrinsic to houses (Gibson et al.,
2011).
Lee (2011) found positive associations between physical attributes
of semi-public spaces of high-rise mixed-use housing buildings, which
includes community facilities and commercial area, and quality of life
(Table 3). The findings of the studies included in this literature review
show that semi-public spaces inherent to high-rises are not necessarily
bad for social well-being and mental health, but that some physical and
spatial configurations are worse than others for social well-being and
mental health.
4.2.2. Discussion and shortcomings
The finding that narrow, dark staircases and elevators are spaces
likely to inhibit the formation of social ties (Pojani & Buka, 2015) and
that corridors accommodate the large majority of social contacts that
take place in a high-rise residential building (Phoon et al., 1976) sug-
gests that if social interactions are too short and infrequent, residents
may not experience a sense of social support, a necessary condition for
the development of more complex domains of social well-being (e.g.
social cohesion).
Semi-public spaces intrinsic to high-rise residential buildings (e.g.
shared entrances) were associated with worse social effects which, in
turn, were associated with poorer mental health outcomes than their
equivalent in houses (e.g. private entrances) (Gibson et al., 2011). This
finding supports the thesis developed by Newman (1972) that those
physical and spatial configurations that inhibit expressions of territorial
claims and offer fewer opportunities for surveillance usually are pro-
blematic:
The problem of unwanted interlopers in housing with shared en-
trances was a theme that recurred frequently, and was described as
causing extreme stress, fear and disturbed sleep. By contrast, private
entrances provided respondents with defensible space which permitted
them to monitor and control entry to their property. Increases in
privacy and security provided by private entrances impacted on affec-
tive outcomes such as well-being, quality of life, stress levels and mood
through the psychosocial process of control (Gibson et al., 2011, p.565).
The marking of territoriality by personalization, however, does
much more than affording the emergence of so called “defensible
spaces”(as proposed by Newman, 1972). As a mode of communication
(Bentley et al., 1985;Hall, 1966), personalization of spaces also fosters
a sense of attachment and belonging (Mehta, 2014). In addition, the
embellishment of the semi-public spaces also may impact on their
maintenance and attractiveness (Mehta, 2014). By placing plants and
paintings in front of the main entrance of their apartments, for example,
dwellers extend a sense of control and identity to the corridor.
4.3. Floor level, social well-being and mental health
4.3.1. Results
Two studies reported six associations between floor level and social
well-being (Kearns et al., 2012;Kowaltowski et al., 2006)(Table 3).
Upper floor levels were consistently associated with better social ef-
fects. Kearns et al. (2012) found that certain social outcomes (e.g. social
cohesion, social contact) were better higher up the building while
Kowaltowski et al. (2006) found that the residential ground floor was
potentially problematic due to the lack of control, privacy and safety.
Hannay (1981) found that primary care patients living on the fifth
floor or above faced a twofold ratio of mental health symptoms com-
pared with those on lower floors. Saito et al. (1993), on the other hand,
reported no association between floor level and psychological distress.
4.3.2. Discussion and shortcomings
Fig. 3 summarizes the key findings about floor level and social well-
being and mental health. Results of the research conducted by Kearns
et al. (2012) and Kowaltowski et al. (2006) reinforce each other and
provide support to the hypothesis that residents living on higher levels
tend to be insulated from the negative effects lower down the building
(e.g. lack of privacy). In the view of the authors, those semi-public
spaces intrinsic to high-rise residential buildings identified as
Fig. 3. Key findings (floor level).
P. Barros, et al.
problematic (Newman, 1972) and situated on the ground floor (e.g.
communal area and shared entrances) may explain, at least partially,
why the lower floor levels are associated with worse social effects.
If we take social outcomes as mediators, better mental health out-
comes would be expected among those living higher up. However, of
the two studies that examined associations between floor level and
mental illness (Hannay, 1981;Saito et al., 1993) a positive association
was reported by one and no association by the other. The former un-
expected finding may be explained by self-selection bias, i.e. people
with mental problems may choose to live on higher floor levels, a
methodological problem previously raised by Evans (2003).
The absence of association between floor level and mental health
reported by Saito et al. (1993), on the other hand, may be elucidated on
the basis that the inter-relationship between floor level and mental
health may also be strongly influenced by culture. The divergent results
may also be explained on the basis that the high-rise residential
buildings investigated presented different types of floor levels.
4.4. House type, social well-being and mental health
4.4.1. Results
All four studies that investigated the associations between high-rise
residential building and different domains of social well-being found
significant associations between these variables (Ghosh, 2014;Korte &
Huismans, 1983;Phoon et al., 1976;Quinn & Biggs, 2010). The findings
show that high-rise residential buildings, even in deprived areas, are
not necessarily associated with poor social well-being. Quinn and Biggs
(2010), for example, reported a significant association between high-
rise residential building and social capital which, in turn, was related to
positive mental health outcomes in an area of high deprivation in
Glasgow.
A total of 13 associations and one nonsignificant association be-
tween living in high-rise versus alternative housing types and different
domains of social well-being were tabulated (Table 3). Of all associa-
tions, the large majority (12) shows high-rise residential buildings to be
associated with worse social outcomes than alternative housing types.
Focusing on the divergent findings, Kowaltowski et al. (2006) re-
ported that apartment dwellers tend to experience a stronger sense of
belonging than those who live in houses and explained that house
owners in the context of low-income housing development in the region
of Campinas (Brazil) value very much their individual lot. Li et al.
(1994) found no association between house type and adolescent risk
behaviour (e.g. drug trafficking and substance abuse). The evidence
shows that risk behaviours are actually associated with parental mon-
itoring, social support and perceived risk exposure (Li et al., 1994).
Two of the included studies examined the associations between
living in high-rise residential buildings versus alternative housing types
and specific sub-domains of social well-being as pathways to mental
health (Gibson et al., 2011;Kitchen, Williams, & Chowhan, 2012).
These studies found high-rise residential buildings to be associated with
poorer social well-being and mental health than alternative housing
types. Kitchen et al. (2012) found a significant association between
sense of belonging and mental health, while Gibson et al. (2011) re-
ported that sense of control mediates mental health. Evidence, there-
fore, confirms the importance of taking into account different domains
of social well-being as possible explanatory mechanisms for mental
health.
Overall, the results of the included papers indicate that house type
and mental health are associated. A total of 13 statistically significant
associations and three nonsignificant associations between housing
type and mental health were mapped (Table 3). Based on the results
obtained by the studies included in this review, the large majority (11)
of associations were in the expected direction: high-rise residential
buildings were (directly or indirectly) associated with worse mental
health outcomes than alternative housing types (Table 3).
The divergent results came from McCarthy et al. (1985) and Kearns,
Whitley, and Ellaway (2015), who reported no association between
housing type and psychological distress and loneliness, respectively.
They found that mental illness correlated less strongly with the type of
housing rather than with where it was located.
To increase the generalizability of these conflicting findings, how-
ever, future empirical research needs to select cases that are better
distributed geographically and take into account the potential influence
of contextual factors. Knipschild (1978) reported that dwellers of high-
rise buildings tended to have fewer psychological problems and use
fewer sedatives and hypnotics than those people living in houses, while
no differences in psychosomatic problems were found.
According to Knipschild (1978), some possible explanations for
these unexpected findings are: (i) unlike previous studies, the apart-
ments studied were better constructed than the houses, (ii) people
mistakenly may say that their problems are caused by their living
conditions rather than other factors (e.g. their families situation), (iii)
people who live in apartments, for some reason, may be less likely to
see a doctor for mental problems, although they may actually occur,
and (iv) most of the apartment dwellers did not live there for more than
five years and it is possible that harmful health effects may occur after
longer periods of exposure.
4.4.2. Discussion and shortcomings
Overall, the evidence shows that although high-rise residential
buildings, even those located in deprived contexts, are not necessarily
associated with poor social well-being and mental health, high-rise
residential buildings are related to worse social effects and mental
health outcomes than alternative types of housing (e.g. Angrist, 1974;
Hooper & Ineichen, 1979;Husaini, Moore, & Castor, 2008,Masters &
Birtchenell, 1989;Zaff& Devlin, 1998)(Fig. 4).
It is important to bear in mind, however, that of all studies that
analysed high-rise residential buildings versus alternative dwellings,
the majority included dwellers that lived on lower floor levels. In the
view of the authors, the inclusion of this group is problematic since
these dwellers have to deal with negative social effects commonly as-
sociated with shared entrances and other semi-public spaces located in
the ground floor.
Based on the general shortage of empirical research, unbalanced
geographical distribution of the cases studied as well as the methodo-
logical inadequacies (e.g. research designs lacked adjustment for con-
founders), we offer an alternative hypothesis to explain why high-rise
residential buildings were associated with worse social effects and
mental health outcomes than other types of buildings.
We note first, that the majority of papers included in this review
report results of research carried out in North America and Europe,
where a large number of high-rise residential buildings were developed
by the public sector after the Second World War in deprived areas
(Verhaeghe, Coenen, & Putte, 2016). Secondly, from the 1970s, high-
rise residential buildings in these continents became associated with a
negative image (Pereira, 2017). Bearing these two facts in mind, it is
plausible to hypothesize that stigmatization might explain the negative
social effects and, in turn, the mental illness associated with this type of
house in the context of North America and Europe (Evans et al., 2003).
4.5. Streetscape, social well-being and mental health
4.5.1. Results
Of the 23 included studies, three examined the social effects and
mental health outcomes associated with streetscapes shaped by high-
rise residential buildings (Asgarzadeh et al., 2014;Gibson et al., 2011;
Jung, Lee, & Kim, 2015)(Table 3). Gibson et al. (2011) found that
streetscapes framed by high-rises are a better predictor of anti-social
behaviour (or perception of anti-social behaviour) than those framed by
houses.
Jung et al. (2015) reported that pedestrian-friendly streetscapes
enclosed by high-rises provide a stronger sense of community that those
P. Barros, et al.
that are car-oriented. Asgarzadeh et al. (2014) reported that opportu-
nities to view sky and trees in front of high-rises tend to attenuate the
sense of oppressiveness associated with streetscapes walled by this
building type.
4.5.2. Discussion and shortcomings
The results of the studies in this review suggest that streetscapes
intrinsic to high-rises are associated with lesser sense of control and
increased perception of anti-social behaviour that those enclosed by
other house types (Gibson et al., 2011). This is to be expected, as they
tend to offer lower external visibility compared with streetscapes as-
sociated with other buildings types.
The findings of the research conducted by Jung et al. (2015) and
Asgarzadeh et al. (2014) show that streetscapes shaped by high-rises
are not necessarily associated with negative social effects or mental
health outcomes. The evidence indicates that the urban design of
streetscapes does matters to public health, or rather, the design and
arrangement of high-rise residential buildings and some micro-scale
physical elements along the streets (e.g. trees) are likely to influence
social well-being and mental health.
5. General discussion and shortcomings
The methodological inadequacies mapped by Evans et al. (2003)
more than 15 years ago still feature in the large majority of the em-
pirical studies included in this systematic literature review. First, no
standard ontology of terms and research approaches exists: different
studies adopt different conceptualizations, operationalisations and
scales to measure what appears to be the same construct.
In addition, the research design and analysis of the large majority of
the included researches did not take into account moderators (e.g.
personal variables), mediators (e.g. social control) nor confounders
(e.g. socio-economic status) (Supplementary Material 2). Additional
research on how different domains of social well-being mediate the
linkage between high-rise and mental health, as previously pointed out
by Evans et al. (2003), is still on needed.
This systematic review has some limitations. Although it included
documents available in six major databases, we could not capture all
potential valuable evidence from the grey literature. In addition, we did
not scan the reference lists of the included papers. Therefore, there is a
possibility that some publications may have been overlooked.
Thus, more rigorous research is needed. Although causality cannot
be assumed because almost all the studies are cross-sectional, this re-
view reveals that although there is no consensus on how different
housing variables impact on social well-being and mental health, they
are inter-related. The results of the included studies also show that al-
though living in high-rise residential buildings is not necessarily bad, it
tends to trigger worse social effects and mental health outcomes than
other types of housing (e.g. low-rise residential buildings). As part of an
attempt to provide a framework for future research, it is important to
highlight that evidence also shows that other environmental aspects
(e.g. noise) can have a direct effect on the residents' mental health
(Evans, 2003)(Fig. 5).
Our review shows a need for a deeper understanding of how plan-
ning and the quality of the urban design and architectural solutions
moderate the harmful effects associated with high-rise residential
buildings (Fig. 5). In this regards, the included studies explored the
social effects and mental health outcomes associated with “generic”
high-rise residential buildings. To deeper our understanding of the
processes underlying the connections between housing variables, social
well-being and mental health, the authors, building on Evans et al.
(2003) previous critical review, suggest a different focus and diagnosis.
Perhaps living in high-rise residential buildings is associated with
worse social effects and mental health outcomes due to the poorer
quality of their semi-public spaces (e.g. shared entrances, communal
spaces, corridors). From the results of the studies selected, it is plausible
to hypothesise that design quality moderates the inter-relationships
between housing and social well-being which, in turn, influences
mental health.
None of the research included investigated, for example, how dif-
ferent types of ground floor level (e.g. with vs. without pilotis), corri-
dors (e.g. with vs. without nice panoramic views) or perceptual
Fig. 4. Key findings (housing type).
P. Barros, et al.
qualities (e.g. human scale, legibility, permeability) may moderate the
inter-relationship between high-rise residential buildings, social well-
being and mental health. These gaps in the literature reinforce the need
for interdisciplinary research, since designers can contribute towards
the operationalization of these variables.
A further strength of this review has been its cross-disciplinary
nature. Working across disciplines challenged the authors' assumptions
and outlooks, leading to a more holistic appraisal of the available lit-
erature. For example, the architects noted the lack of definition of ‘high-
rise’in most of the papers reviewed, while those with epidemiology
expertise were better able to provide critiques of the study methods and
the extent to which each study was capable of answering its own re-
search question(s). All the shortcoming and gaps revealed by this lit-
erature review, however, clearly indicate opportunities for further re-
search.
The conclusions of this review may not be applicable to all cities
worldwide for three main reasons: (1) the definitions of high-rise
housing as well as of the myriad of concepts classified as “social well-
being”and “mental health”are culturally bound; (2) many studies ex-
amined the social effects and mental health outcomes of high-rise re-
sidential building on specific social groups, such as the aged; and (3)
cultural attitudes and norms regarding high-rise dwelling vary sub-
stantially depending on country and context.
6. Avenues for future research agenda on impacts of high-rise
residential buildings on social well-being and mental health
We see a number of prospects for research into the positive and
negative effects of high-rise residential buildings on social well-being
and mental health and how planning, urban design and architectural
decisions influence these.
1. The complexity of the topic requires more inter- and trans-dis-
ciplinary work. Collaboration between different disciplines, such as
architecture, psychology, urban planning, urban design, public
health, epidemiology, sociology, human geography and ecology,
holds the promise of offering new perspectives. Learning and
adapting methods across disciplines are expected to increase
knowledge and help policy makers, planners, urban designers and
architects to take decisions that are more inclusive and evidence-
based.
2. It is important that future studies bring clearer definitions and op-
erationalisations of high-rise housing, social effects and mental
health outcomes. As far as the definitions of “high-rise”and “higher
floor level”are concerned, the adoption of parameters based on our
sensory apparatus may be more universally accepted. Taking into
account how human senses influence perception and behaviour
(Hall, 1966), four storeys can be chosen as a threshold, since above
44 ft (13.5 m) people on the ground cannot be recognized or con-
tacted (Gehl, 2010). Once a more standardized ontology of terms
and research approaches exists, a meta-analysis approach may
provide an invaluable synthesis.
3. Accepting that personal variables are moderators, it is likely that
different groups experience differently some specific physical-spa-
tial configurations in high-rise buildings. Thus, it should be ad-
dressed systematically whether the outcomes identified are mostly
due to design of the high-rise residential buildings or to social class,
life cycle stage, gender, or other moderators.
4. The large majority of papers assessed in this review provide evi-
dence from studies carried out in high-income countries in the
Northern hemisphere. An urgent shift of scientific focus to low- and
middle-income countries, where most of the urban population
growth is concentrated, is needed. This will enable researchers to
discover whether the negative outcomes frequently associated with
living in high-rise buildings are cross-cultural or related to a specific
context.
5. Future research needs to take into account multiple confounding
variables (e.g. socio-cultural-economic position), moderators (e.g.
neighbourhood quality and personal variables), and mediators (e.g.
social support and social control) to deepen our understanding of
the potential roles of urban design and architectural solutions on
enhancing social well-being and mental health of those who live in
high-rise residential buildings.
6. This literature review reveals that there is a need to carry out studies
on how high-rise housing may yield positive mental health out-
comes.
7. Conclusions
The findings of this literature review call for a re-examination of
housing policies from a multidisciplinary perspective that takes into
account public health concerns together with more empirical research
to guide evidence-informed decisions. More needs to be known –and
the evidence put into practice –of how the design of high-rise re-
sidential buildings can influence social relations and, in turn, positive
mental health in cities across the globe, not the least for vulnerable
population groups (e.g. low-income communities and the elderly).
In addition, the evidence, although not consistent, tends to support
the imposition of height limits by planning authorities in contexts
where higher levels are associated with poorer mental health, as well as
Fig. 5. Key conceptual issues.
P. Barros, et al.
the architectural design of spacious, attractive and naturally well-lit
semi-public spaces (e.g. corridors and shared entrances) that facilitate
personalization and support social interactions. From this review, it can
also be suggested that the design of the interfaces between the private
and semi-public (or public) spaces should afford inter-visibility to en-
hance the dwellers sense of control.
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.cities.2019.05.015.
Declaration of Competing Interest
None.
Acknowledgments
This collaboration arose from discussions at a British Council
Newton Fund Researcher Links workshop held at the Federal University
of Minas Gerais, Brazil (204496092, P.I. JM) in June 2016. The dis-
cussions were continued in London in June 2017 at a meeting funded
by UCL's Grand Challenges Human Wellbeing fund (156425 Grand
Challenges, P.I. LNF). LG acknowledges funding from the National
Council for Scientific and Technological Development (402755/2015-
4). ADS thanks São Paulo State Foundation (FAPESP) for their financial
support - as part of FAPESP-ESRC-NOW Joint Call for Transnational
Collaborative Research Projects: Accessibility, Social justice and
Transport emission Impacts of transit-oriented Development strategies
(ASTRID) project FAPESP 2015/50128-9 Fellowship 2016/08826-3.
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