Making cities mental health friendly for adolescents and young adults

The study addresses whether and how cities can be shaped to improve youth mental health amidst rapid urbanization. Historically, research has linked urban environments to mental health, from early notions of environmental causes of mental illness to sociological work connecting social disorganization with mental disorders. Contemporary evidence indicates that urban living is associated with increased risk of psychosis, anxiety and depression, while benefits of cities are distributed unequally, disproportionately affecting marginalized groups. Adolescence and young adulthood are sensitive developmental periods with high incidence of mental disorders and substantial global disease burden. The purpose of this study is to identify and prioritize characteristics of mental health-friendly cities for adolescents and young adults, to inform intersectoral action in urban settings and elevate youth voices in shaping city environments.

The paper situates its inquiry within a body of work on urbanization and mental health, including historical perspectives (Faris and Dunham) and WHO Healthy Cities initiatives, and recent syntheses linking urban exposures to mental disorders. It highlights developmental science showing adolescence as a critical period of vulnerability and opportunity. Evidence on inequities, structural discrimination, environmental toxins, lack of green space and violence is reviewed as risk factors. The concept of restorative urbanism and youth-centered design is introduced, along with literature on social cohesion, collective efficacy, and the benefits of green/blue spaces, safe public realms, and school-based mental health promotion. The COVID-19 pandemic literature is referenced regarding increased youth mental health problems and the impact of social isolation. The review also notes returns on investment for adolescent mental health interventions and frameworks for cross-sector collaboration and equity-focused policy.

Design: A three-round, digitally administered, sequential survey (priority-setting/Delphi-like) conducted in 2020. Governance included a scientific advisory board (n=18), youth advisers (n=8) and an executive committee (n=5). IRB approval was obtained (University of Washington STUDY00008502). Sampling and participants: 825 invited; 518 (62.8%) accepted from 53 countries. Rounds completed: Survey 1 (S1) n=484 (93.4% of consented), Survey 2 (S2) n=303 (58.5%), Survey 3 (S3) n=291 (56.2%). Participants spanned roles (educators, researchers, program managers, advocates, students, clinicians), domains (education, mental health/substance use, healthcare, youth advocacy, adolescent development, technology, built environment, urban planning/development, criminal justice, housing), and age groups (14–17, 18–24, 25–35, >35). Procedure:

• Survey 1 (April–May 2020): Open-ended question, “What are the characteristics of a mental health-friendly city for young people?” Responses underwent conventional content analysis (ATLAS.ti 8) to extract 19 categories and 423 characteristics, consolidated into 134 characteristic statements. Youth advisers reviewed wording for clarity.
• Survey 2 (Aug–Sep 2020): Participants selected their preferred 40 of the 134 statements. Frequencies were analyzed (IBM SPSS 28.0) to produce a ranked list; to amplify younger perspectives, top-ranked items were combined across age strata to yield 40 statements (with 3 later removed as redundant).
• Survey 3 (Nov–Dec 2020): The final 37 characteristic statements were categorized into six socioecological domains (personal, interpersonal, community, organizational, policy, environmental). Panellists rank-ordered statements within each domain after choosing one framing: (1) immediacy of impact on youth mental health in cities, (2) ability to help youth thrive in cities, or (3) ease/feasibility of implementation. Mean ranks and standard deviations were computed per characteristic per framing and averaged across framings to obtain total mean ranks; the proportion ranking each item number 1 was also calculated. COVID-19 module: An open-ended S2 question (“How has the COVID-19 pandemic changed your ideas about the wellbeing of young people in cities?”) elicited 255 responses. Rapid qualitative analysis identified themes of loss, inequity, built environment needs, service access, social isolation, and potential gains (self-reflection, activism). Themes were organized by socioecological level and suggested actions. Recruitment: Nomination by advisory groups (n=763), plus advisory invitees (n=38) and snowball sampling (n=24). Materials provided in English and Spanish via REDCap; youth-friendly communications were used. Demographics and retention were tracked (Table 1).

• Overall: 37 prioritized characteristics were grouped into six socioecological domains. Many respondents framed rankings by ‘immediacy of impact’.
• Personal domain (n≈279): Top-ranked characteristic across framings: teaching life skills, providing opportunities for personal development, and resources to allow youth to flourish. It was ranked first by 93 panellists (33.33%). Preparing youth to handle emotions was ranked first by 62 panellists despite a lower mean rank.
• Interpersonal domain (n≈272): Highest priority: an age-friendly environment in which youth feelings, opinions and choices are valued, and youth are accepted for their uniqueness. Opportunities for safe and healthy relationships and strong intergenerational relationships ranked highly, especially for feasibility.
• Community domain (n≈266): Top across framings: safe, free, public spaces for youth to gather, socialize, learn and connect.
• Organizational domain (n≈265): High ranks for employment opportunities ensuring job security and satisfaction, and for progressive, supportive, culturally responsive education. Feasibility favored employment; immediate impact favored youth-friendly health services.
• Policy domain (n≈264): Highest overall: cities designed and planned with youth input and attention to gender needs, ranked first by 30.68% of panellists. Democratic cooperation and equal opportunity ranked highest on feasibility.
• Environmental domain (n≈261): Highest overall mean: addressing adverse social determinants of health. However, normalizing seeking mental health care and addressing service gaps ranked first for feasibility and immediacy. Access to affordable basic amenities (healthy food, water, electricity, stable internet) was most frequently ranked number 1 (17.62%) in this domain; affordability/inclusive housing, accessible green/blue spaces, recreation, safety for youth/women/LGBT+, and inclusive design for vulnerable and neurodiverse youth also featured.
• COVID-19 insights (n=255 responses): Highlighted exacerbated inequities, economic hardship, loss of opportunities, social isolation, reduced access to education and health care, the importance of open/green spaces, and a need for youth-inclusive governance and supportive digital/physical social spaces. Some reported gains in self-reflection, connection to nature, and youth activism.
• Participation metrics: 518 consented (53 countries); completion: S1=484, S2=303, S3=291; final complete responses for some analyses 261. In personal domain, 53% selected the immediacy framing; similar patterns recurred across domains.

The prioritized characteristics directly address the question of what urban features support adolescent and youth mental health. Findings emphasize youth skills for emotional self-regulation and flourishing, respectful and age-friendly interpersonal environments, safe public spaces for connection, employment security and responsive education, youth-centered urban planning and gender-sensitive policies, and remediation of adverse social determinants. The study underscores that youth mental health in cities is shaped by multi-level socioecological factors, demanding intersectoral collaboration across health, education, urban planning, housing, transport and employment. COVID-19-related analyses reinforced the importance of equity, green/blue space access, and inclusive governance. The results suggest that strengthening the social fabric—facilitating meaningful, safe relationships and belonging—alongside equitable policies (anti-discrimination, violence prevention) could yield significant benefits. Implementation must avoid unintended inequities (for example, green gentrification) through co-design with youth and marginalized communities and robust cross-sector governance.

This multinational, multidisciplinary priority-setting study identifies actionable characteristics of mental health-friendly cities for adolescents and young adults across personal, interpersonal, community, organizational, policy and environmental domains. It advances a consensus agenda emphasizing life skills, respectful relationships, safe public spaces, employment and educational supports, youth-centered urban design, and addressing social determinants. Next steps include convening stakeholders to co-design, contextualize and implement local plans, ensuring inclusive youth participation and equity. Future research should adopt systems and interdisciplinary approaches to evaluate cross-sector interventions, refine exposure and outcome measures (including green space and safety), address racial and place-based opportunity gaps, and expand evidence beyond well-studied regions. Aligning with SDG 11 and the New Urban Agenda, sustained intersectoral policy commitments and efforts to dismantle structural discrimination are essential.

• Sample representativeness: Web-based recruitment through professional networks likely underrepresents the most marginalized youth; participants skewed toward academics, educators, leaders and well-networked young people.
• Potential selection/network bias: Recruitment via authors’ networks may have shaped the range and prioritization of responses.
• Aspirational scope: Calls to end discrimination and structural inequities are complex; study data do not detail implementation pathways.
• Aggregation: Several characteristics are aggregated and may require local disaggregation for implementation.
• Geographic and age skew: Over-representation from certain regions (e.g., North America, Nepal) and few participants aged 14–17; attrition across rounds (S1=484; S2=303; S3=291; final complete n≈261).