Making cities mental health friendly for adolescents and young adults

The relationship between urban environments and mental health has been a subject of inquiry for centuries. Early studies linked social disorganization and unstable communities to mental disorders. While cities offer educational and economic opportunities (the "urban advantage"), rapid urbanization exacerbates inequalities and exposes individuals to various adversities, increasing the risk of poor mental health. This impact is unevenly distributed, disproportionately affecting marginalized groups. Adolescents and young adults (under 25) are particularly vulnerable, as this is a critical period for the onset of mental disorders. The rising rates of mental disorders and suicide among young people, especially during the COVID-19 pandemic, highlight the urgent need to address the mental health challenges faced by this population within urban settings. Adolescents' development is shaped by complex interactions with their urban environment – physical, political, economic, social, and cultural. Their heightened sensitivity to social evaluation and context makes them potentially more susceptible to negative environmental cues such as discrimination or violence. Investing in adolescent well-being offers significant long-term benefits, impacting mortality, disability, and the health of future generations. Interventions aligning with adolescents' developmental needs can positively influence their trajectories into adulthood, potentially preventing chronic conditions. The study uses a socioecological model to examine the interplay between individual experiences, interpersonal relationships, community dynamics, organizational structures, policies, and the physical environment in shaping adolescent mental health. The "Mental Health Friendly Cities" initiative aims to guide transformative actions by focusing on the priorities for urban adolescent mental health globally.

The paper draws upon a substantial body of literature exploring the link between urban environments and mental health. It references classic studies like Faris and Dunham's work linking social disorganization to mental disorders, and Leonard Duhl's efforts to create healthy societies through liveable cities. More recent research has shown the complex and often negative relationship between urban living and mental health outcomes, particularly concerning psychosis, anxiety, and depression. These negative impacts disproportionately affect marginalized groups due to factors like inequality, violence, environmental toxins, and lack of green spaces. The literature also emphasizes the heightened vulnerability of adolescents and young adults to these negative urban influences, given their developmental stage and increased susceptibility to social and environmental cues. The research also acknowledges the "urban advantage," the benefits of city life such as access to education and employment opportunities, but emphasizes the need to mitigate the negative aspects to create a truly beneficial environment for young people. The literature highlights the need for interventions targeting multiple levels—individual, interpersonal, community, organizational, policy, and environmental—to promote adolescent mental well-being within cities.

This study employed a multi-stage, mixed-methods approach to determine the characteristics of a mental health-friendly city for young people. It involved a three-round survey administered through REDCap to a diverse global panel of 518 individuals from 53 countries. The panel included researchers, practitioners, advocates, and young people themselves, aiming for broad representation across disciplines, age groups, and geographic regions. Survey 1 used an open-ended question ("What are the characteristics of a mental health-friendly city for young people?") to gather initial ideas. A total of 134 characteristic statements were derived from the qualitative data of Survey 1. Survey 2 presented these statements to participants, who selected their top 40 choices. An additional open-ended question was included to gauge the impact of the COVID-19 pandemic on perceptions of youth well-being in cities. Survey 3 categorized the 37 (after removing redundant statements) selected statements across six socioecological domains (personal, interpersonal, community, organizational, policy, and environmental). Participants ranked these statements within each domain according to three framing conditions: immediacy of impact, ability to help youth thrive, and ease of implementation. Data from Surveys 2 and 3 were analyzed using quantitative methods (IBM SPSS 28.0) to determine mean rankings and frequency of top rankings. Qualitative data from Survey 1 and the open-ended question in Survey 2 were analyzed using ATLAS.ti 8, employing conventional content analysis to identify themes and patterns related to the impact of COVID-19. The study followed established methods for health research priority-setting, focusing on inclusivity and minimizing attrition.

The study identified 37 key characteristics of a mental health-friendly city for young people, grouped across six socioecological domains. The top-ranked characteristics, varying slightly by framing condition, consistently emphasized the following: **Personal Domain:** Prioritizing life skills education and personal development resources for emotional maturation and self-reflection were top priorities. Many panellists (53%) prioritized these based on their immediacy of impact on youth mental health. **Interpersonal Domain:** Creating age-friendly environments valuing and accepting young people's ideas and choices and fostering safe and healthy relationships were highly ranked. The mean rankings for immediacy of impact and ability to help youth thrive were identical for the top two characteristics in this domain. **Community Domain:** Access to safe public spaces for social connection and youth participation in community life were prioritized. Rankings were identical across all three framing conditions. **Organizational Domain:** Job security and supportive educational systems were highly ranked, with employment opportunities topping the list for feasibility of implementation and youth-friendly health services ranking highest for immediacy of impact. **Policy Domain:** Urban planning and design processes that include youth input and address gender sensitivity were highly prioritized, along with promoting democratic cooperation and equal opportunity and anti-discrimination in all institutions. **Environmental Domain:** Addressing adverse social determinants of health for young people and normalizing youth seeking mental health care received the highest ranked mean, while access to affordable basic amenities was the most frequently ranked first by participants. **COVID-19 Impact:** The open-ended question about the COVID-19 pandemic revealed changes in perspective among participants, who emphasized inequities as determinants of youth well-being. Key losses experienced by youth during the pandemic were identified, including the loss of opportunity, jobs, income, a planned future, social connections, education, healthcare, and loved ones. The pandemic also highlighted the importance of access to green spaces and the need for stronger virtual support networks.

The study's findings address the research question by providing data-driven insights into the characteristics of mental health-friendly cities for young people. The socioecological framework effectively captures the multi-level influences on youth mental health within urban environments. The results emphasize the need for integrated, cross-sectoral interventions addressing individual skills, interpersonal relationships, community resources, organizational support, policy changes, and environmental factors. The COVID-19 pandemic's impact underscores the urgency of these interventions, particularly in addressing the social and economic inequalities that exacerbate mental health disparities. The findings' significance lies in their contribution to shaping urban policies and design practices that prioritize youth mental well-being. The results provide a framework for cities to develop tailored interventions and policies, fostering collaboration across various sectors to create more supportive and equitable urban environments. The study's emphasis on youth participation in city planning and decision-making reflects a commitment to fostering agency and ownership among young people. The integration of the socioecological model offers a comprehensive lens for understanding and addressing the complex interplay of factors impacting youth mental health in urban contexts. The study contributes valuable insights for researchers, policymakers, urban planners, and mental health professionals who are working to improve adolescent mental health within urban areas.

This study provides a comprehensive, globally informed set of priorities for building mental health-friendly cities for youth. The key contribution is the identification of 37 characteristics across six socioecological domains, highlighting the need for multilevel, intersectoral interventions. The results underscore the importance of youth participation in shaping their urban environments. Future research should focus on testing implementation strategies, measuring mental health outcomes of coordinated interventions, and addressing the evidence gap for youth mental health interventions in various urban contexts globally. Further work is needed to refine the identified characteristics, tailoring them to specific cities and cultural contexts, while ensuring equity and inclusivity.

The study's limitations include the potential for sampling bias, as the participant recruitment strategy might not fully reflect the social and economic diversity of urban populations. The web-based format, while maximizing geographic reach, might have underrepresented marginalized groups. The aspirational nature of some recommendations (e.g., eliminating discrimination) requires addressing long-standing structural inequities. The data may require disaggregation to understand variations in priorities across different cities and contexts. Recruitment limitations led to skewed geographic representation, potentially biasing responses. Finally, attrition over the three survey rounds should be noted, with greatest loss occurring between rounds one and two.