Planning for health through the built environment: an introduction.
Researchers and practitioners are drawing attention to the influence that the physical design of our neighbourhoods, towns and cities has on public health (e.g. Transportation Research Board 2005, Frumkin 2004, Frank and Engelke 2001). Indicating some measure of significance, several recent reports have been sponsored by key health and planning organizations such as the Ontario College of Family Physicians (Abelsohn 2005), the Ontario Chief Medical Officer of Health (Basrur 2004), the Canadian Institute for Health Information (2006), the Ontario Professional Planner's Institute (2007), the Ontario Healthy Communities Coalition (Tucs and Dempster 2007) and Smart Growth BC (Frank et al. 2006a).
This research shows that neighbourhoods designed for cars rather than people are strongly correlated with less walking and more negative health impacts such as obesity and heart disease (e.g. Abelsohn et al 2005, Fisher 2005, Frank et al. 2006b). Such neighbourhoods also increase exposure to air pollutants, which subsequently leads to negative impacts on health (e.g. Smargiassi 2006, Finkelstein et al. 2005, Buckeridge et al. 2002). Aspects of the built environment have also been shown to correlate with a variety of other health concerns, including food choices and healthy eating (Apparicio et al. 2007, Smoyer-Tomic et al. 2006, Popkin et al. 2005), traffic-related injuries (Litman, this volume, CIHI 2006), mental health (e.g. Guite et al. 2006, Evans 2003) and coping with disability (Clarke and George 2005, Blackman 2003).
Agreeably, care must be taken in presuming causal connections between aspects of the built environment and the correlated health impacts (CIHI 2006, Frank et al. 2006, Frank and Engelke 2003). Even if one could draw such connections, the synergistic complexity of influences and impacts would make it difficult to specify which particular influences had an impact on which particular health consequences. Nonetheless, researchers again and again note that there is a sufficient amount of quality evidence to call for action (Frank et al. 2006, CIHI 2006, Abelsohnetal. 2005):
The impact of the built environment on health is an emerging field of study and more rigorous research is needed, especially in Canada. Despite this, the results of current studies clearly indicate that serious public health problems will continue to escalate unless decisive and immediate action is taken to control urban sprawl and preserve sufficient greenspace, improve air quality, and protect water sources (Abelsohn 2005: 5).
Planners, then, have a new task: to integrate knowledge about health impacts into the development and regulation of actions that affect the design, construction and re-construction of our built environments. Yet is this entirely new? Many point out that this 'new' linkage between planning, health and the built environment is actually a return to the origins of professional planning (Johnson and Marko, this issue, Corburn 2006). There is, perhaps, an irony here, which provides a cautionary note: some of those original planning practices--separation of land uses, for example--have led to the current design of cities and neighbourhoods that now raise health concerns (Johnson and Marko, this issue.)
Along these lines, there is also research that explores the planning side of the health-built environment connection. This includes a variety of policy analyses, one investigating the impacts of municipal policy as a facilitator/ inhibitor of physical activity (Librett 2003), another looking at the history of the National Capital Commission in Ottawa and its impact on health-related design (Dube 2000) and another considering the capacity of water management policy to ensure appropriate care of the water supply system in the Region of Waterloo, Ontario (Ivey et al. 2006). Other papers consider the role of planning as a more general process that can contribute to development of a healthier community (Corburn 2006, Hirschhorn 2004, Jackson et al. 2002). Such work emphasizes that many types of knowledge are relevant: The breadth and complexity of the issues point to the need to draw upon different types of knowledge--and to apply it through land use planning--if we want to positively impact public health in our communities.
The papers in this volume provide a few examples of the relevant knowledges and the subsequent actions. They are diverse, yet they provide a mere taste of what needs to be considered. Land use planning--for which built environment is the domain--has a key role to play. The papers in this theme issue touch on what some of these roles might be.
Before briefly describing each of the papers, I draw attention to my use of the term 'built environment'. While this has often been used to refer primarily to building structures--and, more specifically, the insides of them--recent use of the term encompasses a broader definition.
The built environment is part of the overall ecosystem of our earth. It includes the land-use planning and policies that impact our communities in urban, rural, and suburban areas. It encompasses all buildings, spaces, and products that are created or modified by people. It includes our homes, schools, workplaces, parks/recreation areas, business areas and roads. It extends overhead in the form of electric transmission lines, underground in the form of waste disposal sites and subway trains, and across the country in the form of highways (Health Canada 1997).
It is this broadly defined built environment--and its impact on health and the subsequent potential for planning to address concerns--that is the focus of this issue.
As something of a review paper, the work of Johnson and Marko paints a richer picture of the context for the rest of the papers than the foregoing comments. They begin by noting the common roots of public health and land use planning in the poor health conditions of 19th century industrial cities. In describing many of the relationships between health concerns and land use planning that have been found, they identify many of the topics discussed in other papers. Consistent with my emphasis on the need for different knowledges to be drawn into planning, they end the paper by emphasizing the need for public health professionals to be involved in the planning process. This means there is a need to ensure health professionals have the capacity and opportunity to contribute to decision-making on land use and the built environment.
The next paper covers one of the better known and better documented influences of the built environment on health: the impact of transportation systems. Providing a broad view of these issues, Litman draws from numerous sources and studies to illustrate many of the impacts, influences and challenges. He also draws attention to some of the ways in which current approaches to researching, reviewing and deciding on transportation lack full accounting of the challenges presented. Using the increasingly popular notion of "smart growth", he briefly describes some of the planning approaches and directions that might assist in developing safer and healthier communities.
The "obesity epidemic" among children in Canada and the US (Basrur 2004, Anderson and Butcher 2006, Davison and Lawson 2006) is a key health concern that has gained recent attention. Taking this as a starting point, McAllister raises questions around the presence of and potential for child-friendly planning. Framing her arguments around four themes (safety, greenspace, access and involvement), she discusses key aspects of the challenge. Then, using the City of Waterloo, Ontario as an example, she considers the child-friendliness of planning policy and processes that are currently in place and considers planning approaches that might make cities more child-friendly. The hope is that such an approach would also lead to improvements in the built environment that will positively affect the health of children.
Given the range of knowledges and approaches that are relevant to planning for health through the built environment, many efforts have taken a multi-sectoral approach. Drawing from their recent work investigating best and promising practices of multi-sectoral collaboratives, Dempster and Tucs discuss some of the lessons relevant to applying such a planning approach. While some of the lessons would be relevant to any collaborative endeavour, their examples are from collaboratives aiming to improve public health through changes to the built environment.
Finally, Alexander takes a more speculative and reflective approach in his paper, raising questions about the built environment and its influence on mental and spiritual health. The paper weaves arguments for and against physical determinism, never quite settling on one or the other. While basic concerns around health are considered, the paper also broadens the discussion to raise bigger questions:
... research suggests that people can only adopt new roles and behaviours to the extent that spaces or settings are created that facilitate these new roles and behaviours. If we want to nurture the emergence of homo sustinens--the sustainable human ... then we need to create the spaces for him or her to flourish.
As McAllister notes in her paper, a broad definition of health--including the complete range of physical, mental and social aspects of well-being--needs to be considered. Recognizing the influential role of the built environment emphasizes the multiplicity of factors that impinge on this well-being. Much of the discussion takes a preventative stance--encouraging the application of land use planning to counter the negative health affects that are being identified. By opening the discussion up to these broader questions, Alexander points to the potential for moving beyond prevention toward more creative and proactive possibilities. Further, the reference to homo sustinens opens the mind to considerations beyond even the broad definition of health by including the health of the world we live in. This seems a fitting way to close a set of papers drawing on current knowledge to discuss actions aimed at improving the future.
Through my involvement in a literature review on the linkages between health and the built environment in a Canadian context (Tucs and Dempster 2007), I have been struck by the range and diversity of research relevant to this topic--a range and diversity that necessarily points to the multiplicity of knowledges that need to be integrated into planning and the subsequent multiplicity of actions that will be required to positively impact public health. While there are a few crossovers and commonalities among the papers in this issue, they are perhaps more notable for the differences in the knowledge they draw upon and the actions they promote. Yet these papers represent only a small portion of the discussions relevant to this topic and primarily in a broad and general way.
Given the nature of the profession, good planners learn to deal with many, diverse issues--and the trade-offs inherent in such multiplicity. Planning for health through the built environment presents a 'new' challenge for planners--and for the people from the diverse disciplines and professions that must be drawn in to facilitate healthier outcomes from planning. The papers in this issue offer a small taste of both challenges and possibilities.
Abelsohn, A., R. Bray, C. Vakil and D. Elliott. 2005. Report on Public Health and Urban Sprawl in Ontario: A Review of the Pertinent Literature. Environmental Health Committee, Ontario College of Family Physicians. Available at http://www.ocfp.on.ca/English/OCFP/UrbanSprawl/ [Accessed in June 2008].
Anderson, P. M. and K. E. Butcher. 2006. Childhood obesity; trends and potential causes. The Future of children 16(1): 19-45.
Apparicio, P., M.-S. Cloutier and R. Shearmur. 2007. The case of Montreal's missing food deserts: Evaluation of accessibility to food supermarkets. International Journal of Health Geographies 6(1): 4-16.
Basrur, S. 2004. Chief Medical Officer of Health Report: Healthy Weights, Healthy Lives. Ontario Ministry of Health and Long-term Care. Toronto, Ontario. Available at http://www.mhp.gov.on.ca/english/health/healthy_weights_112404.pdf [Accessed in June 2008].
Blackman, T., L. Mitchell, E. Burton, M. Jenks, M. Parsons, S. Raman and K. Williams. 2003. The Accessibility of Public Spaces for People with Dementia: A New Priority for the 'Open City'. Disability and Society 18(3): 357--371.
Buckeridge, D. L., R. Glazier, B. J.Harvey, M. Escobar, C. Amrhein and J. Frank. 2002. Effect of motor vehicle emissions on respiratory health in an urban area. Environmental health perspectives 110(3): 293--300.
Canadian Institute for Health Information (CIHI). 2006. Improving the Health of Canadians: An Introduction to Health in Urban Places 05-06. Canadian Institute for Health Information, Ottawa.
Clarke, P. and L.K. George. 2005. Understanding and addressing the challenges of disability. The role of the built environment in the disablement process. American Journal of Public Health 95(11): 1933--1939.
Corburn, J. 2006. Expanding the Agenda for Healthy Urban Planning. Journal of the American Planning Association 72(1): 119-121.
Davison, K. and C. Lawson. 2006. Do attributes in the physical environment influence children's physical activity? A review of the literature. International Journal of Behavioral Nutrition and Physical Activity 3(1): 19-35.
Dempster, B. 1998. A Self-Organizing Systems Perspective on Planning for Sustainability. M.E.S Thesis, School of Planning, University of Waterloo, Waterloo ON. Available at http://bethd.ca/pubs/mesthe.pdf.
Dube, P. 2000. Urban health: an urban planning perspective. Reviews on environmental health (Isreal) 15(39084): 249--265.
Evans, G. W. 2003. The built environment and mental health. Journal of Urban Health 80(4): 536--555.
Finkelstein, M. M.Jerrett and M. R. Sears. 2005. Environmental inequality and circulatory disease mortality gradients descriptors. Journal of epidemiology and community health 59(6): 481--487.
Fisher, P. 2005. Urban Form, Physical Activity and Health. Region of Waterloo Public Health, Waterloo, Ontario.
Frank, L. D., P. Engelke and T. Schmid. 2003. Health and Community Design: The Impacts of the Built Environment on Physical Activity. Island Press, Washington, D.C.
Frank, L. D. and P. Engelke. 2001. The built environment and human activity patterns Exploring the impacts of urban form on public health. Journal of Planning Literature 16(2): 202--218. Available at http://www.act-trans.ubc.ca/publications.htm [Accessed in June 2008].
Frank, L. D., S. Kavage and T. Litman. 2006a. Promoting public health through Smart Growth: Building healthier communities through transportation and land use policies. Smart Growth BC. Available at: http://www.smartgrowth.bc.ca/downloads/SGBC_HealthReportFinal.pdf [Accessed in June 2008].
Frank, L.D., J. F. Sallis, T. Conway, J. Chapman, B. Saelens and W. Bachman. 2006b. Multiple pathways from land use to health: Walkability associations with active transportation, body Mass index, and air quality. Journal of the American Planning Association 72(1): 75--89.
Friedmann, J. 1987. Planning in the Public Domain: From Knowledge to Action. Princeton University Press, Princeton.
Frumkin, H., L. Frank and R. Jackson. 2004. Urban Sprawl and Public Health: Designing, Planning, and Building for Healthy Communities. Island Press, Washington, D.C.
Guite, H. F., C. Clark and G.Ackril. 2006. The impact of the physical and urban environment on mental well-being. Public health 120(12): 1117--1126.
Hirschhorn, J. S. 2004. Zoning should promote public health. American Journal of Health Promotion 18(3): 258--260.
Health Canada. 1997. Health and Environment: Partners for Life. Health Canada, Ottawa, Ontario.
Ivey, J. L, R.C. de Loe and R.D. Kreutzwiser. 2006. Planning for source water protection in Ontario. Applied Geography 26(39145): 192--209.
Jackson, R., T. Harp and T. Wright. 2002. Land use planning: why public health must be involved. Journal of law, medicine and ethics 30(3, Suppl): 70--74.
Johnson, S. and J. Marko. 2008. Designing healthy places: Land use planning and public health. Environments, this volume: 9-20.
Librett, J.J., MM.Yore and T.L. Schmid. 2003. Local ordinances that promote physical activity: A survey of municipal policies. American Journal of Public Health 93(9): 1399-1403.
Litman, T. 2008. Creating safe and healthy communities. Environments, this volume: 21-42.
Ontario Professional Planners Institute. 2007. Healthy Communities Sustainable Communities: The 21st Century Planning Challenge. Ontario Professional Planners Institute Toronto, Ontario.
Popkin, B. M., K. Duffey, P.Gordon-Larsen. 2005. Environmental influences on food choice, physical activity and energy balance. Physiology and behavior 86(5): 603-613.
Smargiassi, A., K. Berrada, I. Fortier and T. Kosatsky. 2006. Traffic intensity, dwelling value, and hospital admissions for respiratory disease among the elderly in Montreal (Canada): a case-control analysis. Journal of epidemiology and community health 60(6): 507--512. Available at: http://jech.bmj.com/cgi/reprint/60/6/507 [Accessed in June 2008].
Smoyer-Tomic, K. E., J. C. Spence and C. Amrhein. 2006. Food deserts in the prairies? Supermarket accessibility and neighborhood need in Edmonton, Canada The Professional Geographer 58(3): 307--326.
Transportation Research Board, Institute of Medicine. 2005. Does the Built Environment Influence Physical Activity?: Examining the evidence. The National Academy of Sciences, Washington, D.C. Available at: http://www.trb.org/news/blurb_detail.asp?id=4536 [Accessed in June 2008].
Tucs, E. and B. Dempster. 2007. Linking Health and the Built Environment: An annotated bibliography of Canadian and other related research. Ontario Healthy Communities Coalition, Toronto, Ontario.
Beth Dempster is a co-director of the Civics Research Co-operative, a small not-for-profit in Kitchener, Ontario that focuses on community-based, social research, Her research interests include systems-without-boundaries. collaborative planning and sustainability. She is also managing editor of Environments.
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