Urban design and health: progress to date and future challenges

Effect of residential relocation on environmental exposures in European cohorts: An exposome-wide approach

Residential relocation is increasingly used as a natural experiment in epidemiological studies to assess the health impact of changes in environmental exposures. Since the likelihood of relocation can be influenced by individual characteristics that also influence health, studies may be biased if the predictors of relocation are not appropriately accounted for. Using data from Swedish and Dutch adults (SDPP, AMIGO), and birth cohorts (BAMSE, PIAMA), we investigated factors associated with relocation and changes in multiple environmental exposures across life stages. We used logistic regression to identify baseline predictors of moving, including sociodemographic and household characteristics, health behaviors and health. We identified exposure clusters reflecting three domains of the urban exposome (air pollution, grey surface, and socioeconomic deprivation) and conducted multinomial logistic regression to identify predictors of exposome trajectories among movers. On average, 7 % of the participants relocated each year. Before relocating, movers were consistently exposed to higher levels of air pollution than non-movers. Predictors of moving differed between the adult and birth cohorts, highlighting the importance of life stages. In the adult cohorts, moving was associated with younger age, smoking, and lower education and was independent of cardio-respiratory health indicators (hypertension, BMI, asthma, COPD). Contrary to adult cohorts, higher parental education and household socioeconomic position were associated with a higher probability of relocation in birth cohorts, alongside being the first child and living in a multi-unit dwelling. Among movers in all cohorts, those with a higher socioeconomic position at baseline were more likely to move towards healthier levels of the urban exposome. We provide new insights into predictors of relocation and subsequent changes in multiple aspects of the urban exposome in four cohorts covering different life stages in Sweden and the Netherlands. These results inform strategies to limit bias due to residential self-selection in epidemiological studies using relocation as a natural experiment.

Climate Solutions Double as Health Interventions

The climate crisis threatens to exacerbate numerous climate-sensitive health risks, including heatwave mortality, malnutrition from reduced crop yields, water- and vector-borne infectious diseases, and respiratory illness from smog, ozone, allergenic pollen, and wildfires. Recent reports from the Intergovernmental Panel on Climate Change stress the urgent need for action to mitigate climate change, underscoring the need for more scientific assessment of the benefits of climate action for health and wellbeing. Project Drawdown has analyzed more than 80 solutions to address climate change, building on existing technologies and practices, that could be scaled to collectively limit warming to between 1.5° and 2 °C above preindustrial levels. The solutions span nine major sectors and are aggregated into three groups: reducing the sources of emissions, maintaining and enhancing carbon sinks, and addressing social inequities. Here we present an overview of how climate solutions in these three areas can benefit human health through improved air quality, increased physical activity, healthier diets, reduced risk of infectious disease, and improved sexual and reproductive health, and universal education. We find that the health benefits of a low-carbon society are more substantial and more numerous than previously realized and should be central to policies addressing climate change. Much of the existing literature focuses on health effects in high-income countries, however, and more research is needed on health and equity implications of climate solutions, especially in the Global South. We conclude that adding the myriad health benefits across multiple climate change solutions can likely add impetus to move climate policies faster and further.

Universal health care - A matter of design and agency?

Universal health care (UHC) is primarily a financing concern, whereas primary health care (PHC) is primarily concerned with providing the right care at the right time to achieve the best possible health outcomes for individuals and communities. A recent call for contributions by the WHO emphasized that UHC can only be achieved through PHC, and that to achieve this goal will require the strengthening of the three pillars of PHC - (a) enabling primary care and public health to integrate health services, (b) empowering people and communities to create healthy living conditions, and (c) integrating multisectoral policy decisions to ensure UHC that achieves the goal of "health for all." "Pillars" - as a static metaphor - sends the wrong signal to the research and policy-making community. It, in fact, contradicts the WHO's own view, namely that there is "the need to strengthen comprehensive primary health care systems based on local priorities, needs and contexts … [that are] co-developed by people who are engaged in their own health." What we really need to develop PHC as the basis to achieve the goal of UHC is a dynamic agency to drive a "system-as-a-whole framework" that simultaneously takes into account finance, individual, and local needs. Health systems are socially constructed organizational systems that are "functionally layered" in a hierarchical fashion - governments and/or funders at the top-level not only promote the goals of the system (policies) but also constrain the system (rules, regulations, resources) in its ability to deliver. Hence, there is a need to focus on two key system features - political leadership and dynamic bottom-up agency that maintains everyone's focus on the goal to be achieved, and a limitation of system constraints so that communities can shape best adapted primary care services that truly meet the needs of their individuals, families, and community.

The Swedish Health Promoting Healthcare network and the built environment

The Health Promoting Hospitals (HPH) networks, founded by the World Health Organisation, support the introduction of health promotion in healthcare. This development involves the creation of a health promoting built environment. However, few studies have explored the HPH in relation to the built environments, and it is unclear how HPH-networks incorporate the built environment in their work. The study therefore examined the Swedish HPH-Network in relation to the built environment. The mixed-method study included data from (i) key online material from the Swedish network, (ii) a survey with open-ended questions of representatives of the networks’ workgroups and (iii) semi-structured interviews with the built environment workgroup. The study showed that the built environment is unevenly and incoherently incorporated in the network. Moreover, there is more attention for healing and healthy rather than health-promotive strategies, indicating a knowledge gap. Descriptions of the health promoting built environment are diverse, and address design features, design strategies or indicate places for health promotion interventions. The descriptions of the built environment are combined with various HPH goals and population groups. To utilize the built environment as a resource for HPHs, the networks should consider incorporating the built environment in documents and action plans at all organizational levels.

Access to Healthcare Following Serious Injury: Perspectives of Allied Health Professionals in Urban and Regional Settings

Barriers to accessing healthcare exist following serious injury. These issues are not well understood and may have dire consequences for healthcare utilisation and patients’ long-term recovery. The aim of this qualitative study was to explore factors perceived by allied health professionals to affect access to healthcare beyond hospital discharge for people with serious injuries in urban and regional Victoria, Australia. Twenty-five semi-structured interviews were conducted with community-based allied health professionals involved in post-discharge care for people following serious injury across different urban and regional areas. Interview transcripts were analysed using thematic analysis. Many allied health professionals perceived that complex funding systems and health services restrict access in both urban and regional areas. Limited availability of necessary health professionals was consistently reported, which particularly restricted access to mental healthcare. Access to healthcare was also felt to be hindered by a reliance on others for transportation, costs, emotional stress and often lengthy time of travel. Across urban and regional areas, a number of factors limit access to healthcare. Better understanding of health service delivery models and areas for change, including the use of technology and telehealth, may improve equitable access to healthcare.

Developing healthy cities with urban facility management

Purpose

Most people live in cities and work in offices, two contexts offering many lifestyle-related and environmental health risks. To advance their health, this paper aims to introduce an analogy between urban design and facility design to explore whether health-directed design interventions in cities and facilities are related and to look for applicable cross-overs and opportunities to develop the facility management (FM) profession on the urban level.

Design/methodology/approach

The principles of abductive reasoning as a first phase of scientific investigation were followed, by introducing a new idea and attentively observing phenomena in the communities of FM and urban design. The method was desk research, in the context of discovery.

Findings

Many possible cross-overs exist which offer opportunities for urban planners and facility managers to reinforce each other and interesting market opportunities for the further development of urban FM. However, more systematic research is needed on efficacious and effective interventions. Furthermore, experiences and capacities of the FM sector should be unlocked and applied within a city context, as the knowledge and experiences of facility managers and urban planners can create synergy.

Practical implications

The findings are directly applicable to facility and urban design practices and to FM education by involving students in city design practices.

Originality/value

Cross-overs between facilities and cities are new and can inspire both facility managers and urban planners to work together more closely for the benefit of citizens and employees.

Strengthening complex systems for chronic disease prevention: a systematic review

BACKGROUND

While frameworks exist for strengthening health care systems and public health systems, there are no practical frameworks to describe, assess and strengthen systems for chronic disease prevention (CDP) using complex systems approaches.

METHODS

A systematic and integrative review of peer reviewed literature was conducted to answer the following questions: How can systems for CDP be defined? What are key attributes of effective systems? How are complex systems approaches discussed? Search terms were identified and the Medline, SCOPUS, and Global Health databases were searched December 2017 and January 2018. Reference lists and selected journals were hand searched. A working definition for a system for CDP was developed to provide a guideline for inclusion. Key exclusion criteria were literature did not address the research questions or working definition; was published in a language other than English and before 2000; focused on specific chronic diseases and/or risk factors and not CDP broadly; concentrated on the health care sector and clinical services and/or health status and surveillance data; and described evaluations of setting specific actions such as policies, programs, interventions, approaches, projects, laws, or regulations. Selected literature (n = 141) was coded in terms of the extent to which the research questions and the working definition of systems for CDP were addressed. Data was then analysed and synthesized to determine key themes.

RESULTS

A revised definition of systems for CDP and seven attributes of effective systems for CDP are reported (collaborative capacity, health equity paradigm, leadership and governance, resources, implementation of desired actions, information and complex systems paradigm). A framework was developed to provide a foundation for describing, assessing and strengthening systems for CDP.

CONCLUSIONS

The results of this literature review provide a strong foundation for a framework to help strengthen systems for CDP. The framework consolidates not only well-established attributes of effective CDP but also highlights theoretical and practical insights from complex systems perspectives.

Comparing private and public transport access to diabetic health services across inner, middle, and outer suburbs of Melbourne, Australia

BACKGROUND

Melbourne, Australia is experiencing rapid population growth, with much of this occurring in metropolitan outer suburban areas, also known as urban growth areas. Currently little is known about differences in travel times when using private and public transport to access primary and secondary services across Melbourne's urban growth areas. Plan Melbourne Refresh, a recent strategic land use document has called for a 20 min city, which is where essential services including primary health care, can be accessed within a 20 min journey. Type 2 diabetes mellitus (T2DM) is a major chronic condition in Australia, with some of Melbourne's growth areas having some of the highest prevalence across Australia. This study explores travel times to diabetic health care services for populations residing in inner, middle and outer suburbs of metropolitan Melbourne.

METHOD

Geographic information systems (GIS) software were used to map the location of selected diabetic primary and secondary health care service providers across metropolitan inner, middle, outer established, outer urban growth and outer fringe areas of Melbourne. An origin-destination matrix was used to estimate travel distances from point of origin (using a total of approximately 50,000 synthetic residential addresses) to the closest type of each diabetic health care service provider (destinations) across Melbourne. ArcGIS was used to estimate travel times for private transport and public transport; comparisons were made by area.

RESULTS

Our study indicated increased travel times to diabetic health services for people living in Melbourne's outer growth and outer fringe areas compared with the rest of Melbourne (inner, middle and outer established). Compared with those living in inner city areas, the median time spent travelling to diabetic services was between 2.46 and 23.24 min (private motor vehicle) and 12.01 and 43.15 min (public transport) longer for those living in outer suburban areas. Irrespective of travel mode used, results indicate that those living in inner and middle suburbs of Melbourne have shorter travel times to access diabetic health services, compared with those living in outer areas of Melbourne. Private motor vehicle travel times were approximately 4 to 5 times faster than public transport modes to access diabetic health services in all areas.

CONCLUSION

Those living in new urban growth communities spend considerably more time travelling to access diabetic health services - particularly specialists - than those living in established areas across Melbourne.

"Just One Thing after Another": Recursive Cascades and Chronic Conditions

Chronic conditions and their resultant difficulties in daily living frequently occur with other health problems, sometimes due to interactions or complications at a biological level, or as a result of common pathogens or risk factors. On other occasions, they develop independently. Drawing on research conducted with Australian women that began in the mid-2000s and is still ongoing, we highlight how chronic structural factors shape the risk factors of "chronic" conditions, influencing health seeking, continuity of care, and health outcomes. Institutional, economic, and other circumstantial factors pertain and impact health trajectories as much in highly industrialized as in resource poor settings. In illustrating how poverty and social exclusion create the preconditions of multiple chronic health problems, and how chronic health problems increase such disadvantages for individuals and their households, we introduce the idea of "recursive cascades" to capture the often inevitable trajectory of increasing ill health and growing empoverishment.

A community-based intervention increases physical activity and reduces obesity in school-age children in North Carolina

BACKGROUND

Community-based interventions are promising approaches to obesity prevention, but few studies have prospectively evaluated them. The aim of this study was to evaluate a natural experiment—a community intervention designed to promote active living and decrease obesity within a small southern town.

METHODS

In 2011, community leaders implemented the Mebane on the Move intervention—a community-wide effort to promote physical activity (PA) and decrease obesity among residents of Mebane, North Carolina. We measured child PA and BMI before and after the intervention, using a nearby town not implementing an intervention as the comparison. In total, we assessed 64 children from Mebane and 40 from the comparison community 6 months before, as well as 34 and 18 children 6 months after the intervention. We assessed PA with accelerometers worn for 7 days and calculated BMI z-scores using children's height and weight. We conducted multivariable linear regressions examining pre- to postintervention change in minutes of PA and BMI z-score, adjusting for confounders.

RESULTS

At follow-up, children in Mebane modestly increased their moderate-to-vigorous PA (1.3 minutes per hour; 95% confidence interval (CI): 0.2, 2.3; p=0.03) and vigorous activity (0.8 minutes per hour; 95% CI: 0.1, 1.5; p=0.04) more than comparison children. In intervention children, BMI z-scores decreased 0.5 units (kg/m(2); 95% CI: -0.9, -0.02; p=0.045), compared to children in the comparison community.

CONCLUSIONS

We observed positive effects on PA level and weight status of children in Mebane, despite high rates of attrition, suggesting that the community-based intervention may have been successful.

Developing a research and practice tool to measure walkability: a demonstration project

ISSUE ADDRESSED

Growing evidence shows that higher-density, mixed-use, pedestrian-friendly neighbourhoods encourage active transport, including transport-related walking. Despite widespread recognition of the benefits of creating more walkable neighbourhoods, there remains a gap between the rhetoric of the need for walkability and the creation of walkable neighbourhoods. Moreover, there is little objective data to benchmark the walkability of neighbourhoods within and between Australian cities in order to monitor planning and design intervention progress and to assess built environment and urban policy interventions required to achieve increased walkability. This paper describes a demonstration project that aimed to develop, trial and validate a 'Walkability Index Tool' that could be used by policy makers and practitioners to assess the walkability of local areas; or by researchers to access geospatial data assessing walkability. The overall aim of the project was to develop an automated geospatial tool capable of creating walkability indices for neighbourhoods at user-specified scales.

METHODS

The tool is based on open-source software architecture, within the Australian Urban Research Infrastructure Network (AURIN) framework, and incorporates key sub-component spatial measures of walkability (street connectivity, density and land use mix).

RESULTS

Using state-based data, we demonstrated it was possible to create an automated walkability index. However, due to the lack of availability of consistent of national data measuring land use mix, at this stage it has not been possible to create a national walkability measure. The next stage of the project is to increase useability of the tool within the AURIN portal and to explore options for alternative spatial data sources that will enable the development of a valid national walkability index.

CONCLUSION

AURIN's open-source Walkability Index Tool is a first step in demonstrating the potential benefit of a tool that could measure walkability across Australia. It also demonstrates the value of making accurate spatial data available for research purposes. SO WHAT?: There remains a gap between urban policy and practice, in terms of creating walkable neighbourhoods. When fully implemented, AURIN's walkability tool could be used to benchmark Australian cities against which planning and urban design decisions could be assessed to monitor progress towards achieving policy goals. Making cleaned data readily available for research purposes through a common portal could also save time and financial resources.