Health inequalities and determinants in the physical urban environment: Evidence briefing

Full text


WHOCollaboratingCentreforHealthyUrbanEnvironments
UniversityoftheWestofEngland,Bristol
1

Workingpaper
Healthinequalitiesanddeterminantsinthephysicalurban
environment:Evidencebriefing

MarcusGrant,CarolineBirdandPennyMarno,March2012

Thisworkingpaperhasbeenwrittentosupportresearchintothespatialandphysicaldeterminantsin
theurbanenvironmentthatleadtohealthinequalities.

Theevidenceisbasedonarapidtrawlforrelevantresearchthatwefoundwhilstcompilingan
‘EvidenceReviewontheSpatialDeterminantsofHealthinUrbanSettings’(Grantetal.,2009)forthe
WHOEuropeanCentreforEnvironmentandHealth,Bonn;andasubsequentupdateforabriefingnote
preparedfortheWHOEuropeanHealthyCitiesmovementannualmeetinginSandnesin2010.Wealso
includehereanewbriefconclusionanddiscussion.

Theintentionofthereportistoserveasadiscussiondocumentandinspirationforthoseassociated
withresearchinthisfield.

OurWHOCollaboratingCentreisdevelopingamethodologysuitableforundertakingasystematic
reviewinsuchafield‐comprisingcomplexinterventions,illdefinedcausalpathways,opensystems
andawealthofgreyliterature.Wearealsolookingforfundingopportunitiestoestablishacognate
researchnetwork.



SYNOPSIS

Thebuiltandnaturalenvironmentisanimportantdeterminantofhealth.Evidenceshowsthata
disproportionateburdenofill‐healthassociatedwiththebuiltenvironmentisbornebypoorerpeople
livinginpoorqualitybuiltenvironments.Poorerfamilieshavelowermobilitybutgreaterexposureto
theadverseenvironmentalconditionsrelatedtotransportsuchasairandnoisepollutionandhigher
trafficlevelswhichcauserespiratorydisease,mentalstressandroadtrafficinjury.Deteriorating
featuresofanurbanenvironmentsuchasdilapidation,vandalism,graffitiandlitterare
disproportionatelyfoundindisadvantagedareasandleadtoasenseofinsecurityonstreetsandin
parksandplayareasmeaningthatthemorevulnerableinparticularusethemless,leadingtoreduced
physicalactivityandsocialinteractionandexacerbatinghealthproblemssuchasobesityandisolation.
Greenspacehasmanybenefitsforphysicalandmentalhealthandpopulationsthatareexposedtothe
greenestenvironmentsalsohavelowestlevelsofhealthinequalityrelatedtoincomedeprivation,but
poorerneighbourhoodsoftenlackgreenspaceorhavepoorlymaintainedorvandalisedgreenareas.
Climatechangewillalsoimpactsignificantlyontheurbanenvironmentanddisproportionatelyonthe
disadvantaged,particularlythroughincreasingtemperaturesandflooding.

Inconclusion,landuse,transportanddevelopmentpoliciesandassociatedstrategicdecisions
determiningurbanformarekeytotacklinghealthinequalitiesrelatedtothebuiltenvironment
throughhousing,proximityoffacilities,greenspaceandviablemodesoftransport.



2

Healthinequalitiesanddeterminantsinthephysicalurban
environment:Evidencebriefing









Introduction

Thebuiltandnaturalenvironmentthatformsthebackclothtoourlivesisalsoanimportant
determinantofhealth.Thisisparticularlysoforpopulationgroupsdisadvantagedbyrelativepoverty,
unemployment,lowstatusanddisability.Thosewhoforfinancial,physicalorcultural/racialreasons
aremorevulnerable,andhavefewerchoicesfindthemselvestypicallyinlocationsandsettingsthatare
lessconducivetogoodhealthwithlittleabilitytomoveawayfromunhealthyworkingandliving
environmentsortomitigatetheirimpact.

Evidenceshowsthatadisproportionateburdenofill‐healthassociatedwiththebuiltenvironmentis
bornebycertaingroupswithinthepopulation(CSDH,2008).Studiesintheearly2000susedtheterm
‘environmentaljustice’todescribespatialpatternswheredisadvantageandpoorenvironmental
qualitycoincide(e.g.MitchellandDorling,2003).Severalreviewsindicatethatpoorpeoplearemore
likelytoliveinpoorqualitybuiltenvironments(includingincreasedhealthriskexposurefromnoise
andairquality)andthiscontributestopoorhealth.Socio‐economichealthtrendshavebeenwell
documented.Weknowforinstancethattheleastwell‐offpeopleinsocietysufferpoorerhealth
(Marmot,2004).Layersofhealthriskcanalsooverlap,forexampleLavinetal.(2007)identifychildren
andtheelderlyasbeingparticularlyvulnerablenotonlybecauseofabiologicalvulnerabilitybutalso
becauseofthesignificantnumbersofchildrenandelderlywhoarepoor.Howeverthespatial
componentsoftheurbanenvironmentthatcanbeassociatedwith,andsometimescontributeto,a
divergenceinhealthoutcomeshavenotreceivedsystematicattention.Webelievethattherearesome
keyspatialmechanismswhichexaggeratehealthinequity.Thisbriefingoutlinessomeoftherecent
evidencethatwehavefoundinareviewofmetastudies,systematicreviewsandpolicyreportsthat
showpotentialinequalitiesinhealthliterallybuiltintourbanenvironments.

Theevidencehasbeengroupedintosixthematicheadingsbasedonthestudiesfound:
Transport
Landusemix:Neighbourhoodsandfacilities
Crimeandfearofcrime
Housingandresidentialareas
Greenspace
Theurbanenvironmentandclimatechangeimpacts


3
Anevidencebriefing

Transport

Accesstoactivetravelmodesandlocalpublictransportnetworksisgreatlyaffectedbyurbanform.
Criticalphysicalparametersarelandusemix,streetnetworkformanddevelopmentdensity(Bartonet
al.,2010).

Therearemanyconnectionsbetweentransportandhealthwhichimpactmoreonpoorerfamilieswho
havelowermobilitybutgreaterexposuretotheadverseenvironmentalconditionsrelatedtotransport
suchasairandnoisepollutionandhighertrafficlevels.Peoplewhoaremostdeprivedarealsomore
susceptibletodamaginghealtheffectsbecauseofhigherlevelsofpre‐existingillnessorother
vulnerability.

Accesstotransportthatenablesresidentstomoveoutsideoftheirowncommunityhasbeenshownto
positivelycorrelatewithareducedfearofsocialisolationandpositivementalhealth(Whitleyetal,
2005).Forthoseonhigherincomes,thisisbycarortaxi.However,forthoseonlowerincomes,access
topublictransportisimportant(Whitelyetal,2005).

Healthinequalitiesevidencefoundinrelationtothedistincttransportissuesofairpollution,road
casualtiesandmobilityandphysicalactivityaregivenbelow.

Airpollution
AcomprehensivereviewreportfromWalker(2003)isespeciallyusefulhere.Transportrelatedair
pollutionimpactsmostonthedisadvantagedwithincreasedriskofrespiratorydiseasesandother
illness.Peopleinthe10percentmostdeprivedareasinEnglandexperienceworstairquality,suffering
forexample41percenthigherconcentrationsofnitrogendioxidethantheaverage(Walker,2003).

Thereportstatedthat:
TherelationshipbetweenpoorairqualityanddeprivationinEnglandisparticularlystrongforpeak
pollutantvalues,includingexceedencesofstandards.Thenumberofpeopleinwardsabovepollution
thresholdsincreasesprogressivelywithincreasingdeprivation.

ThereversepatternwasfoundinWales,acountrywithamuchmoreruralpopulation.Thiswasdueto
theleastdeprivedhouseholdsinWalestendingtobemoreurbanthantheirEnglishequivalentsand
mostlylocatedinthemoreurbanizedsouth,wheremostofthepoorestairqualityoccurs.

Thereportalsodescribes“clustersofwards[localelectionareas]thathavepooraggregateairquality
andhighdeprivation”or“hot‐spots…[of]…pollution‐poverty”,withlargeclustersinthepartsofthe
maincities(Walker,2003)

IntheUK,intermsofNO2,PM10andSO2,thereisatendencyforthemostdeprivedcommunitiesto
experiencethepoorestairquality;thesedeprivedareasoftenhaveahigherproportionofchildren
livingthere,increasingtheoverallsusceptibilityofthepopulation(NETCEN2006,MitchellandDorling
2003).

Linksbetweenhigherairpollutionlevelsanddeprivedneighbourhoodshavealsobeenfoundinother
countriessuchasNorway(Naessetal2007).Otherstudieshavehighlightedthatevenincitiesthat
mightnotfollowthistrendandwherepeoplewithhighersocio‐economicstatusareexposedtothe
highestpollutionconcentrations,mortalityratesfromairpollutionrelatedcausesarestillhighest
amongstthosewithlowersocio‐economicstatusindicatingagreatersusceptibilitytotheeffectsofair
pollutionamongstpeoplewhoaremostdeprived(Forastiereetal2007).


4
Roadcasualties
Thedesignofourtransportnetworksatthelocallevelisreceivingattentionfromurbandesignersand
publichealthwiththeadventofinitiativessuchas20mphareas,homezonesandcyclepaths.Studies
areinhandthatareevaluatingtheseagainstroadtrafficdanger.Broadstatisticsindicatethat,globally,
roadtrafficcollisionsarethesinglelargestcauseofunintentionalinjury(WHO,2008b).Therearevery
widesocio‐economicdifferentialsinthelevelsofdeathandseriousinjuryfromroadtraffic.Astudyin
Englandshowedthatchildreninthemostdeprived10percentofareasarefourtimesmorelikelyto
behitbyacaraschildrenintheleastdeprived10percent.Childrenaged0‐19yearsandolderadults
aged60plusareparticularlyvulnerabletoinjurythroughroadtrafficaccidents,(DfT2005a;DfT2004).

Mobilityandphysicalactivity
Individualsfromlow‐incomegroups,olderpeopleandthosewithdisabilitiesarelesslikelytohave
accesstopersonaltransport(Lavinetal.,2006).Thesegroupsmayfindthataccesstoservicessuchas
shopsandhealthcareisreduced.Consequently,theymayspendahigherproportionoftheirincome
ontransport(Lavinetal.,2006).

Perceivedphysicaldangerposedbymotorisedtraffichasbeencitedasoneofthemainbarriersto
engaginginwalkingandcycling(Davis,2002).Thishashadadisproportionateeffectonactivitylevels
inbothchildrenandolderadults.However,theseissuesdonotseemtohavebeenthefocusofany
recentsystematicreviewstudies.

Onthepositiveside,walkingtoandfrompublictransportationcanhelpphysicallyinactive
populations,especiallylow‐incomeandminoritygroups,attaintherecommendedlevelofdaily
physicalactivity(BesserandDanneberg,2005).Thereforeincreasedaccesstopublictransportmay
helppromoteandmaintainactivelifestyles.


Landusemix:Neighbourhoodsandfacilities

Urbanlandusepatternisoneofthemaininfluencesonlevelsofphysicalactivity,particularlyamong
lowerincomegroupswhogetmuchoftheirphysicalactivitythroughactivetravelratherthan
recreation(RCEP,2007).

Deterioratingfeaturesofanurbanenvironmentsuchasdilapidation,vandalism,graffitiandlitterare
disproportionatelyfoundindisadvantagedareas,leadingtoasenseofinsecurityonstreetsandin
parksandplayareas(Lavinetal.,2006).Thismeansthatthemorevulnerableinparticularusethem
lessandthatchildrenarelesslikelytobeletouttoplay–bothleadingtoreducedphysicalactivityand
exacerbatinghealthproblemssuchasobesitywhichismoreprevalentinlowerincomegroups.

TheimpactsareconfirmedbyEllawayetal.(2005)inthesecondaryanalysisofaEuropeancross
sectionalsurveyof12cities.Theyfoundthat,comparedtorespondentsfromareaswithlowlevelsof
litterandgraffiti,thosefromareaswithhigherlevels,were50%lesslikelytobephysicallyactiveand
50%morelikelytobeoverweight.

Lackoffacilitiessuchaspublictoilets(Greed,2006)impactsonvulnerablegroups,forexampleyoung
children,olderpeopleandthosewithillnessesorchronicdiseases.Lackofsuitableareasforresting,
forexamplebenchesandseatingmayalsolimittheabilityforcertaingroupstoexploreorwalklonger
distances.Withrespecttotheelderlythisimpactsnegativelyonsocialisolation.

Moreover,lackofavailabilityandaccessibilityofmunicipalservicessuchaslibraries,healthfacilities,
doctors’surgeries,schoolsandsocialsupportcanhaveanegativesocialimpactoncommunitiesand
affectbothphysicalandmentalhealth(Horowitzetal,2005;Lavinetal,2006).Placeswhichlack
facilitiesoftenbecomeghettoisedfosteringariskoffurthercriminalactivities(Horowitzetal,2005).

5

Iffacilities,jobsandsocialcontactsarewithincertaindistancethresholdsofhouseholds,withroutes
thatareperceivedasrelativelypleasantandsafe,thenwalkingandcyclingwillbecommon(Leeand
Moudin2008).Moreovernotonlywillactivetravelbetherule,butsocialnetworksandthesenseof
communitymaybeenhanced(CalveBlanco2009).


Crimeandfearofcrime

Oneofthemainsocialimpactsrelatedtourbanform,isresidents’perceivedfearofviolenceorcrime
(Horowitzetal,2005;Whitleyetal,2005).Theseaspectshavebeenshowntonegativelyaffectmental
health.Groupswhofeelmostvulnerableincludewomen,inparticularmothersonalowincome,and
thosewithmentalillness(Horowitzetal,2005;Whitleyetal,2005).Perceptionsofsafetyare
influencedbyfearofstreetcrimebutalsoinjuryfromtraffic(Croucheretal.2007)andareactionto
theaestheticimpression,whichincludesthepresenceofgraffiti,litterandstateofdisrepairofthe
surroundingcommunity(Lavinetal,2006).Thelatterisdisproportionatelyhighinlow‐incomeand
disadvantagedareas(Lavinetal,2006).

EvidencefromaninnerurbanareainNorthLondonfoundthatresidentsexperienceda‘time‐space
inequality’asaconsequenceofcrimeandotherrelatedfactors(Whitleyetal,2005).Thishasbeen
showntoresultinpoormentalhealthincludingfeelingsofsocialisolation,negativemoodandlowself‐
esteem.‘Time‐spaceinequality’describesthevariationinabilityofcommunityresidentstoaccessand
usespacesbothwithintheirimmediateandwiderenvironmentatdifferenttimesduringthedayor
night.Thiswaslessprevalentinmentallyhealthymenormiddle‐incomewomen.Time‐space
inequalitiesseemedtobediminishedbyinterventionsthatencouragedspatialandtemporal
movementsandencourageconnectivitytoawidergeography,forexamplecomprehensivelocalpublic
transportsystemsandgovernment‐issuedfreetravelpassesforvulnerablepopulations.

Fearofcrimehasbeenshowntobeabarriertotheuseofbicyclesastransportorforrecreation
(Staffordetal,2007).


Housingandresidentialareas

Older,poorerqualityhousingwhichisharderandmoreexpensivetoheatisalsomorelikelytobe
occupiedbypoorerhouseholds.ExtradeathsbetweenDecemberandMarchareattributedtothecold
weatherwithchildren,olderpeopleandpeoplewithlongtermillnessesthemostvulnerable(RCEP,
2007).Risingfuelpricesexacerbatetheproblemforpeopleinpoorlyinsulatedhomescausingmore
fuelpovertyandworseninghealth.

Environmentalnoiseproblemshavebeenshowntoleadtosleepdisturbance,cardiovasculardisease
andimpairedmentalhealth.Mosturbannoiseinresidentialareasistrafficrelated.Nightclubs,bars
andpartiesareothersourcesofnoiseinmorecentralareas.Innon‐industrialurbanenvironments,
opinionpollresearchconductedin2003(citedinRCEP,2007)foundthatenvironmentalnoise
problemsareworseinareasofhighdensityhousing,rentedaccommodation(bothsocialandprivate
sectors),areasofdeprivationandareaswhicharehighlyurbanised.


Greenspace

Thereismuchevidenceforthebenefitsofgreenspaceforphysicalandmentalhealthandwellbeing;
theseincludedecreasesingeneralhealthcomplaints,cholesterol,bloodpressureandstresslevelsand
improvedperceivedgeneralhealthandresilience(egRCEP,2007).Evidencesuggeststhatpopulations

6
thatareexposedtothegreenestenvironmentsalsohavelowestlevelsofhealthinequalityrelatedto
incomedeprivation(MitchellandPopham,2008).Theinequalityinmortalityislowerinpopulations
livinginthegreenestareas.However,greenspaceisnotequallyavailabletoallofthepopulation,with
poorerneighbourhoodsoftenlackingingreenspaceorwithpoorlymaintainedorvandalisedgreen
areas.Thebenefitsofincreasesinphysicalactivityandimprovedmentalhealthonlyarisewherethe
greenspaceishighquality,accessibleandsafe(Croucheretal,2007).

Accordingtoseveralreviews,accesstogreenspacesandnaturehasbeenshowntopositivelyaffect
mentalhealth,possiblythroughreducingstressandthroughprovidingadistractionanddistancing
ourselvesfromtheeverydayactivities(HCN,2004;Prettyetal.,2005;Lavinetal,2006).Additionally,
greenspaceshaveapositiveeffectonpromotingsocialinteractionandcohesion(Greenspace
Scotland,2008).

Conversely,restrictedaccesstogreenspaceshasbeenassociatedwithpoorermentalhealth(Guiteet
al,2006;Kuo2001).Residentsinurbansocialhousingwhohadviewsoftreesandopenspaces
demonstratedagreatercapacitytocopewithstresscomparedtothosewhodidnothavesuchaccess
(Kuo,2001).Olderpeopleinparticularbenefitfromsuchaccess(Orsega‐Smithetal,2004).Accessto
greenspacealsohasanaccentuatedpositiveeffectonphysicalhealthforthosefromlowincome
groups(Mitchelletal,2008).

However,intheUK,thosewholiveindisadvantagedareasarelesslikelytobenefitfromgreenspaces
andparks(Lavinetla,2006).AccordingtoaUKreportonurbangreenspaces(Departmentof
Transport,2002),inthe100mostdeprivedauthorities,40%ofparkswereindeclineand88%ofparks
thatwerealreadyassessedasbeinginpoorconditionwereinfurtherdecline.

Anegativeimpactonhealthregardingthesocialimpactofgreenspaceisacommunity’sperceivedrisk
ofcrime,inparticularfearfromassaultorviolence(Croucheretal,2007).Thisfearmanifestsitselfina
reducedabilitytoaccruethepositivebenefitstomentalhealthfromaccessinggreenspaces(Croucher
etal,2007).


Theurbanenvironmentandclimatechangeimpacts

Therearetwoparticularaspectsofclimatechangewhicharelikelytoimpactsignificantlyontheurban
environmentanddisproportionatelyonthedisadvantaged;increasingtemperatureandfloodrisk.

Increasingtemperatures
Exposuretoheatisacauseofmorbidityandmortalityintheurbanenvironment,andheatstressisa
conditionthatcancauseillnessanddeath.Humanexposuretoexcessivelywarmweather,especiallyin
cities,isanincreasinglyimportantpublichealthproblem.Harlan(2006)examinedheat‐relatedhealth
inequalitieswithinonecityinordertounderstandtherelationshipsbetweenthemicroclimatesof
eightdiverseurbanneighbourhoods,populationcharacteristics,thermalenvironmentsthatregulate
microclimatesandtheresourcespeoplepossesstocopewithclimaticconditions.Statistically
significantdifferenceswerefoundintemperaturesbetweentheneighbourhoodsduringtheentire
summer,whichincreasedduringaheatwaveperiod.Lowersocioeconomicandethnicminoritygroups
weremorelikelytoliveinwarmerneighbourhoodswithgreaterexposuretoheatstress.High
settlementdensity,sparsevegetation,andhavingnoopenspaceintheneighbourhoodwere
significantlycorrelatedwithhighertemperatures.Peopleinwarmerneighbourhoodsweremore
vulnerabletoheatexposurebecausetheyhadfewersocialandmaterialresourcestocopewith
extremeheat.Interestinglythismirrorsthecasepreviouslyprovenabouttheinequitableimpactsof
coldweatheronresidents.

Intermsofpopulationeffectsatasettlementlevel,olderpeople,childrenandinfantsaremore

7
susceptibletoprolongedexposuretoheat(RCEP,2007).Theremayalsobeanunevendistributionin
heatinrelationtoincome,withmorewealthyresidentstendingtoliveinareaswithmoremicro‐
climatemoderationthroughbeinglesslow‐lyingandhavingagreaterproportionofgreenspace.

Flooding
Urbanfloodingfromsealevelriseandfluvialinundationwillpresentanincreasingrisktohealth.
Healtheffectsfromfloodingincludedrowning,injuries,infectiousdiseases,stressandlossofessential
urbanservices.Intermsofhealthinequality,theeffectsoffloodingcanbeparticularlydevastatingto
alreadysociallyvulnerablepopulationssuchaschildren,olderpeopleand/ordisabledpeople,ethnic
minoritiesandthosewithlowincomes(WHO,2003b).

AstudyintheUnitedKingdom(Walkeretal.,2003)foundthatforEngland,livinginthetidalfloodplain
hadaclearrelationshipwithdeprivation.Ofthepopulationwithinthetidalfloodplain,therewere
eighttimesmorepeopleinthemostdepriveddecilecomparedtotheleastdeprived.Incontrast,for
thefluvialfloodplain,therewasaninverserelationshipwithdeprivation,althoughoflesserstrength,
withahigherproportionofthefloodplainpopulationinthemoreaffluentcomparedtothemore
depriveddeciles.ForWales,thepatternofsocialdistributionwaslessdistinctbutshowedsome
similaritiestoEngland.


Discussion

Potentialofusingspatialplanningtomitigateinequalitiescausedbyurbanform

Spatialorbuiltenvironmentfactorswhichaffecthealthunevenlyacrossthesocio‐economicspectrum
tendtocompoundtheeffectofexitingsocialandeconomicdeterminants.Theyalsoreflectthemuch
biggerpolicycontext,spatialplanning,inwhichlanduse,transportanddevelopmentpoliciesare
shaped.Inotherwords,strategicdecisionsdeterminingurbanformcanaffectaperson’sproximityto
facilities,greenspaceandtheirviableoptionofmodesoftransport.Thiseffectsthedeterminantsof
mentalandphysicalhealthinplaceswherepeopleliveandwork.

Sowhatcanbedone?

AnillustrationoftheeffectofproactivetownplanningcanbefoundintheGermancityofFreiburg
whereexistingtrendstowardsamorecarorientatedanddispersedsocietyhavebeenreversed.
Freiburghas,forthelast40years,pursuedacommitted,progressiveandcomprehensivelanduse/
transportstrategybasedonwalking,cyclingandpublictransport.Peopleonallincomeshavemoved
awayfromcaruseandbeengiventhefreedomtotravelaroundthecity,givingequalaccesstojobs
andhousinginahealthierenvironmentfreefromthedominanceofthecar.Recenturban
developmentinthenewneighbourhoodofVaubanhasestablishedextensivevirtuallycar‐freeareas,
wherechildrencanplayfreelyandcommunityisstrengthened.

Freiburgwentdownthisroute,notduetoaspecificvisionofapublichealthoutcome,butduetoa
questforimprovedqualityoflifewithinthelocalconstraintsimposedbyitssetting.Beingsurrounded
bytheBlackForest,notonlywouldphysicalgrowthofthecityencroachontheforest,buttheforest
wasalready,inthe1970s,startingtoshowdamagefromacidraincausedbypollution‐muchofitfrom
roadtransport.

Intheabsenceofsuchspecificcircumstances,othertoolsneedtobebroughtin.Healthequitychecks
couldbeonemechanismappliedtobothstrategicplansandneighbourhoodproposalstoensurethat
healthinequalitiesarenotintroducedorexaggerated.Oneapproachcouldbethroughbringinggreater
healthandhealthinequalityfocusintoStrategicEnvironmentalAssessments,orthroughHealthand
EqualityImpactAssessments.

8

AusefulexampleofgoodpracticecanbefoundinWhitechapel,London.Aphysicalmasterplan
underwentaSustainabilityAssessmentwhichincludedanEqualityImpactAssessment.Thisidentified
lowerlifeexpectancyandvulnerablegroupsasakeyinequalityissueandrecommendedactionsto
reduceinequalities.Theseincludedimprovingoutdoorspaceandindoorleisurefacilitiestomakethem
inclusiveandsafeforall–includingminorityethnicgroupswhohavetendedtousethemlessand
thosewithill‐health.

Questionsremainabouttheroleofthebuiltenvironmentinthecausalchain.Doesthebuilt
environmentactsaconfounderintherelationshipbetweenhealthanddeprivation,orviceversa?

AttheWHOCollaboratingCentreforHealthyUrbanEnvironments,wefeelisimportanttokeepthe
evidencebaseandpotentialresultantactionsclosetogetherinourresearch.Assuch,thenextstagein
thisresearchwouldbetoconductasystematicreviewoftheliteratureattemptingtolocatebetter
qualityevidenceandalsotoyieldsomecasestudies,wherethesecouldbeauthoritativelyevaluated.
Casestudiesareaveryvaluablewayofcommunicatingwiththepolicyandpracticecommunities.

























Contactdetails
WHOCollaboratingCentreforHealthyUrbanEnvironments
DepartmentofPlanningandArchitecture
UniversityoftheWestofEngland,Bristol
W:www.uwe.ac.uk/research/who

MarcusGrant,ActingDirector
E:marcus.grant@uwe.ac.uk

CarolineBird,ResearchFellow
E:caroline3.bird@uwe.ac.uk

9
Appendix:Searchstrategy

Thisreviewwasextractedfromalargerreportthatsoughttoprovideabriefoverviewofthemajor
healthchallengesandrisksinurbansettings(Grantatal.2009).Allevidencerelatingtodisparities
betweenpopulationgroupswasextracted.

Duetothetimeframeandresourcesavailable,theoriginalstudywasnotasystematicreviewofthe
literature.Inthemain,sourcesreviewedweremeta‐studies,reviewsoftheliteratureandreviewsof
reviews.Whereparticularlyrelevant,seminalpeerreviewarticlesandkeynationalandinternational
reportspublishedbynotedagenciesinthefieldofhealthandthebuiltenvironmenthavealsobeen
included.

Thesearchstrategywasafilteredsnowballtechnique.Earlysearchesadvisedlatersearchdecisions,
searcheswereextendedthroughfollowingcitationsuntilapointofsaturationwasreachedwhen
additionalsearchesdidnotfurtherenrichtheliteraturealreadyobtained.Filteringwasappliedsuch
thatliteraturerelevanttohealthandtheurbanenvironmentbutwithoutaspatialplanningdimension
wasexcluded,suchasliteratureon(noiseorairpollution)emissionsfromspecificplantorprocesses.
Theinitialsearchstrategywaslimitedbythefollowing:

- Years;2005‐2009
- Humansonly
- PublishedintheEnglishlanguage
- Reviewsandmeta‐studiesonly

Searchterms:health,environment,transport,greenspace,urbandesign,urbanservicing,airquality,
airpollutionwaterpollution,physicalactivity,socialpathologies,mentalhealth,airpollution,noise
exposure,injuriesandaccidents,urbanformandcrime.

Primarydatasources:CBAabstracts,EncyclopaediaofLifeSciences,Geobase,GreenFILE,Science
CitationIndex,ScienceDirect,SocialSciences,CitationIndexandtheCochranelibrary.

Primarywebsitesforreports:DepartmentofHealth,UK;NationalInstituteofClinicalExcellence;
DepartmentfortheEnvironment,FoodandRuralAffairs,UK;SouthWestPublicHealthObservatory;
DepartmentforTransport,UKandtheWorldHealthOrganisation.

Somemateriallyingoutsidethesearchparameters,suchasrefereedarticles,hasbeenincludedwhere
ithasbeencitedbyitemsrecoveredusingtheinitialsearchitemsanditisrelevanttothestudy.

Manyexistingstudiessheddinglightonhealthriskintheurbanenvironmentdonotmeetthemedical
professions’requirementsforrobustclinicalandquantitativeevidence.Thiscanresultinatendencyto
discountarangeofin‐depthandrichqualitativestudies.Suchresearchisimportantforanalysingand
explainingrelationshipsintheurbansystemandhasbeenincludedwhererelevant.

Additionally,abibliographyresource,relatedtotheeffectofthebuiltenvironmentonhealth,whichis
currentlyunderdevelopmentbytheWHOCollaboratingCentreforHealthyUrbanEnvironments,
commissionedbytheDepartmentofHealth,wasusedtoidentifykeyliterature.

Thismaterialwassupplementedbynewliteratureaddedwhenabriefingnotewaspreparedforthe
WHOEuropeanHealthyCitiesNetworkannualmeetinginSandnes,Norwayin2010.Thiswasnota
furthercomprehensivetrawlthroughtheliteraturebutratherabriefsnapshotofkeyinteractionsand
effectsofelementsofthebuiltenvironmentonhealthequity.


10
References

Barton,H.,Grant,M.,Guise,R.(2010).ShapingNeighbourhoodsforlocalhealthandglobalsustainability,
London:Routledge
Besser,L.,Dannenberg,A.(2005)WalkingtoPublicTransit:StepstoHelpMeetPhysicalActivity
RecommendationsAmericanJournalofPreventiveMedicine,29,4,273‐280
Calve‐Blanco,T.(2009).Theimpactoflocalfacilityprovisiononsocialnetworksandmentalwell‐being.DraftPhD
thesis,(personalcommunication)UniversityoftheWestofEngland,Bristol
CroucherK,MyersL,JonesR,EllawayA,BeckS(2007).HealthandthePhysicalCharacteristicsofUrban
Neighbourhoods:ACriticalLiteratureReview,FinalReport.Glasgow,GlasgowCentreforPopulationHealth.
CSDH(2008).Closingthegapinageneration:healthequitythroughactiononthesocialdeterminantsofhealth.
FinalreportoftheCommissiononSocialDeterminantsofHealth,Geneva,WorldHealthOrganisation
DavisA(Ed.)(2002).APhysicallyActiveLifeThroughEverydayTransport.Copenhagen,WHORegionalOfficefor
Europe.
EllawayA,MacintyreS,BonnefoyX(2005).Graffiti,greenery,andobesityinadults:secondaryanalysisof
Europeancross‐sectionalsurvey.BritishMedicalJournal,331:611‐2
Forastiere,F.,Stafoggia,M.,Tasco,C.,Picciotto,S.,Agabiti,N.,Cesaroni.G.,Perucci,C‐A.(2007).Socioeconomic
status,particulateairpollution,anddailymortality:Differentialexposureordifferentialsusceptibility.American
JournalofIndustrialMedicine,50,208‐216
Grant,M.,Barton,H.,Coghill,N.,andBird,C.(2009).EvidenceReviewontheSpatialDeterminantsofHealthin
UrbanSettings,contactGrantforpublicationdetails.
Greed,C.(2006).CASwaffieldpaper:Theroleofthepublictoilet:pathogentransmitterorhealthfacilitator?
BuildingServicesEngineeringResearchandTechnology.27,2,1‐13
HarlanSL,BrazelaAJ,PrashadaL,StefanovbW,LarsencL(2006).Neighborhoodmicroclimatesandvulnerability
toheatstress.SocialScience&Medicine,63(11):2847‐63.
HorowitzK,McKayM(2005)Communityviolenceandurbanfamilies:Experienced,effectanddirectionsfor
intervention.AmericanJournalofOrthopsychiatry,75:356‐68.
IEGMP(2000).MobilePhonesandHealth,IndependentExpertGroupOnMobilePhoneschairedbySirWilliam
Stewart,Didcot,Oxon:NationalRadiologicalProtectionBoard(availableon‐lineat
http://www.iegmp.org.uk/report/text.htm)
LavinT,HigginsC,MetcalfeO,JordanA(2006).HealthEffectsoftheBuiltEnvironment:AReview.Dublin,Belfast,
TheInstituteofPublicHealthinIreland.
LeeCandMoudonA(2008).NeighbourhooddesignandphysicalactivityBuildingResearchandInformation36
(5),pp395‐411.
MarmotM(2004).TheStatusSyndrome:HowSocialStandingAffectsOurHealthandLongevity.London,
BloomsburyPublishing.
MitchellG,DorlingD(2003).AnEnvironmentalJusticeAnalysisofBritishAirQuality.EnvironmentandPlanningA
35,909‐929.
Mitchell,R.andPopham,F.(2008)Effectofexposuretonaturalenvironmentonhealthinequalities:an
observationalpopulationstudy.Lancet2008,372,1655‐1660
NaessO,PiroFN,NafstadP,SmithGD,LeylandAH(2007).Airpollution,socialdeprivation,andmortality:a
multilevelcohortstudy.Epidemiology.Nov18,6,686‐94.
NETCEN(2006).AirQualityandSocialDeprivationintheUK:anenvironmentalinequalitiesanalysis.UK:AEAT
(availableon‐lineathttp://www.airquality.co.uk/reports/cat09/0701110944_AQinequalitiesFNL_AEAT_0506.pdf
accessed20September2009).
PlanningAdvisoryService(2008).EqualityandDiversity:Improvingplanningoutcomesforthewholeofthe
community.IDeA,London

11
Power,A.,Davis,J.,Plant,P.,Kjellstrom,T.(2009).StrategicReviewofHealthInequalitiesinEnglandpost‐2010:
TaskGroup4:TheBuiltEnvironmentandHealthInequalities.FinalReport12June2009.UCL,London.
RoyalCommissiononEnvironmentalPollution(2007),Twentysixthreport:TheUrbanEnvironment.HMSO,
London.
StaffordM,ChandolaT,MarmotM(2007).Associationbetweenfearofcrimeandmentalhealthandphysical
functioning.AmericanJournalofPublicHealth,97:2076‐81.
SustainableDevelopmentCommission(2010).SustainableDevelopment:ThekeytoTacklinghealthinequalities.
SDC,London.
WalkerG,FairburnJ,SmithG,Gordon,M(2003).EnvironmentalQualityandSocialDeprivation,R&DTechnical
ReportE2‐067/1/TR,Bristol:EnvironmentAgency.
WhitleyR,PrinceM(2005)Fearofcrimeandmentalhealthininner‐cityLondon,UK.SocialScienceMed,
61:1678‐88.
WHO(2002b).Flooding:Healtheffectsandpreventivemeasures,Factsheet05/02,CopenhagenandRome,13
September2002,(availableonlinefromhttp://www.euro.who.int/document/mediacentre/fs0502e.pdfaccessed
7June2009)
WHO(2008b).OurCities,OurHealth,OurFuture.ActingonSocialDeterminantsforHealthEquityinUrbanAreas.
(http://www.who.or.jp/knusp/KNUS_final_report.pdf,accessed17March2009).





















WHOCollaboratingCentreforHealthyUrbanEnvironments
DepartmentofPlanningandArchitecture
UniversityoftheWestofEngland,Bristol
W:www.uwe.ac.uk/research/who

