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

Authors:
  • Environmental Stewardship for Health
WHOCollaboratingCentreforHealthyUrbanEnvironments
UniversityoftheWestofEngland,Bristol
1
Workingpaper
Healthinequalitiesanddeterminantsinthephysicalurban
environment:Evidencebriefing
MarcusGrant,CarolineBirdandPennyMarno,March2012
Thisworkingpaperhasbeenwrittentosupportresearchintothespatialandphysicaldeterminantsin
theurbanenvironmentthatleadtohealthinequalities.
Theevidenceisbasedonarapidtrawlforrelevantresearchthatwefoundwhilstcompilingan
‘EvidenceReviewontheSpatialDeterminantsofHealthinUrbanSettings’(Grantetal.,2009)forthe
WHOEuropeanCentreforEnvironmentandHealth,Bonn;andasubsequentupdateforabriefingnote
preparedfortheWHOEuropeanHealthyCitiesmovementannualmeetinginSandnesin2010.Wealso
includehereanewbriefconclusionanddiscussion.
Theintentionofthereportistoserveasadiscussiondocumentandinspirationforthoseassociated
withresearchinthisfield.
OurWHOCollaboratingCentreisdevelopingamethodologysuitableforundertakingasystematic
reviewinsuchafield‐comprisingcomplexinterventions,illdefinedcausalpathways,opensystems
andawealthofgreyliterature.Wearealsolookingforfundingopportunitiestoestablishacognate
researchnetwork.
SYNOPSIS
Thebuiltandnaturalenvironmentisanimportantdeterminantofhealth.Evidenceshowsthata
disproportionateburdenofillhealthassociatedwiththebuiltenvironmentisbornebypoorerpeople
livinginpoorqualitybuiltenvironments.Poorerfamilieshavelowermobilitybutgreaterexposureto
theadverseenvironmentalconditionsrelatedtotransportsuchasairandnoisepollutionandhigher
trafficlevelswhichcauserespiratorydisease,mentalstressandroadtrafficinjury.Deteriorating
featuresofanurbanenvironmentsuchasdilapidation,vandalism,graffitiandlitterare
disproportionatelyfoundindisadvantagedareasandleadtoasenseofinsecurityonstreetsandin
parksandplayareasmeaningthatthemorevulnerableinparticularusethemless,leadingtoreduced
physicalactivityandsocialinteractionandexacerbatinghealthproblemssuchasobesityandisolation.
Greenspacehasmanybenefitsforphysicalandmentalhealthandpopulationsthatareexposedtothe
greenestenvironmentsalsohavelowestlevelsofhealthinequalityrelatedtoincomedeprivation,but
poorerneighbourhoodsoftenlackgreenspaceorhavepoorlymaintainedorvandalisedgreenareas.
Climatechangewillalsoimpactsignificantlyontheurbanenvironmentanddisproportionatelyonthe
disadvantaged,particularlythroughincreasingtemperaturesandflooding.
Inconclusion,landuse,transportanddevelopmentpoliciesandassociatedstrategicdecisions
determiningurbanformarekeytotacklinghealthinequalitiesrelatedtothebuiltenvironment
throughhousing,proximityoffacilities,greenspaceandviablemodesoftransport.
2
Healthinequalitiesanddeterminantsinthephysicalurban
environment:Evidencebriefing
Introduction
Thebuiltandnaturalenvironmentthatformsthebackclothtoourlivesisalsoanimportant
determinantofhealth.Thisisparticularlysoforpopulationgroupsdisadvantagedbyrelativepoverty,
unemployment,lowstatusanddisability.Thosewhoforfinancial,physicalorcultural/racialreasons
aremorevulnerable,andhavefewerchoicesfindthemselvestypicallyinlocationsandsettingsthatare
lessconducivetogoodhealthwithlittleabilitytomoveawayfromunhealthyworkingandliving
environmentsortomitigatetheirimpact.
Evidenceshowsthatadisproportionateburdenofillhealthassociatedwiththebuiltenvironmentis
bornebycertaingroupswithinthepopulation(CSDH,2008).Studiesintheearly2000susedtheterm
‘environmentaljustice’todescribespatialpatternswheredisadvantageandpoorenvironmental
qualitycoincide(e.g.MitchellandDorling,2003).Severalreviewsindicatethatpoorpeoplearemore
likelytoliveinpoorqualitybuiltenvironments(includingincreasedhealthriskexposurefromnoise
andairquality)andthiscontributestopoorhealth.Socioeconomichealthtrendshavebeenwell
documented.Weknowforinstancethattheleastwelloffpeopleinsocietysufferpoorerhealth
(Marmot,2004).Layersofhealthriskcanalsooverlap,forexampleLavinetal.(2007)identifychildren
andtheelderlyasbeingparticularlyvulnerablenotonlybecauseofabiologicalvulnerabilitybutalso
becauseofthesignificantnumbersofchildrenandelderlywhoarepoor.Howeverthespatial
componentsoftheurbanenvironmentthatcanbeassociatedwith,andsometimescontributeto,a
divergenceinhealthoutcomeshavenotreceivedsystematicattention.Webelievethattherearesome
keyspatialmechanismswhichexaggeratehealthinequity.Thisbriefingoutlinessomeoftherecent
evidencethatwehavefoundinareviewofmetastudies,systematicreviewsandpolicyreportsthat
showpotentialinequalitiesinhealthliterallybuiltintourbanenvironments.
Theevidencehasbeengroupedintosixthematicheadingsbasedonthestudiesfound:
Transport
Landusemix:Neighbourhoodsandfacilities
Crimeandfearofcrime
Housingandresidentialareas
Greenspace
Theurbanenvironmentandclimatechangeimpacts
3
Anevidencebriefing
Transport
Accesstoactivetravelmodesandlocalpublictransportnetworksisgreatlyaffectedbyurbanform.
Criticalphysicalparametersarelandusemix,streetnetworkformanddevelopmentdensity(Bartonet
al.,2010).
Therearemanyconnectionsbetweentransportandhealthwhichimpactmoreonpoorerfamilieswho
havelowermobilitybutgreaterexposuretotheadverseenvironmentalconditionsrelatedtotransport
suchasairandnoisepollutionandhighertrafficlevels.Peoplewhoaremostdeprivedarealsomore
susceptibletodamaginghealtheffectsbecauseofhigherlevelsofpreexistingillnessorother
vulnerability.
Accesstotransportthatenablesresidentstomoveoutsideoftheirowncommunityhasbeenshownto
positivelycorrelatewithareducedfearofsocialisolationandpositivementalhealth(Whitleyetal,
2005).Forthoseonhigherincomes,thisisbycarortaxi.However,forthoseonlowerincomes,access
topublictransportisimportant(Whitelyetal,2005).
Healthinequalitiesevidencefoundinrelationtothedistincttransportissuesofairpollution,road
casualtiesandmobilityandphysicalactivityaregivenbelow.
Airpollution
AcomprehensivereviewreportfromWalker(2003)isespeciallyusefulhere.Transportrelatedair
pollutionimpactsmostonthedisadvantagedwithincreasedriskofrespiratorydiseasesandother
illness.Peopleinthe10percentmostdeprivedareasinEnglandexperienceworstairquality,suffering
forexample41percenthigherconcentrationsofnitrogendioxidethantheaverage(Walker,2003).
Thereportstatedthat:
TherelationshipbetweenpoorairqualityanddeprivationinEnglandisparticularlystrongforpeak
pollutantvalues,includingexceedencesofstandards.Thenumberofpeopleinwardsabovepollution
thresholdsincreasesprogressivelywithincreasingdeprivation.
ThereversepatternwasfoundinWales,acountrywithamuchmoreruralpopulation.Thiswasdueto
theleastdeprivedhouseholdsinWalestendingtobemoreurbanthantheirEnglishequivalentsand
mostlylocatedinthemoreurbanizedsouth,wheremostofthepoorestairqualityoccurs.
Thereportalsodescribes“clustersofwards[localelectionareas]thathavepooraggregateairquality
andhighdeprivation”or“hotspots[of]pollutionpoverty”,withlargeclustersinthepartsofthe
maincities(Walker,2003)
IntheUK,intermsofNO2,PM10andSO2,thereisatendencyforthemostdeprivedcommunitiesto
experiencethepoorestairquality;thesedeprivedareasoftenhaveahigherproportionofchildren
livingthere,increasingtheoverallsusceptibilityofthepopulation(NETCEN2006,MitchellandDorling
2003).
Linksbetweenhigherairpollutionlevelsanddeprivedneighbourhoodshavealsobeenfoundinother
countriessuchasNorway(Naessetal2007).Otherstudieshavehighlightedthatevenincitiesthat
mightnotfollowthistrendandwherepeoplewithhighersocioeconomicstatusareexposedtothe
highestpollutionconcentrations,mortalityratesfromairpollutionrelatedcausesarestillhighest
amongstthosewithlowersocioeconomicstatusindicatingagreatersusceptibilitytotheeffectsofair
pollutionamongstpeoplewhoaremostdeprived(Forastiereetal2007).
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Roadcasualties
Thedesignofourtransportnetworksatthelocallevelisreceivingattentionfromurbandesignersand
publichealthwiththeadventofinitiativessuchas20mphareas,homezonesandcyclepaths.Studies
areinhandthatareevaluatingtheseagainstroadtrafficdanger.Broadstatisticsindicatethat,globally,
roadtrafficcollisionsarethesinglelargestcauseofunintentionalinjury(WHO,2008b).Therearevery
widesocioeconomicdifferentialsinthelevelsofdeathandseriousinjuryfromroadtraffic.Astudyin
Englandshowedthatchildreninthemostdeprived10percentofareasarefourtimesmorelikelyto
behitbyacaraschildrenintheleastdeprived10percent.Childrenaged019yearsandolderadults
aged60plusareparticularlyvulnerabletoinjurythroughroadtrafficaccidents,(DfT2005a;DfT2004).
Mobilityandphysicalactivity
Individualsfromlowincomegroups,olderpeopleandthosewithdisabilitiesarelesslikelytohave
accesstopersonaltransport(Lavinetal.,2006).Thesegroupsmayfindthataccesstoservicessuchas
shopsandhealthcareisreduced.Consequently,theymayspendahigherproportionoftheirincome
ontransport(Lavinetal.,2006).
Perceivedphysicaldangerposedbymotorisedtraffichasbeencitedasoneofthemainbarriersto
engaginginwalkingandcycling(Davis,2002).Thishashadadisproportionateeffectonactivitylevels
inbothchildrenandolderadults.However,theseissuesdonotseemtohavebeenthefocusofany
recentsystematicreviewstudies.
Onthepositiveside,walkingtoandfrompublictransportationcanhelpphysicallyinactive
populations,especiallylowincomeandminoritygroups,attaintherecommendedlevelofdaily
physicalactivity(BesserandDanneberg,2005).Thereforeincreasedaccesstopublictransportmay
helppromoteandmaintainactivelifestyles.
Landusemix:Neighbourhoodsandfacilities
Urbanlandusepatternisoneofthemaininfluencesonlevelsofphysicalactivity,particularlyamong
lowerincomegroupswhogetmuchoftheirphysicalactivitythroughactivetravelratherthan
recreation(RCEP,2007).
Deterioratingfeaturesofanurbanenvironmentsuchasdilapidation,vandalism,graffitiandlitterare
disproportionatelyfoundindisadvantagedareas,leadingtoasenseofinsecurityonstreetsandin
parksandplayareas(Lavinetal.,2006).Thismeansthatthemorevulnerableinparticularusethem
lessandthatchildrenarelesslikelytobeletouttoplaybothleadingtoreducedphysicalactivityand
exacerbatinghealthproblemssuchasobesitywhichismoreprevalentinlowerincomegroups.
TheimpactsareconfirmedbyEllawayetal.(2005)inthesecondaryanalysisofaEuropeancross
sectionalsurveyof12cities.Theyfoundthat,comparedtorespondentsfromareaswithlowlevelsof
litterandgraffiti,thosefromareaswithhigherlevels,were50%lesslikelytobephysicallyactiveand
50%morelikelytobeoverweight.
Lackoffacilitiessuchaspublictoilets(Greed,2006)impactsonvulnerablegroups,forexampleyoung
children,olderpeopleandthosewithillnessesorchronicdiseases.Lackofsuitableareasforresting,
forexamplebenchesandseatingmayalsolimittheabilityforcertaingroupstoexploreorwalklonger
distances.Withrespecttotheelderlythisimpactsnegativelyonsocialisolation.
Moreover,lackofavailabilityandaccessibilityofmunicipalservicessuchaslibraries,healthfacilities,
doctors’surgeries,schoolsandsocialsupportcanhaveanegativesocialimpactoncommunitiesand
affectbothphysicalandmentalhealth(Horowitzetal,2005;Lavinetal,2006).Placeswhichlack
facilitiesoftenbecomeghettoisedfosteringariskoffurthercriminalactivities(Horowitzetal,2005).
5
Iffacilities,jobsandsocialcontactsarewithincertaindistancethresholdsofhouseholds,withroutes
thatareperceivedasrelativelypleasantandsafe,thenwalkingandcyclingwillbecommon(Leeand
Moudin2008).Moreovernotonlywillactivetravelbetherule,butsocialnetworksandthesenseof
communitymaybeenhanced(CalveBlanco2009).
Crimeandfearofcrime
Oneofthemainsocialimpactsrelatedtourbanform,isresidents’perceivedfearofviolenceorcrime
(Horowitzetal,2005;Whitleyetal,2005).Theseaspectshavebeenshowntonegativelyaffectmental
health.Groupswhofeelmostvulnerableincludewomen,inparticularmothersonalowincome,and
thosewithmentalillness(Horowitzetal,2005;Whitleyetal,2005).Perceptionsofsafetyare
influencedbyfearofstreetcrimebutalsoinjuryfromtraffic(Croucheretal.2007)andareactionto
theaestheticimpression,whichincludesthepresenceofgraffiti,litterandstateofdisrepairofthe
surroundingcommunity(Lavinetal,2006).Thelatterisdisproportionatelyhighinlowincomeand
disadvantagedareas(Lavinetal,2006).
EvidencefromaninnerurbanareainNorthLondonfoundthatresidentsexperienceda‘timespace
inequality’asaconsequenceofcrimeandotherrelatedfactors(Whitleyetal,2005).Thishasbeen
showntoresultinpoormentalhealthincludingfeelingsofsocialisolation,negativemoodandlowself
esteem.‘Timespaceinequality’describesthevariationinabilityofcommunityresidentstoaccessand
usespacesbothwithintheirimmediateandwiderenvironmentatdifferenttimesduringthedayor
night.Thiswaslessprevalentinmentallyhealthymenormiddleincomewomen.Timespace
inequalitiesseemedtobediminishedbyinterventionsthatencouragedspatialandtemporal
movementsandencourageconnectivitytoawidergeography,forexamplecomprehensivelocalpublic
transportsystemsandgovernmentissuedfreetravelpassesforvulnerablepopulations.
Fearofcrimehasbeenshowntobeabarriertotheuseofbicyclesastransportorforrecreation
(Staffordetal,2007).
Housingandresidentialareas
Older,poorerqualityhousingwhichisharderandmoreexpensivetoheatisalsomorelikelytobe
occupiedbypoorerhouseholds.ExtradeathsbetweenDecemberandMarchareattributedtothecold
weatherwithchildren,olderpeopleandpeoplewithlongtermillnessesthemostvulnerable(RCEP,
2007).Risingfuelpricesexacerbatetheproblemforpeopleinpoorlyinsulatedhomescausingmore
fuelpovertyandworseninghealth.
Environmentalnoiseproblemshavebeenshowntoleadtosleepdisturbance,cardiovasculardisease
andimpairedmentalhealth.Mosturbannoiseinresidentialareasistrafficrelated.Nightclubs,bars
andpartiesareothersourcesofnoiseinmorecentralareas.Innonindustrialurbanenvironments,
opinionpollresearchconductedin2003(citedinRCEP,2007)foundthatenvironmentalnoise
problemsareworseinareasofhighdensityhousing,rentedaccommodation(bothsocialandprivate
sectors),areasofdeprivationandareaswhicharehighlyurbanised.
Greenspace
Thereismuchevidenceforthebenefitsofgreenspaceforphysicalandmentalhealthandwellbeing;
theseincludedecreasesingeneralhealthcomplaints,cholesterol,bloodpressureandstresslevelsand
improvedperceivedgeneralhealthandresilience(egRCEP,2007).Evidencesuggeststhatpopulations
6
thatareexposedtothegreenestenvironmentsalsohavelowestlevelsofhealthinequalityrelatedto
incomedeprivation(MitchellandPopham,2008).Theinequalityinmortalityislowerinpopulations
livinginthegreenestareas.However,greenspaceisnotequallyavailabletoallofthepopulation,with
poorerneighbourhoodsoftenlackingingreenspaceorwithpoorlymaintainedorvandalisedgreen
areas.Thebenefitsofincreasesinphysicalactivityandimprovedmentalhealthonlyarisewherethe
greenspaceishighquality,accessibleandsafe(Croucheretal,2007).
Accordingtoseveralreviews,accesstogreenspacesandnaturehasbeenshowntopositivelyaffect
mentalhealth,possiblythroughreducingstressandthroughprovidingadistractionanddistancing
ourselvesfromtheeverydayactivities(HCN,2004;Prettyetal.,2005;Lavinetal,2006).Additionally,
greenspaceshaveapositiveeffectonpromotingsocialinteractionandcohesion(Greenspace
Scotland,2008).
Conversely,restrictedaccesstogreenspaceshasbeenassociatedwithpoorermentalhealth(Guiteet
al,2006;Kuo2001).Residentsinurbansocialhousingwhohadviewsoftreesandopenspaces
demonstratedagreatercapacitytocopewithstresscomparedtothosewhodidnothavesuchaccess
(Kuo,2001).Olderpeopleinparticularbenefitfromsuchaccess(OrsegaSmithetal,2004).Accessto
greenspacealsohasanaccentuatedpositiveeffectonphysicalhealthforthosefromlowincome
groups(Mitchelletal,2008).
However,intheUK,thosewholiveindisadvantagedareasarelesslikelytobenefitfromgreenspaces
andparks(Lavinetla,2006).AccordingtoaUKreportonurbangreenspaces(Departmentof
Transport,2002),inthe100mostdeprivedauthorities,40%ofparkswereindeclineand88%ofparks
thatwerealreadyassessedasbeinginpoorconditionwereinfurtherdecline.
Anegativeimpactonhealthregardingthesocialimpactofgreenspaceisacommunity’sperceivedrisk
ofcrime,inparticularfearfromassaultorviolence(Croucheretal,2007).Thisfearmanifestsitselfina
reducedabilitytoaccruethepositivebenefitstomentalhealthfromaccessinggreenspaces(Croucher
etal,2007).
Theurbanenvironmentandclimatechangeimpacts
Therearetwoparticularaspectsofclimatechangewhicharelikelytoimpactsignificantlyontheurban
environmentanddisproportionatelyonthedisadvantaged;increasingtemperatureandfloodrisk.
Increasingtemperatures
Exposuretoheatisacauseofmorbidityandmortalityintheurbanenvironment,andheatstressisa
conditionthatcancauseillnessanddeath.Humanexposuretoexcessivelywarmweather,especiallyin
cities,isanincreasinglyimportantpublichealthproblem.Harlan(2006)examinedheatrelatedhealth
inequalitieswithinonecityinordertounderstandtherelationshipsbetweenthemicroclimatesof
eightdiverseurbanneighbourhoods,populationcharacteristics,thermalenvironmentsthatregulate
microclimatesandtheresourcespeoplepossesstocopewithclimaticconditions.Statistically
significantdifferenceswerefoundintemperaturesbetweentheneighbourhoodsduringtheentire
summer,whichincreasedduringaheatwaveperiod.Lowersocioeconomicandethnicminoritygroups
weremorelikelytoliveinwarmerneighbourhoodswithgreaterexposuretoheatstress.High
settlementdensity,sparsevegetation,andhavingnoopenspaceintheneighbourhoodwere
significantlycorrelatedwithhighertemperatures.Peopleinwarmerneighbourhoodsweremore
vulnerabletoheatexposurebecausetheyhadfewersocialandmaterialresourcestocopewith
extremeheat.Interestinglythismirrorsthecasepreviouslyprovenabouttheinequitableimpactsof
coldweatheronresidents.
Intermsofpopulationeffectsatasettlementlevel,olderpeople,childrenandinfantsaremore
7
susceptibletoprolongedexposuretoheat(RCEP,2007).Theremayalsobeanunevendistributionin
heatinrelationtoincome,withmorewealthyresidentstendingtoliveinareaswithmoremicro
climatemoderationthroughbeinglesslowlyingandhavingagreaterproportionofgreenspace.
Flooding
Urbanfloodingfromsealevelriseandfluvialinundationwillpresentanincreasingrisktohealth.
Healtheffectsfromfloodingincludedrowning,injuries,infectiousdiseases,stressandlossofessential
urbanservices.Intermsofhealthinequality,theeffectsoffloodingcanbeparticularlydevastatingto
alreadysociallyvulnerablepopulationssuchaschildren,olderpeopleand/ordisabledpeople,ethnic
minoritiesandthosewithlowincomes(WHO,2003b).
AstudyintheUnitedKingdom(Walkeretal.,2003)foundthatforEngland,livinginthetidalfloodplain
hadaclearrelationshipwithdeprivation.Ofthepopulationwithinthetidalfloodplain,therewere
eighttimesmorepeopleinthemostdepriveddecilecomparedtotheleastdeprived.Incontrast,for
thefluvialfloodplain,therewasaninverserelationshipwithdeprivation,althoughoflesserstrength,
withahigherproportionofthefloodplainpopulationinthemoreaffluentcomparedtothemore
depriveddeciles.ForWales,thepatternofsocialdistributionwaslessdistinctbutshowedsome
similaritiestoEngland.
Discussion
Potentialofusingspatialplanningtomitigateinequalitiescausedbyurbanform
Spatialorbuiltenvironmentfactorswhichaffecthealthunevenlyacrossthesocioeconomicspectrum
tendtocompoundtheeffectofexitingsocialandeconomicdeterminants.Theyalsoreflectthemuch
biggerpolicycontext,spatialplanning,inwhichlanduse,transportanddevelopmentpoliciesare
shaped.Inotherwords,strategicdecisionsdeterminingurbanformcanaffectaperson’sproximityto
facilities,greenspaceandtheirviableoptionofmodesoftransport.Thiseffectsthedeterminantsof
mentalandphysicalhealthinplaceswherepeopleliveandwork.
Sowhatcanbedone?
AnillustrationoftheeffectofproactivetownplanningcanbefoundintheGermancityofFreiburg
whereexistingtrendstowardsamorecarorientatedanddispersedsocietyhavebeenreversed.
Freiburghas,forthelast40years,pursuedacommitted,progressiveandcomprehensivelanduse/
transportstrategybasedonwalking,cyclingandpublictransport.Peopleonallincomeshavemoved
awayfromcaruseandbeengiventhefreedomtotravelaroundthecity,givingequalaccesstojobs
andhousinginahealthierenvironmentfreefromthedominanceofthecar.Recenturban
developmentinthenewneighbourhoodofVaubanhasestablishedextensivevirtuallycarfreeareas,
wherechildrencanplayfreelyandcommunityisstrengthened.
Freiburgwentdownthisroute,notduetoaspecificvisionofapublichealthoutcome,butduetoa
questforimprovedqualityoflifewithinthelocalconstraintsimposedbyitssetting.Beingsurrounded
bytheBlackForest,notonlywouldphysicalgrowthofthecityencroachontheforest,buttheforest
wasalready,inthe1970s,startingtoshowdamagefromacidraincausedbypollution‐muchofitfrom
roadtransport.
Intheabsenceofsuchspecificcircumstances,othertoolsneedtobebroughtin.Healthequitychecks
couldbeonemechanismappliedtobothstrategicplansandneighbourhoodproposalstoensurethat
healthinequalitiesarenotintroducedorexaggerated.Oneapproachcouldbethroughbringinggreater
healthandhealthinequalityfocusintoStrategicEnvironmentalAssessments,orthroughHealthand
EqualityImpactAssessments.
8
AusefulexampleofgoodpracticecanbefoundinWhitechapel,London.Aphysicalmasterplan
underwentaSustainabilityAssessmentwhichincludedanEqualityImpactAssessment.Thisidentified
lowerlifeexpectancyandvulnerablegroupsasakeyinequalityissueandrecommendedactionsto
reduceinequalities.Theseincludedimprovingoutdoorspaceandindoorleisurefacilitiestomakethem
inclusiveandsafeforallincludingminorityethnicgroupswhohavetendedtousethemlessand
thosewithillhealth.
Questionsremainabouttheroleofthebuiltenvironmentinthecausalchain.Doesthebuilt
environmentactsaconfounderintherelationshipbetweenhealthanddeprivation,orviceversa?
AttheWHOCollaboratingCentreforHealthyUrbanEnvironments,wefeelisimportanttokeepthe
evidencebaseandpotentialresultantactionsclosetogetherinourresearch.Assuch,thenextstagein
thisresearchwouldbetoconductasystematicreviewoftheliteratureattemptingtolocatebetter
qualityevidenceandalsotoyieldsomecasestudies,wherethesecouldbeauthoritativelyevaluated.
Casestudiesareaveryvaluablewayofcommunicatingwiththepolicyandpracticecommunities.
Contactdetails
WHOCollaboratingCentreforHealthyUrbanEnvironments
DepartmentofPlanningandArchitecture
UniversityoftheWestofEngland,Bristol
W:www.uwe.ac.uk/research/who
MarcusGrant,ActingDirector
E:marcus.grant@uwe.ac.uk
CarolineBird,ResearchFellow
E:caroline3.bird@uwe.ac.uk
9
Appendix:Searchstrategy
Thisreviewwasextractedfromalargerreportthatsoughttoprovideabriefoverviewofthemajor
healthchallengesandrisksinurbansettings(Grantatal.2009).Allevidencerelatingtodisparities
betweenpopulationgroupswasextracted.
Duetothetimeframeandresourcesavailable,theoriginalstudywasnotasystematicreviewofthe
literature.Inthemain,sourcesreviewedweremetastudies,reviewsoftheliteratureandreviewsof
reviews.Whereparticularlyrelevant,seminalpeerreviewarticlesandkeynationalandinternational
reportspublishedbynotedagenciesinthefieldofhealthandthebuiltenvironmenthavealsobeen
included.
Thesearchstrategywasafilteredsnowballtechnique.Earlysearchesadvisedlatersearchdecisions,
searcheswereextendedthroughfollowingcitationsuntilapointofsaturationwasreachedwhen
additionalsearchesdidnotfurtherenrichtheliteraturealreadyobtained.Filteringwasappliedsuch
thatliteraturerelevanttohealthandtheurbanenvironmentbutwithoutaspatialplanningdimension
wasexcluded,suchasliteratureon(noiseorairpollution)emissionsfromspecificplantorprocesses.
Theinitialsearchstrategywaslimitedbythefollowing:
- Years;20052009
- Humansonly
- PublishedintheEnglishlanguage
- Reviewsandmetastudiesonly
Searchterms:health,environment,transport,greenspace,urbandesign,urbanservicing,airquality,
airpollutionwaterpollution,physicalactivity,socialpathologies,mentalhealth,airpollution,noise
exposure,injuriesandaccidents,urbanformandcrime.
Primarydatasources:CBAabstracts,EncyclopaediaofLifeSciences,Geobase,GreenFILE,Science
CitationIndex,ScienceDirect,SocialSciences,CitationIndexandtheCochranelibrary.
Primarywebsitesforreports:DepartmentofHealth,UK;NationalInstituteofClinicalExcellence;
DepartmentfortheEnvironment,FoodandRuralAffairs,UK;SouthWestPublicHealthObservatory;
DepartmentforTransport,UKandtheWorldHealthOrganisation.
Somemateriallyingoutsidethesearchparameters,suchasrefereedarticles,hasbeenincludedwhere
ithasbeencitedbyitemsrecoveredusingtheinitialsearchitemsanditisrelevanttothestudy.
Manyexistingstudiessheddinglightonhealthriskintheurbanenvironmentdonotmeetthemedical
professions’requirementsforrobustclinicalandquantitativeevidence.Thiscanresultinatendencyto
discountarangeofindepthandrichqualitativestudies.Suchresearchisimportantforanalysingand
explainingrelationshipsintheurbansystemandhasbeenincludedwhererelevant.
Additionally,abibliographyresource,relatedtotheeffectofthebuiltenvironmentonhealth,whichis
currentlyunderdevelopmentbytheWHOCollaboratingCentreforHealthyUrbanEnvironments,
commissionedbytheDepartmentofHealth,wasusedtoidentifykeyliterature.
Thismaterialwassupplementedbynewliteratureaddedwhenabriefingnotewaspreparedforthe
WHOEuropeanHealthyCitiesNetworkannualmeetinginSandnes,Norwayin2010.Thiswasnota
furthercomprehensivetrawlthroughtheliteraturebutratherabriefsnapshotofkeyinteractionsand
effectsofelementsofthebuiltenvironmentonhealthequity.
10
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WHOCollaboratingCentreforHealthyUrbanEnvironments
DepartmentofPlanningandArchitecture
UniversityoftheWestofEngland,Bristol
W:www.uwe.ac.uk/research/who
... Infatti, la mobilità locale, gli standard energetici, le infrastrutture per il riscaldamento degli edifici e la realizzazione di centrali per la produzione di energia da fonti rinnovabili dipendono direttamente da decisioni prese a livello locale. Per tale motivo una città moderna deve, sempre più, investire e lavorare per uno sviluppo sostenibile, ponendo particolare attenzione al capitale sociale, ambientale e culturale, tenendo in debita considerazione la creazione di ambienti favorevoli, come gli spazi verdi, che portano vantaggi sia alla salute fisica e mentale sia al benessere generale (Grant et al, 2012). Tali vantaggi potrebbero tradursi in riduzione dei problemi generali di salute, della pressione sanguigna, del colesterolo, dei livelli di stress e forniscono un diversivo, allontanando le persone dalle loro attività quotidiane e promuovendo l'interazione sociale e la coesione (Lavin et al, 2006). ...
... Come dimostrato fin qui, numerose sono le evidenze scientifiche che indicano i diversi vantaggi determinati dalla presenza di spazi verdi sia per la salute fisica e mentale sia per il benessere generale (Grant et al, 2012). L'esposizione a spazi verdi può però anche avere un impatto sulle disuguaglianze urbane e socioeconomiche della salute (Mitchell e Popham, 2008). ...
... As trees and other vegetation mitigate air pollution generated by road traffic and industry through carbon capture [54], it is interesting to note that the 'most affluent 20 per cent of wards have five times the amount of parks or general green space (excluding gardens) per person than the most deprived ten per cent of wards' ( [55]:7). Conversely, the most deprived urban communities tend to experience the poorest air quality [56], with increasing risk of cancer, asthma, heart disease, dementias, mortality, and hospital admissions [57]. In addition to air pollution from traffic, noise pollution can also threaten human health [58], although well-designed urban green spaces can buffer noise and negative perceptions of it [59]. ...
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Background Reducing health inequalities in the UK has been a policy priority for over 20 years, yet, despite efforts to create a more equal society, progress has been limited. Furthermore, some inequalities have widened and become more apparent, particularly during the Covid-19 pandemic. With growing recognition of the uneven distribution of life expectancy and of mental and physical health, the current research was commissioned to identify future research priorities to address UK societal and structural health inequalities. Methods An expert opinion consultancy process comprising an anonymous online survey and a consultation workshop were conducted to investigate priority areas for future research into UK inequalities. The seven-question survey asked respondents (n = 170) to indicate their current role, identify and prioritise areas of inequality, approaches and evaluation methods, and comment on future research priorities. The workshop was held to determine areas of research priority and attended by a closed list of delegates (n = 30) representing a range of academic disciplines and end-users of research from policy and practice. Delegates self-selected one of four breakout groups to determine research priority areas in four categories of inequality (health, social, economic, and other) and to allocate hypothetical sums of funding (half, one, five, and ten million pounds) to chosen priorities. Responses were analysed using mixed methods. Results Survey respondents were mainly ‘academics’ (33%), ‘voluntary/third sector professionals’ (17%), and ‘creative/cultural professionals’(16%). Survey questions identified the main areas of inequality as ‘health’ (58%), ‘social care’ (54%), and ‘living standards’ (47%). The first research priority was ‘access to creative and cultural opportunities’ (37%), second, ‘sense of place’ (23%), and third, ‘community’ (17%). Approaches seen to benefit from more research in relation to addressing inequalities were ‘health/social care’ (55%), ‘advice services’ (34%), and ‘adult education/training’ (26%). Preferred evaluation methods were ‘community/participatory’ (76%), ‘action research’ (62%), and ‘questionnaires/focus groups’ (53%). Survey respondents (25%) commented on interactions between inequalities and issues such as political and economic decisions, and climate. The key workshop finding from determining research priorities in areas of inequality was that health equity could only be achieved by tackling societal and structural inequalities, environmental conditions and housing, and having an active prevention programme. Conclusions Research demonstrates a clear need to assess the impact of cultural and natural assets in reducing inequality. Collaborations between community groups, service providers, local authorities, health commissioners, GPs, and researchers using longitudinal methods are needed within a multi-disciplinary approach to address societal and structural health inequalities.
... The corresponding benefits of GSA are the prevention of obesity, cancer, and osteoporosis, neurocognitive, cardiovascular, mental or immune improvements (Kuo, 2015;Lachowycz and Jones, 2014). While some authors have shown that the lowest socio-economic groups have higher GSA (Mitchell and Popham, 2008;Barbosa et al., 2007;Cutts et al., 2009), others have shown that the most-deprived neighborhoods have, on average, less available green space, and that which is available is of poor environmental quality in terms of air quality or heat stress (Grant and Bird, 2012;Comber et al., 2008). Crucially, equal access to a healthy environment and inequalities in GSA is strongly coupled to distance (Wolch et al., 2014;Dai, 2011;Jennings et al., 2012). ...
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Improving Green Space Accessibility (GSA) in public spaces in cities and communities reduces disparities among people and fosters sustainable development. However, traditional mapping approaches in cities neglects green spaces in the hinterland and treats the geographical distance as a fixed quantity. This limits conclusions about spatial inequalities in Green Space Accessibility and influences the evaluation of current policies which seek to ensure a high local recreation quality for all residents irrespective of any administrative boundaries. This paper aims to detect spatial inequalities in Green Space Accessibility for urban green (UG) and non-urban green (NUG) across Europe, and reveals the role of the rural-urban interface (RUI). The approach taken here calculates Green Space Accessibility across administrative boundaries, which enables distance to be treated as a flexible variable. The results highlight major inequalities between and within regions and countries. However, unequal Green Space Accessibility for urban green is compensated in most countries by more equal one for non-urban green, which is of particular relevance in the rural-urban interface. The combined perspective on both relative and absolute Green Space Accessibility suggests a new perspective on the rural-urban interface that is critical for equitable green infrastructure planning. This paper concludes that, in order to bridge the urban-rural-divide, monitoring and planning tools that examine the arbitrary use of thresholds and existing administrative boundaries are needed.
... 63 A legnagyobb növekedés az olyan, már most is sűrűn lakott térségekbenjelentkezik, mint például Kelet-és Délkelet Anglia. 64 Ez részben betudható az épített környezetnek 69 , amelyben élünk és ahol a légszennyezés, a közúti forgalom, a zaj, az éghajlat és az árvizek közvetlenül, míg más tényezők, mint az elérhetőség, a közbiztonság, a területfelhasználási mix, az utca dizájn vagy a nyitott zöldterületek közvetetten befolyásolják az egészségi állapotot. 70 Nem meglepő tehát, hogy a szegényebb emberek élnek rosszabb minőségű épített környezetben, ártalmas környezeti hatásoknak kitéve, miközben a szabad, nyitott közterületekhez való hozzáférésük limitált. ...
Book
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Planning as a profession has integrated spatial thinking into its decision-making; planners aim to look beyond individual policies and decisions in order to take a broader and longer-term view. This helps them to decide between often competing interests (for example, regarding the use of land). The same could be true for other areas of public policy. Spatial thinking is not constrained to the planning profession; the importance of space in understanding and predicting human behaviour and finding solutions to societal problems is well known, and sociologists, geographers and economists frequently use spatial approaches to decision-making. Having said this, spatial thinking is not prevalent across all policy areas. This paper examines the consequences of taking a spatially insensitive approach to policymaking, and highlight case studies where a greater consideration and understanding of spatial impacts could have made a policy or initiative more effective. The paper also reflects on the tools available to policymakers which can assist spatial thinking in decision-making. The use of tools such as GIS and impact assessment has become more widespread in recent years, but barriers remain which prevent the use of these tools across all policy areas.
... There is a common tendency for the most deprived urban communities to experience the poorest air quality, as has been shown for the United Kingdom (Grant et al., 2012) and Norway (Naess et al., 2007). This can contribute to excess mortality in deprived neighbourhoods. ...
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Publications Partners Contact us Urban green spaces and health - a review of evidence (2016) Download English (PDF, 3.0 MB) Modern urban life style is associated with chronic stress, insufficient physical activity and exposure to anthropogenic environmental hazards. Urban green spaces, such as parks, playgrounds, and residential greenery, can promote mental and physical health, and reduce morbidity and mortality in urban residents by providing psychological relaxation and stress alleviation, stimulating social cohesion, supporting physical activity, and reducing exposure to air pollutants, noise and excessive heat. This report summarizes evidence of health benefits, discusses pathways to health and evaluates health-relevant indicators of urban green space. An example of green space accessibility indicator with a detailed methodological tool kit is provided at the end of the report
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Background: Reducing health inequalities in the UK has been a policy priority for over 20 years, yet, despite efforts to create a more equal society, progress has been limited. Furthermore, some inequalities have widened and become more apparent, particularly during the Covid-19 pandemic. With growing recognition of the uneven distribution of life expectancy and of mental and physical health, the current research was commissioned to identify future research priorities to address UK societal and structural health inequalities. Methods: An expert opinion consultancy process comprising an anonymous online survey and a consultation workshop were carried out to investigate priority areas for future research into UK inequalities. The seven-question survey asked respondents (n=170) to indicate their current role, then identify and prioritise areas of inequality, approaches and evaluation methods. The workshop was held to determine areas of research priority and attended by a closed list of delegates (n=30) representing a range of academic disciplines and end-users of research from policy and practice. Delegates self-selected one of four breakout groups, to participate in determining research priority areas in four categories of inequality (health, social, economic, and other) and to allocate hypothetical sums of funding (half, one, five, and ten million pounds) to chosen priority areas. Responses were analysed using mixed methods. Results: Survey respondents determined the main areas of inequality as ‘health’, ‘social care’, ‘living standards’, and ‘economic factors’. The highest research priorities were ‘access to creative and cultural opportunities’, ‘sense of place’ and ‘community’. Approaches seen to benefit from more research were ‘health/social care’, ‘advice services’ and ‘adult education/training’. Preferred evaluation methods were ‘community/participatory’, ‘action research’, ‘questionnaires/focus groups’ and ‘ethnographic studies’. The key workshop finding was that health equity could only be achieved by tackling societal and structural inequalities, environmental conditions and housing, and having an active prevention programme. Conclusions: Research demonstrates a clear need to assess the impact of cultural and natural assets in reducing inequality. Collaborations between community groups, service providers, local authorities, health commissioners, GPs and researchers using longitudinal approaches are needed within a multi-disciplinary approach to address societal and structural health inequalities.
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The current review aimed to explore the association between urban greenspaces and health indicators. In particular, our aims were to analyze the association between publicly accessible urban greenspaces exposure and two selected health outcomes (objectively measured physical activity (PA) and mental health outcomes (MH)). Two electronic databases—PubMed/Medline and Excerpta Medica dataBASE (EMBASE)—were searched from 1 January 2000 to 30 September 2020. Only articles in English were considered. Out of 356 retrieved articles, a total of 34 papers were included in our review. Of those, 15 assessed the association between urban greenspace and PA and 19 dealt with MH. Almost all the included studies found a positive association between urban greenspace and both PA and MH, while a few demonstrated a non-effect or a negative effect on MH outcomes. However, only guaranteeing access is not enough. Indeed, important elements are maintenance, renovation, closeness to residential areas, planning of interactive activities, and perceived security aspects. Overall, despite some methodological limitations of the included studies, the results have shown almost univocally that urban greenspaces harbour potentially beneficial effects on physical and mental health and well-being.
Chapter
Health is a critical indicator of human well-being because an ailing population cannot spur socio-economic development of a community. As high population densities allow the spread of infectious diseases, cities were historically unhealthy places, only able to maintain their populations through in-migration. The provision of clean water and sound sanitation changed the situation dramatically, enabling the growth of large urban areas. However, where basic services such as water, sanitation, and stormwater drainage are neglected, the situation can rapidly deteriorate. The prevailing patterns of urbanisation in Zimbabwe expose urbanites to numerous infectious diseases such as typhoid, cholera, influenza, and zoonotic diseases and sexually transmitted diseases. Based on a mix of desktop and empirical research from Harare, this chapter maps and characterises the public health problems that are increasingly overwhelming cities in Zimbabwe. Cities in Zimbabwe are experiencing degradation of natural environments, poorly built environments with unsafe drinking water, sanitation and waste management, all arising from poor urban management and contributing to urban poverty. This chapter therefore argues that despite the vulnerability of these urban areas to health threats, the planning and management of cities seem to marginalise health concerns, rather than integrating them into the land use and urban planning systems.
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Urban green spaces provide cultural ecosystem services, and urban policies typically aim to enhance these services by targeting new investments in deprived areas. The implementation of urban greening policies is one way to reduce inequalities in well-being, for example by targeting areas where increased access to green spaces will benefit citizens of low socioeconomic status. Most research has addressed the targeting of green infrastructure development by considering income and access to green spaces, while few studies have considered a multidimensional definition of well-being. The aims of this paper are to i) integrate inputs from the economic and political philosophy literature to propose a broader definition of well-being, including health, education, insecurity, and social relations; ii) develop a criterion to prioritise areas where urban greening would have the greatest impact on well-being inequalities; and iii) apply this criterion to the Paris metropolitan area (Ile-de-France region), a spatially heterogeneous region where areas deprived of access to green spaces are not systematically deprived in other dimensions. Our analysis shows that the city of Paris and the inner suburbs would be targeted when considering inequality in access to green spaces only. The results differ when inequalities in income or multidimensional well-being are taken into account, in which case the northern inner suburbs and some outer suburbs become a higher priority.
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This paper discusses the role of public toilets, as transmitters of disease, but also of their importance in contributing to the health and well-being of society. Research has shown that public toilets are vital components in creating sustainable, accessible, inclusive cities. But there is no mandatory legislation requiring local authorities to provide them. Over 40% have been closed in the UK in the last 10 years. The promotion of the 24 hour city, characterized by a male youth drinking culture, along with toilet closure, has resulted in increased street urination, creating the conditions for the spread of previously-eradicated, water borne diseases in city streets. Less visible, but as virulent, has been the effect of toilet closure for women. Women, in response to lack of toilet provision, are likely to ‘hold on’ resulting in urine (and pathogen) retention, and bladder distension increasing the propensity for continence problems. The elderly and people with disabilities may simply not go out for fear of there being no toilet when they need one. Those toilets that are available may be unusable. Lack of regulation or compulsory standards result in poor toilet design, inadequate maintenance and management, and unhygienic conditions, resulting in the spread of MRSA and other drug-resistant diseases. Recommendations are summarized for the provision of a spatial hierarchy of toilet provision that would both meet user needs and reduce the chances of the public toilets acting as epicentres of germ transmission. Unless compulsory legislation, increased funding, and improved management, maintenance and cleaning regimes are instigated, public toilet provision will continue to be a source of disease.
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Health problems related to physical inactivity have become a global health challenge affecting people from the full spectrum of income, age, and ethnicity. This paper examines if neighbourhood environments are associated with physical activity, especially walking and cycling. It analyses 608 respondent survey data from Washington State in the US and Geographic Information System-derived measures of the neighbourhood environment. Respondents reported traffic volume to be the most significant barrier, and good lighting to be the most important facilitator of walking and cycling. Utilitarian destinations, such as grocery stores, restaurants, retail stores and convenience stores, were significant correlates of walking and moderate-intensity physical activities, while housing type, sports facility and transportation infrastructure were correlated with vigorous physical activities. Active people rated higher for their neighbourhood attributes including safety, visual quality, knowing neighbours, seeing many other people walking and cycling, and the availability of sports facilities, parks, and bike racks. Simple interventions such as street lighting, pavements/sidewalks, street trees, benches, bike lanes or trails, bike racks, and traffic-calming devices appeared to hold some promise in promoting physical activities in neighbourhoods. Long-term solutions should include strategies to enhance overall aesthetics, safety, accessibility, street connectivity, and social interactions among neighbours.