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Built environment stakeholders’ experiences of
implementing healthy urban development: an
exploratory study
Helen Pineo & Gemma Moore
To cite this article: Helen Pineo & Gemma Moore (2021): Built environment stakeholders’
experiences of implementing healthy urban development: an exploratory study, Cities & Health,
DOI: 10.1080/23748834.2021.1876376
To link to this article: https://doi.org/10.1080/23748834.2021.1876376
© 2021 The Author(s). Published by Informa
UK Limited, trading as Taylor & Francis
Group.
Published online: 22 Jan 2021.
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ORIGINAL SCHOLARSHIP
Built environment stakeholders’ experiences of implementing healthy urban
development: an exploratory study
Helen Pineo and Gemma Moore
Institute for Environmental Design and Engineering, Bartlett School of Environment, Energy and Resources, University College London,
London, UK
ABSTRACT
Healthy urban development, in the form of buildings and infrastructure, is necessary to reduce
disease and injury internationally. The urban development process is complex, characterised by
a plurality of actors, decisions, delays, and competing priorities that aect the integration of
health and wellbeing. Despite clear shifts in the built environment sector towards considering
health, there is a lack of research about how the principles of healthy design are put into practice
in development projects. We explored this topic via semi-structured interviews with 31 built
environment and public health professionals involved in such projects in Australia, China,
England, the Netherlands, Sweden and the United States. We used thematic analysis and three
themes emerged from our hybrid deductive and inductive approach, encompassing challenges
and potential solutions for integrating health in development. Managing risk, responsibility
and economic constraints were paramount to persuade developers to adopt healthy design
measures. Participants could push business-as-usual practices towards healthy urbanism by
showing economic benets or piloting new approaches. Finally, participants had contrasting
views on whether increasing professional knowledge is required, with several arguing that
nancial barriers are more problematic than knowledge gaps. This exploratory study contributes
insights into an under-research topic and outlines priorities for further investigation.
ARTICLE HISTORY
Received 22 September 2020
Accepted 11 January 2021
KEYWORDS
Design; development; health
and wellbeing; planning
Introduction
Changes to urban environments in the form of build-
ings, infrastructure and public spaces affect health and
wellbeing. This fact is widely recognised in academic
literature, yet relatively new to the educational curri-
cula and professional practice of those who make
decisions about urban development (e.g. planners,
urban designers, developers, architects, surveyors and
others). Many international and national policy agen-
das promote healthy urban development principles
and professional bodies provide guidance and case
studies to inspire good practice. Yet, there is often
a question about how far the aspirations of policy
and guidance can be connected to the reality of imple-
menting change on the ground. Applying healthy
development principles is perceived to be difficult by
professionals for a wide range of reasons including
unsupportive regulatory systems, lack of economic
viability, and the complexity of the development pro-
cess (McGreevy et al. 2019, Carmichael et al. 2020).
Scholars, governments and professional organisa-
tions have produced frameworks and design guidance
for healthy urban environments that aim to influence
planning, design and construction (e.g. UN-Habitat
and World Health Organization 2020; Urban Land
Institute 2015, WHO 2018, Clements-Croome et al.
2019). Relevant planning and design strategies include
those which are: spatial and infrastructural (e.g. walk-
able neighbourhoods, networks of green infrastruc-
ture, integrated transport systems), technological
(e.g. air quality sensors or low toxicity building mate-
rials), architectural (e.g. adequate space and thermal
comfort) and social (e.g. accessible open space and
affordable housing). Pineo (2020) reviewed 15 healthy
urban design and planning guidance documents and
argued that many perpetuated a narrow model of
health, one which emphasises supporting ‘healthy life-
style choices’ (e.g. physical activity and diet) rather
than recognising structural barriers to health and the
urgent risks of environmental degradation. The review
indicates a gap between the social and environmental
justice imperatives of healthy urbanism and the exist-
ing professional guidance.
Creating healthy developments is challenging in
part because the development process is highly com-
plex and no single actor or institution is in control;
they are part of a system responding to and managing
the effects of each others’ activities over time (Rydin
et al. 2012). Urban development is ‘the process of
physically producing the built environment, by bring-
ing together multiple actors from construction com-
panies to development financiers to local planners and
others’ (Rydin 2010, p. 15). Development may be large
CONTACT Helen Pineo Helen.pineo@ucl.ac.uk Institute for Environmental Design and Engineering, Bartlett School of Environment, Energy and
Resources, University College London, Central House, 14 Upper Woburn Place, London WC1H 0NN, UK
CITIES & HEALTH
https://doi.org/10.1080/23748834.2021.1876376
© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
or small in scale, including major urban redevelop-
ment projects and incremental improvements to exist-
ing buildings (ibid). Urban development processes are
characterised by a plurality of decisions, stakeholders
and competing priorities that create both challenges
and opportunities for the integration of health and
wellbeing. Urban designers and planners, land owners,
developers, investors, communities and others have
key roles to play in creating healthy places. Scholars
have highlighted the importance of building profes-
sional relationships across sectors (and community
groups) to support collaboration and knowledge shar-
ing for healthy development. This is particularly
important since healthy planning and design are not
typically covered in university curricula for built
environment professionals (Pilkington et al. 2013,
Marsh et al. 2020).
Looking upstream in the development process,
there has been considerable research on the process
of integrating health into urban planning policy, with
some research on implementation. Challenges for
healthy planning policy include: a requirement for
more localised and simplified evidence about environ-
mental health impacts and associated economic argu-
ments, lack of a shared understanding of ‘health’
across policy actors, ‘silo’ working across relevant sec-
tors, conflicting goals across tiers of government and
under-resourcing of delivery mechanisms
(Carmichael et al. 2012, 2019, Fazli et al. 2017, Lowe
et al. 2018, Ige-Elegbede et al. 2020, Pineo et al. 2020).
Implementation of healthy places is hindered by the
perception that healthy places are more expensive to
design, build and maintain. This has been identified as
a key barrier across markets and different types of
development (e.g. residential, mixed use, office)
(Carmichael et al. 2012, Chang 2018, Design Council
2018). The costs and benefits of achieving healthy
development are distributed across a wide range of
actors, with differences in who pays and who benefits,
making it difficult to easily demonstrate the ‘business
case’ (Pineo and Rydin 2018). In many countries, this
financial challenge is related to a reliance on private
sector developers to deliver healthy places within the
margins that can be reasonably expected from such
investments (Rydin, 2013). Developers may argue that
policy requirements tied to permission to build
(including sustainability standards, impact fees/con-
tributions and affordable housing) reduce their ability
to meet additional healthy design objectives. This
challenge has been raised by Carmichael et al. (2020)
as they argue that ‘the existence of sub-standard hous-
ing in England can be seen as a market failure’ that is
driven by ‘the legitimate use of viability assessment
findings by developers to reduce the number of afford-
able homes, quality of the design, or size of the homes
they are required to build’ (p.2). Scholars and profes-
sional bodies have worked with developers and other
actors to quantify the financial value created through
healthy placemaking to counteract the viability chal-
lenge (Kramer et al. 2014, Chang 2018, Carmona
2019).
Whether driven by an urge to bolster an unsuppor-
tive policy landscape or capitalise on a new market,
healthy building rating tools have proliferated in
recent years. Voluntary standards and assessment
tools such as WELL, Fitwel and RESET are influencing
development projects internationally (McArthur and
Powell 2020) and creating a new mark of ‘value’ for
buildings that promote health and wellbeing (Pineo
and Rydin 2018). Sustainability rating tools have been
credited as supporting occupant health (Colton et al.
2014, 2015, MacNaughton et al. 2017). However, they
have also been criticised for being too costly, con-
straining innovation and failing to integrate local con-
text (including social, environmental, and economic
factors) into a one-size-fits-all approach (Ding 2008,
Retzlaff 2009, Boyle et al. 2018). There is a lack of
literature on healthy building rating tools, including
studies of their application and measurable health
impacts after construction. In a paper linked to our
study, Callway et al. (2020) consider the role of such
rating tools in the negotiation of health objectives in
development processes.
Despite a clear international shift in the develop-
ment sector towards healthy design and building,
there is a lack of research about how healthy develop-
ment policies are implemented in practice. There is
a pressing need to understand the ‘jump’ from theory
(i.e. the principles of healthy urbanism) to built envir-
onment professionals’ practice. A theory-practice gap
has been identified and explored in other fields,
including healthcare, where practitioners struggle
with implementing research or theoretical knowledge
in real-world settings (Nilsen 2015, Greenway et al.
2019). Within practice it can be challenging to apply
principles and theories to specific contexts or situa-
tions. Furthermore, there can be discrepancies
between what professionals’ claim underlie their prac-
tices and what implicit understandings and values are
unknowingly embedded in their work. This study aims
to explore how the principles of healthy urbanism are
put into practice through investigating built environ-
ment professionals’ experiences of implementing
health in new urban developments.
This exploratory study is part of a wider collabora-
tive research project with Guy’s and St Thomas’
Charity on integrating health into new development.
In this study we aim to provide insights into the
healthy development process from the perspectives
of experienced professionals working in international
contexts, in Australia, China, England, the
Netherlands, Sweden, and the USA. We explore the
following questions through semi-structured
interviews:
2H. PINEO AND G. MOORE
1) How is healthy urban development conceptualised
and applied in practice by built environment
professionals?
2) Which factors influence or drive the implementa-
tion of health in new urban development?
3) What are the opportunities and barriers for inte-
grating health into new urban development?
Through exploring practitioners’ experiences, this
scoping study contributes to knowledge of how
healthy placemaking can be successfully delivered.
The paper is structured as follows: the next section
briefly outlines the policy and practice context for
healthy urbanism in the study’s geographic areas, fol-
lowed by a description of our methodological
approach. The findings begin with an overview of
participants’ perceptions on the drivers of healthy
development followed by descriptions of the impor-
tant role of developers. We then describe the three
themes that emerged from the thematic analysis:
managing risk, responsibility and economic con-
straints; pushing business-as-usual practices; and
building knowledge and capacity. The discussion sec-
tion considers our findings in the context of wider
literature and considers the strengths and limitations
of the study. Our conclusions outline priority areas for
further research.
Drivers and status of healthy development
internationally
Healthy urbanism is influenced by the agendas of inter-
national organisations, which are diversely interpreted
and applied according to local contexts and priorities.
The World Health Organization (WHO) has supported
healthy built environment efforts, particularly through
its Healthy Cities movement, since the 1980s (Hancock
and Duhl 1986). The social and environmental deter-
minants of health have been integrated with wider
sustainable development priorities through the work
of UN Habitat and others, exemplified by the
Sustainable Development Goals’ explicit links between
health and the environment (UN General Assembly
2015). As argued by Pineo (2020), an important driver
for healthy property development relates to the framing
of health and sustainability as overlapping goals by
industry bodies such as the World Green Building
Council (WGBC 2013, 2014, 2016) and Urban Land
Institute (Kramer et al. 2014, ULI 2015,
Hammerschmidt et al. 2016). This section briefly
describes the policy and practice context for healthy
urbanism in countries explored within this study.
Australia
The healthy built environment agenda in Australia has
progressed through academic and government
activities promoting ‘liveability’ and healthy planning,
particularly in the more populated states of New South
Wales and Victoria. Planners have benefited from
guidance and assessment tools (Lowe et al. 2015,
2018, Paine and Thompson 2017, Kent and
Thompson 2019). Similar to the US and Europe, issues
of health equity are recognised in the Australian
healthy planning literature. McGreevey et al. (2019)
evaluated two planning processes in Adelaide and
found that ‘liveability’ policies (i.e. health-
promoting) could result in further investment in
‘image enhancing parts of the city, not to areas of
social or locational disadvantage’ (p.7), further exacer-
bating existing inequalities. Pineo et al. (2020) found
that implementation of healthy planning policies in
new development near Sydney and Melbourne was
heavily constrained by economic factors and the
requirement for new housing.
China
The Healthy China 2030 strategy (Central Committee
of Chinese Communist Party and State Council 2016)
has been a significant driver for intersectoral action for
health in China, including the development of healthy
buildings (Wang et al. 2020). In response to the gov-
ernment’s health agenda and influence from the
WELL standard, the Chinese Academy of Building
Science published the Assessment Standard for
Healthy Building (T/ASC02-2016) in January 2017,
which defines healthy buildings as those ‘that can
provide healthier environment, facilities and services,
promote users’ physical and mental health, and
achieve the improvement of health performance, on
the basis of fundamental functions’ (ibid). There has
been considerable adoption of the standard, yet some
scholars do not believe it encompasses the right prio-
rities for healthy urban development in China. Hu
(2020) argues that the focus of healthy urban design
should be through the regeneration of existing places,
in the context of demand for more leisure and com-
munity spaces, design for all ages, and healthy indoor
and outdoor environments. However, there is a lack of
theory, standard, technique, and practice of healthy
regeneration in China (ibid). Hu (2020) and Meng
(2017) state that the key priorities for the Chinese
healthy building agenda going forward are developing
a more detailed standard system to guide design and
construction, evaluating performance, and establish-
ing industry networks/communication platforms.
England
The English planning system promotes health in its
strategic National Planning Policy Framework, yet
scholars and practitioners feel that this requirement
has relatively low weight in decision-making
CITIES & HEALTH 3
compared to economic and housing development
goals (McKinnon et al. 2020, Carmichael et al. 2020).
A recent initiative by the National Health Service
highlighted the links between development and health
through ten Healthy New Town demonstrator sites
(NHS England 2019). English practitioners often see
healthy placemaking as being in competition with
other development objectives and too costly to imple-
ment (Design Council 2018), yet there are active prac-
titioner networks and interest among developers
highlighted by the recent work of the Town and
Country Planning Association (Chang 2018). The
TCPA brought together housing developers, public
health teams and others to explore how consensus
and action regarding high-quality healthy develop-
ment could be achieved. Key findings included the
need to fix fundamental ‘flaws’ with the housing mar-
ket, increasing the quality and availability of affordable
homes, engaging early in the development process,
identifying incentives to engage more developers,
finding ways to share risks and rewards, improving
the ‘commercial case’ and increasing the use of health
evidence (ibid).
Sweden and the Netherlands
Cities in Sweden and the Netherlands are often cited
as examples of sustainable and healthy urban form,
particularly with regards to cycling infrastructure
(Creutzig, Mühlhoff, and Römer 2012, Fishman et al.
2015). Recently, scholars have investigated the health
impacts of urban regeneration in the Netherlands, yet
the focus has been predominately on socioeconomic
over environmental improvements (Droomers et al.
2014, 2016, Ruijsbroek et al. 2017). The European
WHO Healthy Cities programme widely promoted
healthy urban planning. Their work has increased:
cross-sectoral health promotion activities; application
of health impact assessments; and leadership support-
ing participatory governance, health equity and
healthy ‘lifestyle programmes’ (de Leeuw et al. 2014,
Grant 2015). Sweden and the Netherlands have policy
initiatives and Healthy Cities networks (although the
Dutch network is not accredited) encouraging healthy
placemaking.
United States
The United States has been a leader in healthy place-
making research and practice, resulting in significant
international influence (see Dannenberg et al. 2011,
Galea et al. 2019). In recent years, professional bodies
and their local chapters have published guidance, case
studies and policy initiatives (e.g. Washington
American Planning Association Game Changing
Initiative Health and Planning Working Group
2016). This knowledge-building activity has coincided
with the development of new healthy building stan-
dards (the WELL Building Standard, Living Building
Challenge and Fitwel) that have subsequently influ-
enced international practice. A recent review of build-
ing standards reports that WELL and Fitwel have been
applied in 51 and 36 countries, respectively (McArthur
and Powell 2020). These standards have ridden a wave
of interest in health, comfort, well-being, and produc-
tivity in buildings across practitioners and scholars,
and they have benefitted from explicit links to the
green building agenda (Allen et al. 2015,
Cedeño-Laurent et al. 2018, Allen and Macomber
2020). Recent research seeks to unpick the health
impact of urban regeneration, with significant focus
on structural inequities linked to the environment (see
Schnake-Mahl et al. 2020).
In summary, the countries covered in this study
have explicit drivers for healthy urban development.
There is variation in their respective areas of focus and
the availability of studies about policy implementa-
tion. This study focuses on professionals’ experiences
of how policy is used to leverage health through pro-
jects across these regions, ranging from single build-
ings to large-scale developments.
Methodology
We aim to understand the integration of health into
new development through an interpretive exploration
of professionals’ experiences and perceptions.
Through adopting a qualitative, interpretative form
of inquiry this study aimed to, as phrased by
Schwandt (1994, p. 118), ‘elucidate the process of
meaning construction and clarify what and how
meanings are embodied in the language and actions
of social actors’. We briefly report our methods for
data collection and analysis below, with further detail
in the supplementary material.
Semi-structured interviews
We conducted semi-structured interviews with 31
professionals. We met 17 participants in Beijing,
China (May 2019); London, England (June/
July 2019); Seattle, USA (August 2019) and spoke
with an additional 14 via Skype (June 2019 to
February 2020 covering participants in Australia,
England, Sweden and the Netherlands). We selected
the geographic regions of China, Australia, Europe
(specifically England, Sweden and the Netherlands)
and the USA for this scoping study because they
have policy drivers for integrating health in new devel-
opment. We conducted this study internationally for
two reasons: 1) the presence of international guidance
documents and standards (e.g. WELL) suggest poten-
tial similarities across contexts; and 2) our research
4H. PINEO AND G. MOORE
partner, Guy’s and St Thomas’ Charity (GSTC),
requested knowledge about international best practice.
As healthy urban development is recognised as
a relatively new area of professional practice (Marsh
et al. 2020), we used purposive and snowball sampling
to recruit participants. We used professional contacts
and LinkedIn to identify participants in the targeted
geographical areas. We corresponded with potential
participants over email to understand their suitability
for the study based on two inclusion criteria for parti-
cipants: 1) they were either a built environment or
public health professional and 2) they had experience
of working on new developments which have inte-
grated health and wellbeing. Sixty-two potential parti-
cipants were invited to take part, and 31 accepted,
a response rate of 50%. Within the sampling process
we repeatedly assessed the balance of participants over
different geographic areas. The supplementary mate-
rial provides further details about our process for
ethics, transcription, translation, and participant
recruitment.
Participants’ professional roles
Table 1 summarises the geographical distribution of
participants, alongside their organisation type and
profession. Participants worked primarily in the built
environment (27/31). Their work was often domestic
in their country of employment, though some worked
internationally. In the supplementary material we pro-
vide data about participants sector of employment and
demographic information.
Analysis framework
We analysed the data in Nvivo qualitative data analysis
software (QSR International Pty Ltd., version 12.6.0,
2019) using thematic analysis (Braun and Clarke 2006,
Nowell et al. 2017). We used deductive and inductive
coding (Fereday and Muir-Cochrane 2006). Our pre-
defined codebook was based on our research questions
and conceptual approach to the study (see supplemen-
tary material). Both researchers read all transcripts
and we coded the data twice (once each, using the
same Nvivo file) and inductively derived categories
and codes were added in both stages. The data were
grouped into overarching themes through an iterative
process involving regular reflection between research-
ers regarding the interpretation of the data.
The interview guide and thematic analysis were
informed by systems thinking (Meadows 2008) in
recognition of the complexity of healthy built envir-
onments and the process of new development (Pineo
et al. 2020). Although we were interested in the chal-
lenges and opportunities for implementing healthy
development, these classifications can be overly reduc-
tionist and may miss the important interconnections
that are visible through a systems thinking lens (Nilsen
2015). In the interviews we asked multiple questions to
understand drivers, conflicts or complementary agen-
das, challenges and opportunities. We inductively
coded under these topics as categories or codes and
then looked for causal relations between codes (the
final codebook is reported in the supplementary mate-
rial). Rather than undertake a comparative analysis
examining the differences across geographic condi-
tions, we focused on exploring the similarties in
experiences across contexts.
Results
This section begins by setting the context for the find-
ings with participants’ perceptions on the drivers of
healthy development. Then we report the key role of
Table 1. Interview participants (n = 31) by country, organisa-
tion and profession.
Geographic area
(participants) Organisation type Profession
No. of par-
ticipants
Australia (6) Planning
commission
Planning 1
Planning
consultancy
Planning 1
Architecture and
design practice
Architecture 1
Public health
department
Public health 3
China (7) Engineering
consultancy
Sustainability and
engineering
2
Engineering
consultancy
Landscape
Architecture
1
Architecture and
design practice
Urban design and
planning
2
Building standard
organisation
Project
management
1
Building standard
organisation
Architecture 1
England (7) Engineering
consultancy
Sustainability and
engineering
1
Architecture and
design practice
Project
management
1
Architecture and
design practice
Sustainability 3
Housing
association
Research 1
Public health
department
Public Health 1
Netherlands (1) Engineering
consultancy
Indoor
Environmental
Engineering
1
Sweden (2) Architecture and
design practice
Architecture 1
Real estate
developer
Property
Development
1
USA (8) Engineering
consultancy
Sustainability 1
Architecture and
design practice
Urban design (and
planning)
2
Architecture and
design practice
Sustainability 1
Architecture and
design practice
Architecture 1
Building
permitting
department
Planning 1
Planning
department
Planning 1
Building standard
organisation
Urban design and
planning
1
CITIES & HEALTH 5
developers through a general classification based on
their respective goals from development, as described
by participants. This is followed by a description of the
three themes that emerged from the thematic analysis:
managing risk, responsibility and economic con-
straints; pushing business-as-usual practices; and
building knowledge and capacity.
Drivers of healthy building
The drivers for integrating health as a more explicit
objective in development projects were described as
emerging from regulations, standards, client briefs,
government initiatives and changing public aware-
ness. Some participants noted a shift in wider concep-
tualisations of health in their society. A Chinese
participant said that ‘people start to think healthy
means healthy taste, healthy living, quality’. A similar
view was evident in London where a sustainability and
engineering consultant said: ‘ . . . it just feels like every-
one is very aware of issues around, not just inside
buildings, but air quality and stu’. There was
a perception that the office sector in particular is
shifting toward attention to health, wellbeing and pro-
ductivity (described under ‘Evidence of added value’).
Health and sustainability were explicitly linked by
most participants, both when prompted and
unprompted. An American urban designer said ‘my
take on healthy communities is an evolved version of
sustainability’. Participants in all settings described
health and sustainability as two overlapping objectives
that are ‘intertwined’, ‘almost the same’, ‘very comple-
mentary’, and ‘a very natural pairing’. However, some
tensions were raised. An architect in China responded
to our question about the relations between sustain-
ability and health by exclaiming ‘You’ve just hit
Pandora’s box’, in relation to the energy costs of better
indoor air quality. In summary, participants had
a broad view of the drivers for health in development,
covering regulation, client briefs, public awareness
and the link to the sustainability agenda.
Classication of outcome- and output-driven
developers
Participants had common ways of explaining develo-
per’s willingness, or lack thereof, to pursue health and
wellbeing outcomes through design, from which we
derived a general classification of developers.
Perceived differences among developers were not
solely attributed to their sector (e.g. private or public)
and common descriptions persisted across interview
contexts. Table 2 outlines our classification of organi-
sations leading new development, with those who are
more willing to take a healthy design approach
described as outcome-driven and those who are not
described as output-driven. Each of these general
classifications is illustrated with participants’ quotes
below. We adopted the terms outcome and output
based on Weiss (1998). Outcomes describe longer-
term goals and societal impacts (e.g. supporting local
economies, sustainability and health). Outputs
describe shorter-term goals and impacts (e.g. property
sales values and ease of leasing property).
Outcome-driven developers were described as tak-
ing a ‘long-term’ interest in the development.
Organisations that looked after their interests (i.e.
assets and reputation) over time included real estate
owner/occupiers, universities, housing associations,
government-owned developers and ‘legacy land-
owners’. A project manager in London explained
how the type of developer influenced what could be
achieved on the project. Their client was an owner/
occupier (called a Real Estate Investment Trust) so
they were ‘pushing against an open door’. Usually
developers would ‘build and then sell it, having added
value’ but their client was interesting in learning from
occupants, resulting in ‘the next building they develop,
being improved by feedback from them, so it’s in their
interests to make buildings better’.
Another feature of outcome-driven developers is an
organisational ethos, described as ‘values based’, ‘mis-
sion driven’ or ‘enlightened’. These terms were some-
times used to characterise commercial developers. In
one case, the investors’ values and dedication to the
community were seen to strongly influence a large-
scale mixed-use project in the USA: ‘ . . . the goals that
they gave us [were] to create the most sustainable design
you possibly can, but build houses that are aordable to
a broad range of people . . . that is not generally the type
of investor that developers get to work with . . . ’.
In contrast, the output-driven description typically
related to ‘commercial’ or ‘private’ developers who
were primarily focused on the financial ‘bottom line’,
with little regard for the long-term impact of their
projects. One quotation contrasts these two classifica-
tions clearly:
“ . . . the education sector tend to be long-term owner/
occupiers which is quite an important consideration,
Table 2. Characteristics of outcome- and output-driven
developers.
Outcome-driven developers Output-driven developers
Longer-term goals and interests Shorter-term goals and interests
Broader, interconnected impacts Narrower, focused impacts
Focus on finances Focus on finances
Interests in societal impacts e.g.
supporting local economies,
sustainability and health
Interests in economic impacts as
property sales value, ease of
leasing property
Go beyond regulations Meet regulations
Pilot, experiment Follow known practice
6H. PINEO AND G. MOORE
I think, when you’ve got big, commercial developer
landlords just building and ipping buildings.
Arguably, they’re less interested in the longevity of the
people that are in it” (sustainability consultant,
London).
This short-term focus was perceived by some partici-
pants as a systemic failure rather than a vilification of
certain property developers, as the same consultant
explained: ‘ . . . fair enough, they’re businessmen.
That’s what happens when you’ve got a housebuilding
industry and on large scale, that has been set up to
make money . . . ’. Notably, both outcome- and output-
driven developers were focused on finances. There was
a perception that outcome-driven developers ‘want
everything’ (e.g. homes that support health, sustain-
ability, etc.) and ‘they’ll want to sell them for a good
price’, yet their outlook towards these goals means that
health-promoting design is more likely to be inte-
grated, within financial limits. The next three sections
describe the themes that emerged through our the-
matic analysis.
Managing risk, responsibility and economic
constraints
There were financial, professional and reputational
risks that influenced how health could be promoted
at different stages of urban development. Many of
these perceived risks rested with the developer.
Participants noted that making claims that a project
would be ‘healthy’ or would adhere to a particular
healthy building standard introduced additional risks
than would otherwise be present. These risks related to
a perceived lack of control about the measurable or
perceived health impacts of development, sometimes
due to the performance gap between design and
occupation.
Risk of failure
Developers are aware of the risk of not producing
a healthy development, if they pledge to do so in pre-
construction phases. In one case, an English housing
association representative explained how negative out-
comes on a particular project increased the organisa-
tion’s perception of risk associated with publicly
aiming for healthy development:
“Health, I think because you don’t have direct control
over it . . . (. . .) we get all ambitious about it and then
we get part way through a process and we sort of go,
‘oh, we haven’t made the impact’ and that’s really quite
hard and I think that’s quite a big risk . . . ”.
The difference between the intended and actual
performance of a building or place (i.e. performance
gap) was frequently described as a risk. Participants
noted that healthy building standards (primarily
WELL) require many verifications (e.g. air quality)
when the building is occupied. This results in risks
for design teams, developers, landlords and tenants,
with no single party being in full control of the
outcome. Such standards also require that informa-
tion is shared between actors that was previously
not transparent, again contributing to perceived
risk. An American sustainability consultant
explained difficulty finding a new office space that
would meet WELL: ‘ . . . there were many landlords
that just told us, “we’re not doing that, we’re not
going to monitor and share information, that’s none
of your business.” There’s a lot of that attitude out in
the market place . . . ’. The landlord and tenant had
to form a ‘partnership’ and agree to take on risk
together; both parties were mutually dependent to
achieve and maintain the certification status.
In other contexts, standards were seen to de-risk
healthy building processes because the responsibility
can be shifted to the standard itself (i.e. for both
success or lack thereof) and because such standards
require post-occupancy verification. An engineer in
the Netherlands explained their national challenge
with the performance gap stating that they ‘never
verified if those requirements were met and even if
they did, they had no way to get the contractor to
improve the building to meet those requirements’. The
benefit of the WELL standard was described as its
explicit requirement for performance verification.
This example also exposes that the responsibility for
performance in a new building is not fully resolved
and actors are likely to resist exposing failures.
Economic risks
A primary risk (perceived and actual) associated with
healthy urban design relates to the cost of going beyond
business-as-usual. Participants explained that significant
perceived risk is introduced with the objective to achieve
healthy development through increased, and largely
unknown, costs associated with design team knowledge
gaps, expensive materials or technical systems, certifica-
tion, community participation, maintenance and more.
Because health is seen as a relatively new design goal,
these costs are currently high. Furthermore, there is
a lack of data about whether healthy buildings can
achieve a higher value for commercial developers.
Several interview participants noted that cost-
related risks will continue to drop over time as the
supply chain (and potentially the public) respond to
the healthy building agenda. An architect in China
explained how this occurred on the RESET healthy
building standard. Certification was ‘very expensive’
initially and limited to ‘luxury projects up until 2012’.
Over time, some of the technical ‘solutions have been
commercialised and prices have just plummeted’ result-
ing in expansion of the standard to different develop-
ment types and locations. Notably, the economic
constraints and risks associated with healthy
CITIES & HEALTH 7
development may be dampened for developers classed
as outcome-driven, for example if they retain proper-
ties and measure their return on investment over
many years.
Taking risks: pilot projects
A key opportunity to overcome the perceived risks
and typical economic constraints of new development
was through a ‘pilot’ or demonstration project. Such
projects were used to explore innovative practices
without necessarily promising success. If projects are
shown to be successful over time and for different
objectives (e.g. environmental performance or cost),
they become a ‘template’ for further work.
A Seattle-based architect described pilot projects
as a means to de-risk the process for the public
sector and allow an innovative ‘biologically based,
waste water treatment system’ to be adopted. The
project was not compliant with local regulations so
‘we called it an “experimental system” which then
provided cover for everybody to monitor extremely
carefully, but to allow [it] to proceed and then prove
itself . . . ’. Pilot projects were described in other
settings as a means to try new design approaches,
demonstrate viability and build client demand. In
a similar vein, two participants described the last
recession as providing an opportunity for the pro-
ject teams to try innovative approaches.
This section has described the perceived risks asso-
ciated with healthy design and building practices for
different actors. Challenges associated with increased
costs and potential for failure were offset through the
use of standards and pilot projects. However, standards
created their own challenges by increasing transpar-
ency about building performance, thereby potentially
increasing risk and responsibility for some parties.
Pushing business-as-usual practices
There was a clear perception that not all developers
were willing to consider health objectives in their
projects. Participants in public sector roles noted that
without supportive policies in place, ‘we beg, we plead’,
to negotiate for amenities and health-promoting
design. To move beyond requirements in regulations
and planning policy (described here as ‘business-as-
usual’ or ‘standard’ practice), participants described
building a business case, advocacy, collaboration and
early engagement on projects.
Evidence of added value
Developers were frequently described as needing to be
convinced of the added value of healthy developments,
using ‘data’ and ‘evidence’ about health improvements
or financial benefits from other projects. Participants
noted that this evidence was not always available and
therefore building a ‘business case’ was difficult. An
American sustainability consultant explained the chal-
lenge of convincing developers of integrating healthy
design strategies, either for a specific standard (in this
case it was WELL) or more broadly:
“The problem is the price point. No developer is going
to pay . . . (. . .) we’re still arguing the value of LEED
certification, even though we can easily demonstrate
how it pays for itself. (. . .) With health and wellness, it’s
a harder sell because we don’t know if these good ideas
will truly make us healthier or not because there’s no
real good way to measure it”.
Evidence was seen as important to drive the design
process, particularly because health and wellbeing was
a relatively new design objective and architects had
been relying on ‘intuitive’ knowledge. An American
architect said ‘ . . . I would say, we’re in the precau-
tionary period, as opposed to having the data to prove
that the things we think we’re doing actually are right . .
. .’. Similarly, an Australian architect said: ‘ . . . we
haven’t quite gotten to the point where we can put
some data up and put some numbers against it and
actually say to people, “this is a good thing because this,
this and this”’. These excerpts show design profes-
sionals’ interest in measuring the outcomes of their
work, because the data about impact becomes part of
the business case to inform future projects.
The kind of evidence that could be used to build
a case for healthy design was not only from project
monitoring, but also from health impact assessment.
An American urban designer and planner noted that
evidence about local health and built environment-
related challenges helped their team to negotiate with
the city for specific adjustments to local policy to
support health outcomes in a large new community:
‘ . . . by taking this health approach, what we were able
to do was to have some data and evidence to build the
case for why certain interventions were important’.
There was an indication from some participants of
a recent shift in developers’ conceptualisations of eco-
nomic value, from short-term costs to long-term gains,
thereby affecting how design teams can make a business
case. A sustainability consultant in London said:
“It just fundamentally boils down to what is, in essence,
a business case. It’s, ‘alright, we’re happy to spend the
money, but what value does it deliver?’ I think there
is . . . maybe not a macro shift, but certainly, more than
a micro shift in . . . it certainly seems like people are
starting to consider, more comprehensively, whole life
cost, return on investments, pay back, all those sorts of
things . . . ”.
This shift in attention to wider values was linked to
other participants’ descriptions of changing demands
from office space tenants in particular (tenants who
are competing for highly educated and ‘talented’ staff).
This has resulted in greater focus on the perceived
quality of space and its actual impact on staff, includ-
ing metrics such as stress and productivity.
8H. PINEO AND G. MOORE
Ways of working: advocacy and negotiation
Negotiation, ‘advocacy’ and ‘leadership’ were described
as ways to mobilise actions towards healthy urbanism.
Participants talked about bringing together stake-
holders’ diverse agendas and goals, recognising the
importance of the social aspects of healthy placemak-
ing. One sustainability consultant explained that ‘ . . .
the barriers are not technical’ and instead ‘it’s all sta-
keholder oriented, it’s all political. . . . it involves com-
pensation and money and ego and huge institutions
and organisations that are not easy to penetrate or to
change . . . ’.
Participants spoke of discussing, persuading, nego-
tiating, and influencing to bring forward specific
healthy design measures. An American planner said
‘ . . . it’s all about telling a story in a vision that really
does spark change’. It was seen as valuable to have
multiple parties from different sectors communicating
the same message: ‘it’s tough going if you’re the lone
voice’. Advocates or ‘champions’ were seen as impor-
tant to set out and maintain the level of ambition, with
one English housing association participant remarking
that a project champion needed to ‘fight his corner’. On
one large-scale English development, a local GP (out-
side of the project team) was an ‘absolutely critical
person’ in ‘justifying’ the case for healthy design mea-
sures and working across local stakeholders to move
the project forward.
Practices of collaboration and communication
Collaboration and sharing knowledge between parties
were key tools for those working within the field of
healthy urban development. Collaboration supports
information sharing, the generation of new insights,
and the broadening of networks. Communicating
a healthier living approach was seen as a ‘powerful’
message that ‘ . . . helped us prioritise what strategies
were hitting on multiple benefits or goals’. Adopting
healthy building standards helped an architect in
Sweden to work across disciplines: ‘it actually knits
together the people that are working with health and
wellbeing and all of these experts because we’re having
more profound discussions’. In other cases, the goal of
collaboration was to open up design and decision-
making to a wider range of voices, which some parti-
cipants reflected as being a difficult process.
An American urban designer described a university
campus design project that sought to bring in stu-
dents’ voices, particularly regarding race and other
under-represented groups in the design process. The
client wanted to know ‘if there was racial bias in the
design of their spaces’. This was seen as a new concern:
‘it really has been the first time an institution wanted to
see how the school’s design . . . just didn’t create a sense
of comfort or wellness for many students’. A series of
meetings were organised to speak with under-
represented groups on the campus, including those
related to race, sexual orientation, disability and mili-
tary service. The design team was surprised by the
findings. They thought that ‘the older buildings on
campus would be unwelcoming, they would appear
too neo-classical or they would just look like white
spaces, from euro-centric design bias’. In fact, the meet-
ings showed that in those spaces students ‘felt cosy,
they felt warm, they felt like they were designed for
students’. Instead it was the new buildings that were
problematic; they ‘felt really cheap’ and there were ‘too
many transparent spaces, not enough spaces to hide or
feel comfortable’. The designer said the students’ aver-
sion to transparent spaces was about wanting to ‘feel
like it’s our own, cosy space’. One student mentioned
the risk of active shooters and the designer noted that
‘the idea of safety and security is much higher’ than the
design team had understood. This discussion high-
lighted the importance of participatory processes to
raise under-represented voices in healthy design
processes.
Early engagement
Early discussion of health-related objectives was
important to ensure achievement of those goals within
a development. Likewise, early engagement with end-
users, typically over a client brief, was a strategy to
understand their requirements and have time to
respond. An Australian planner said ‘we were fortu-
nate to be in the early stages with the client and so we
were able to encourage him to include those features’. In
that case, the features related to landscaping, shade
structures and solar panels. The developer was initially
concerned about cost implications but the planners
were able to frame that cost as having wider value:
‘they could use this as a marketing tool’.
This section has described the multiple strategies
that can be used to push for better practice than busi-
ness-as-usual development. Design teams and consul-
tants frequently had to make a business case for
healthy design measures using evidence and data
from monitoring, health impact assessment or scien-
tific studies. Advocates helped to ensure that commit-
ments were made and retained throughout a project.
Collaboration and communication across project
partners and sectors helped to make a business case,
but could also produce challenges to the design pro-
cess. Finally, early engagement in the design and plan-
ning process was important to influence the
integration of health measures.
Building knowledge and capacity
The final theme relates to the built environment sec-
tor’s current ability to integrate health into new devel-
opment. There were conflicting views whereby some
participants highlighted knowledge gaps and others
focused on what is already known. Capacity refers to
CITIES & HEALTH 9
a broad set of factors, including the availability of non-
toxic building materials, time to engage all actors and
permission from decision-makers.
Lack of public awareness
Public awareness about buildings and health was viewed
as low (although possibly increasing), across all regions.
Participants noted that low public awareness reduced
demand for healthy buildings, at least in the residential
sector, but possibly more widely due to the potential
political or market pressure that could result from public
awareness. An English sustainability consultant said: ‘ . . .
why would an end user know about their indoor air
quality or pollutants . . . I guess [developers are] betting
on that not being on people’s agenda when they’re buying
a new house . . . ’. Similarly, a Chinese sustainability and
engineering consultant felt that low public awareness
affected the business case for healthy development: ‘ . . .
a lot of building users they don’t know how many cate-
gories are related to their health . . . If they didn’t have
awareness they would not seek for the oce or residential
with this kind of a good design.’ Some participants felt
that organisations producing building standards should
try to increase public knowledge to shift demand.
Knowledge among professionals
Despite recognising some gaps in the scientific evi-
dence base about health and the built environment,
participants generally said that there was enough
knowledge to act now. However, not all participants
reflected this view. For example, an American sustain-
ability consultant noted that knowledge of toxins in
building materials was low in the sector: ‘ . . . you have
to have a PhD in chemistry to understand what’s in
those . . . ’. Furthermore, such knowledge requirements
were constantly shifting ‘as one substance gets elimi-
nated . . . then another substance takes its place . . . ’.
A Swedish property developer explained knowledge
gaps among real estate managers and others, citing
a need to fix this through communication: ‘ . . . you
have to try to get it out, so all the consultants, the
architects, the constructors, even the tenants, get the
knowledge, so it’s a lot of hard work . . . ’.
Participants valued different forms of knowledge,
not just evidence and research, but also relying on tacit
knowledge from experience and ‘intuition’. For exam-
ple, an Australian architect described their personal
reflections, ‘making sure that each step, each building
that we do is better than the last one’. To achieve this,
the architect built knowledge from their experience
over time by ‘writing these principles down and saying,
“what is a non-negotiable in [one of our buildings]?”
and learning from each one’.
Potential knowledge gaps were downplayed by
some participants, particularly when compared to
financial barriers. An American sustainability consul-
tant said: ‘We can design and build healthy all day long,
it’s not that dicult, if the client’s willing to do it and
they want to spend the money, we have the expertise, it’s
not rocket science’. However, it was not only technical
knowledge that was seen as necessary, but also knowl-
edge on ways of engaging and encouraging participa-
tion in design, as described in the university campus
project above.
Increasing capacity in the sector
Professional bodies and informal networks were
described as key factors for sharing good practice
and building capacity in the sector. A range of profes-
sionals were involved in knowledge production, vali-
dation, legitimisation and dissemination. A planner in
Australia described how a small group of interested
professionals and academics (in the Premier’s Council
for Active Living) were drivers of the healthy place-
making agenda in Sydney and elsewhere in New South
Wales. Through their ‘communication’ and ‘co-
ordination’ they brought ‘dierent government depart-
ments together’ to make things happen. They also used
‘demonstration projects’ for building capacity as they
‘educate people and then sharing the learnings and
having it infiltrate across dierent skill sets . . . ’.
In summary, many participants emphasised that
healthy buildings and development are an emerging
field that provides opportunities for different forms of
knowledge, innovative ways of learning, and new ways
of sharing learning. Whilst some professionals identi-
fied specific knowledge gaps (e.g. toxins in building
materials), others felt that the sector knows how to
design healthy places, pinning finances as the key bar-
rier to progress. Some participants highlighted the
importance of gathering knowledge held by future
building or neighbourhood occupants/residents to
ensure that health is integrated into projects. Finally,
informal and formal networks were described in several
settings to fill gaps in professional knowledge, including
through the use of demonstrator/pilot projects.
Discussion
This exploratory study has contributed insights into
built environment professionals’ experiences of imple-
menting healthy urban development. We have pro-
vided a more nuanced understanding of developers’
roles in this process of change, exploring how their
diverse goals and risks must be accounted for when
attempting to persuade them to adopt healthy design
measures. Our research has also highlighted specific
strategies to push beyond business-as-usual practices,
through: the creation of data about health impacts (and
increased value) to build a business case; adopting pilot
projects and healthy building standards; using cham-
pions within or outside the project team, engaging early
in the design process; and increasing public awareness
and professional knowledge through communication.
10 H. PINEO AND G. MOORE
In this section, we consider our findings in relation to
existing research and theory. First we describe the
strengths and limitations of our approach. Then we
discuss potential mechanisms to manage developers’
risks, including networks and standards. We then con-
sider the potential impact of Covid-19 on our findings
related to public and professional awareness of healthy
places. Finally, we consider the importance of reflective
practice and diverse knowledge types from a multi-level
learning perspective.
This study adopted semi-structured interviews to
explore professionals’ experiences of integrating health
into new development across six countries. The credibil-
ity of the study is reinforced by the confirmation of some
of our findings in scholarly and professional literature.
For example, supporting innovation in sustainable design
and construction has been achieved through champions,
pilot projects and early engagement in the design process
(Mills and Glass 2009, Chang 2018, Martiskainen and
Kivimaa 2018). We have provided several detailed
accounts from the interviews, and highlighted common-
alities across geographies, to increase the transferability of
findings. However there are limitations with this study.
Our purposive and snowball sampling approach is not
a representative sample, although we believe this strategy
was appropriate for the area of enquiry. We acknowledge
that participant numbers per country are limited, thus it
was not possible to look in depth at single areas or to
conduct a comparative analysis. The international sample
meant that the analysis did not include extensive reviews
of local policy and market contexts, which limits the
depth of analysis and interpretation. In countries where
participants spoke English as a second language, under-
standing of questions and responses may have been
reduced for both participants and researchers. The litera-
ture review in China, Sweden and the Netherlands was
also limited by publications that were available in English
(although we were able to translate some key Chinese
literature). In using video-conferencing for interviews we
were able to invite participants from a range of geogra-
phical regions, but a key drawback was the difficulty in
building rapport and noticing non-verbal cues (Lo
Iacono et al. 2016). Given the limitations of this explora-
tory research, we focused our analysis on commonalities
across contexts and we draw out priority areas for further
research below. We acknowledge that this research is
a starting point in an under-researched area.
Our study revealed the key role of developers in the
integration of health in developments. Developers’
financial and reputational risks must be understood
and managed to achieve healthy development. Ways
to manage developers’ risks were described through
pilot projects and using healthy building standards.
Managing their perceptions of risk may be more chal-
lenging and relates to making a business case that the
value created through the development will offset the
costs. Both ‘value’ and ‘cost’ are diversely interpreted
by the stakeholders involved in healthy placemaking
and our general classification of developers highlights
how a business case could respond to some of these
different perspectives. Carmona (2019) provides evi-
dence that high-quality development creates value for
health, social, economic and environmental outcomes.
Yet, Henneberry et al. (2011) argue that market struc-
tures prevent developers from accounting for these
wider economic costs and benefits in their financial
viability calculations. The distributed value of high-
quality developments, in terms of health benefits
alone, does not offset the costs for developers, creating
a real challenge for implementation (Pineo and Rydin
2018). There is an unresolved question as to whether
professionals can ‘convince private sector developers’,
as Carmichael et al. (2019) argue is needed, with
arguments about wider value. This points to inherent
power differentials between developers and other sta-
keholders, but also a need to pragmatically evaluate
the mechanisms that could change the viability equa-
tion for developers.
New incentives in the form of voluntary healthy build-
ing standards may shift the market, yet our research
indicates that other incentives may be needed. Rydin
(2010) describes incentives as mechanisms to change
power dynamics and ‘alter the underlying frameworks
setting the costs and benefits of decision making’ (p.58),
including taxation, subsidies, transfer of landownership,
and collaborative action through networks and partner-
ships. Participants did not describe examples of such
financial incentives, yet we are aware of some examples,
such as Fannie Mae’s Healthy Housing Rewards pro-
gramme (Center for Active Design n.d.). Similar
approaches could be identified and explored to under-
stand their value to developers. Interview participants did
describe both informal and formal networks in Australia,
England and the USA that helped build capacity for
healthy urban development. The existing literature on
planning healthy built environments supports the impor-
tance of building cross-sectoral relationships to support
collaboration and knowledge sharing over time
(Carmichael et al. 2012, 2019, Lowe et al. 2018, Pineo
et al. 2020). A recommendation for practice would be to
strengthen these networks. The potential for further taxa-
tion, subsidies or incentives for healthy building is an area
for further exploration in practice and research.
There was a perception that no matter how strong
a business case can be made, some developers will not
produce healthy development unless it is a legal require-
ment. It is unclear whether the Covid-19 pandemic
(which occurred after our data collection) could shift
the political acceptability of legal requirements for
healthy development. The pandemic could have multiple
effects on the healthy building agenda. It may shift focus
to infectious disease prevention, which could have unin-
tended consequences in excess energy consumption in
building ventilation systems, ultimately harming humans
CITIES & HEALTH 11
through planetary and ecosystem health systems (Pineo
2020). Covid-19 may increase public awareness about
health and place, yet this requires further exploration.
Interview participants called for more evidence that ties
specific design interventions to health and wellbeing out-
comes; however, it is unclear which parts of the evidence
base need strengthening. Perhaps the greater challenge
(that was raised by participants) is in communicating the
evidence to increase general awareness, shifting the
incentives for action. This is not a likely task for the
research community alone, but perhaps one that can be
taken up with diverse professional bodies using new
communication techniques such as the ‘evidence-based
framing strategies’ produced by Moyer et al. (2019).
Finally, we note that in practicing healthy place-
making, evaluative and critical reflection is an instru-
ment for progress in order to build capacity and
knowledge in the sector. Healthy development is an
iterative process in which participants attempt to
solve a problem, create a solution, critique that solu-
tion, and then take forward that knowledge in future
practice. The interviews revealed plural and varied
ways of learning, that seemed to respond to the
‘knowledge gap’, resulting in reflective practice.
Models of multi-level, multi-loop and double-loop
learning may describe this practice, drawing on sys-
tems thinking (Argyris and Schön 1974, Meadows
2008). In these models of learning, a person draws
upon information in their environment (feedback) to
modify their mental model of cause and effect rela-
tions in a particular system, and they use that altered
model to shift decision-making in light of experience.
Collaborative and shared knowledge can also be
used to achieve such reflective practice (Diduck
2010). Gathering diverse types of knowledge is a
recognised strategy to deal with the complexity and
contested nature of development (Innes and Booher
2010) and the complexity of urban health challenges
(Gatzweiler et al. 2018). Interaction with future
building and neighbourhood occupants was not
a widely discussed way to gather knowledge in the
interviews, and this could be a recommendation for
further improvement in practice.
Conclusion
This exploratory study has contributed insights into
potential approaches for integrating health into new
development and priority areas for further research.
The following conclusions focus on next steps for
research and practice:
●Research about creating healthy places has primarily
focused on planning policy, yet other stages of urban
development are key to successfully negotiate and
integrate health objectives. Future studies should
explore implementation through the motivations
and capabilities of different actors (particularly
developers) in specific policy contexts and the role
of development financing.
●Further research in specific policy contexts could
explore the potential for financial or other incen-
tives to improve healthy development and stake-
holders reaction to different approaches. This
relates to our finding that developing a business
case is an important step to convince developers
to incorporate healthy design measures, because
the financial argument depends on local policy
requirements, land values and other context-
specific factors.
●The potential to build knowledge and capacity
in the sector is key. There are similarities
between the sustainable and healthy property
agendas, not least because participants saw
their respective goals as overlapping, but also
because both agendas are seen as trends that
require new knowledge, technology and ways
of working. It may be helpful to increase sharing
of knowledge and lessons for successful imple-
mentation of sustainability and health objec-
tives, including through Environmental, Social,
and Corporate Governance (ESG) processes.
●In relation to building knowledge and capacity
within professional communities, we found evi-
dence of evaluative and reflective practices, wider
than building performance evaluation, that could be
further explored and exploited to integrate health.
●There is a need to understand why professionals
do not feel that the existing evidence base sup-
ports their design decision-making, and whether
monitoring in specific developments could over-
come this challenge.
Acknowledgments
We would like to thank interview participants for their
valuable time and knowledge. We thank Yuhong Wang for
reviewing Chinese literature.
Data availability statement
Due to the nature of this research, participants of this study
did not agree for their data to be shared publicly, so sup-
porting data are not available.
Disclosure statement
The authors declare that they have no conflicts of interest.
Funding
This research was supported by funding from Guy’s and St
Thomas’ Charity and the Complex Urban Systems for
Sustainability and Health project (Wellcome Trust grant
209387/Z/17/Z).
12 H. PINEO AND G. MOORE
Notes on contributors
Helen Pineo is a Lecturer in Sustainable & Healthy Built
Environments in the Bartlett Faculty of the Built
Environment at University College London (UCL). Prior
to 2018 she was a practicing urban planner (MRTPI) inte-
grating health and sustainability into new developments and
planning policy, in the UK and internationally. Her research
and practice has focused on the topics of sustainable urba-
nisation, health, equity and climate change.
Gemma Moore is an environmental geographer, her
research interests focus upon knowledge production, parti-
cipation, community engagement and social sustainability,
particularly understanding the relationships between peo-
ple, their local environment and decision-making processes.
She completed her PhD at the UCL: she used an action
research approach to examine participatory processes in
regeneration projects, to build ‘sustainable urban commu-
nities’. She has significant experience of working on activ-
ities that bridge research, evaluation and community
engagement.
ORCID
Helen Pineo http://orcid.org/0000-0003-1029-3022
Gemma Moore http://orcid.org/0000-0001-8175-4645
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