The challenge of planning for healthier urban environments

Growing inequalities, strained infrastructure, the housing crisis, unhealthy lifestyles and extreme heat are just some of the major health challenges in planning for urban spaces, according to papers from a special issue of Public Health Research & Practice focused on urban planning and development for health.

The Sax Institute sat down with the issue’s Guest Editors, Professor Jason Prior and Dr Edgar Liu – both of the Institute for Sustainable Futures at the University of Technology Sydney – for a wide-ranging discussion on the challenges in planning for healthier urban environments and how the papers in the current issue of PHRP are addressing them.

Why has health emerged as an important focus in urban planning in recent years?

jason prior
Professor Jason Prior, Institute for Sustainable Futures at the University of Technology Sydney

Jason Prior: Public health and urban planning have always been entwined. They developed together in the nineteenth century, with a shared focus on urban sanitation, and they used infrastructure and physical urban form to address overcrowding and unsanitary conditions. In the early twentieth century, planners introduced zoning, which is the segregation of land uses, e.g. factories from homes, and regulated development to help improve public health.

Since the turn of the 21st century, there has been a rekindling of the relationship between public health and urban planning. This was triggered by an increased recognition and awareness of the diverse social, economic, cultural, and environmental determinants of health – urban planning has become increasingly understood as a determinant of health, and the planning and design of our cities have become recognised as a key avenue for promoting public health. In the NSW context, we saw this new approach in the publication of the Health Urban Development Checklist by NSW Health in 2007, which I was involved in developing, and which was intended to help public health and urban planning professionals understand how participation in urban planning processes can promote public health. The original checklist I worked on was revised by others in 2020, and is now called the Healthy Built Environment checklist.   

What are we concretely talking about when we consider planning for healthier urban environments?

Edgar Liu
Dr Edgar Liu, Institute for Sustainable Futures at the University of Technology Sydney

Jason Prior: Most Australian and world populations now live in urban environments; they have become our dominant habitat and, as such, they can have a significant impact on our health and wellbeing.

Unplanned urban development runs the risk of amplifying the way in which our cities adversely impact human health and wellbeing, while at the same time amplifying environmental degradation, climate change, and competition for scarce resources, which deplete the environmental services – fresh air, clean water, food and moderate temperatures – on which our lives depend. A participatory system mapping paper by preventive health and urban planning experts within the special issue provides a useful map of the complex ways in which urban environments adversely impact population health and where best to prioritise interventions.

There is a growing body of evidence on how different aspects of urban environments – whether it be their density, street layout and connectivity, their walkability, accessibility to green and blue spaces, a person’s proximity and accessibility to fresh food, employment opportunities, facilities and services, provision of adequate and affordable housing, and level of pollution and contamination in their air, soil and water – have impacts on the physical and mental health and wellbeing of their population.  

At the same time, there is growing evidence that urban areas, which only account for a small percentage of the earth’s land area, have high levels of greenhouse gas emissions that amplify climate change; that urban populations are increasingly being exposed to dangerously high temperatures due to climate change and the urban heat island effect; and also that they are disproportionally exposed to extreme weather events, such as flooding, that accompany climate change.

Urban planning is a powerful determinant of health that we can harness to provide solutions that enhance wellbeing and deliver improved physical and mental health for all, together with respect for the natural systems on which our health depends. Some examples of this are in the following:

  • Green spaces and blue spaces in cities, such as parks and biodiversity corridors, can deliver services such as reducing air pollution, temperature regulation, and provide people with opportunities for physical activity and recreation—all contributing to the physical and mental health of their populations.
  • Well-connected and tree-lined street systems, with accessible public transport, cycle and pedestrian networks, that allow people to be in walking distance to services and fresh food outlets, encourage healthy activity, a safer environment, reduced car reliance, equity in access and can reduce greenhouse emissions, prevent sprawl and decrease the magnitude of urban heat islands.
  • Housing typologies need to be created that are affordable, allow people to age in place, andreduce energy demands, water use and greenhouse gas emissions (e.g. zero net energy developments).

Edgar Liu: As Jason said, planning essentially started as a response to sanitation, but now we are also addressing other health-related issues like pollution and climate change. Another important issue addressed in the special issue, is equity and access. One of the challenges we have in harnessing urban planning for health is that urban planning, infrastructure and services, have often been designed to benefit some members of the urban population and exclude the needs of others.  In the paper about Indigenous people living in urban environments within the special issue, for example, we’re addressing a particular population which has had a terrible history of displacement, and now we need to find a way to address that as a solution to a health problem. In the LGBTQIA+ paper within the special issue, we’re looking at how we work around urban governance to make sure that everyone has access to the same kinds of things. Furthermore, another paper in the special issue explores ways of measuring tenant health amid social housing redevelopment.

What are the top priorities in planning for healthier urban environments?

Jason Prior: There are two key priority areas in planning for healthier urban environments.

Firstly, urban planning and development can be harnessed to provide solutions that enhance the physical and mental health and wellbeing of urban populations. Increasingly, urban planning is being used to address a range of non-communicable diseases, ranging from heart disease, cancer, and diabetes to chronic lung disease, that are affected by diverse aspects of our urban environments. For example, the planning of our urban environments to support walkability, cycling and other forms of active transport, and access to healthy food, has helped address the rise in obesity, which leads to diabetes and heart disease, and which has been influenced by urban sprawl and automobile-dominated transportation which has contributed to sedentary lifestyles.  More recently, the COVID-19 has highlighted the role that urban planning and development can play in both the spread of communicable diseases and their suppression, leading to a reconsideration of how ventilation regulations, and how urban environments are laid out. There is an increasing focus on how urban planning can be harnessed to promote mental health, wellbeing, safety, security, and opportunity within urban populations, although less attention has been paid to this when compared to physical health. A paper within the special issue provides an overview of the evidence on how exposure to urban environments during the first 2000 days of life can have positive or negative physical and mental health outcomes across the life course, providing needed guidance for prioritizing public health and urban planning interventions during this early period of life.

Secondly, urban planning and development can be harnessed to support the natural systems on which our health depends, by addressing air pollution, access to fresh water, and climate change.  These have direct and indirect effects on the health of urban populations, which range from extreme weather in the forms of floods and heatwaves, and exposure to pollutants, to population displacement. Importantly, a paper within the special issue focuses on methodologies for developing a climate change inequality health impact assessment for health services, to provide a systematic process for assessing potential unequal health impacts of climate change on vulnerable and marginalised populations and places, and to develop contextually appropriate local strategies. A further paper within PHRP provides practical insights into the ways in which urban planning, urban design and architectural practices are addressing the health effects of climate change.

Edgar Liu: Housing is an obvious priority that is addressed in the special issue, particularly with the present cost of living crisis. When you are financially stressed, you may not necessarily be living in an environment that’s suitable to your needs. Often people may not be living in an environment that caters to their particular needs – which is often the case for people with disability, for example. So they might not be going to places that they would need to because they can’t get there. Touching on the importance of housing security, one of the papers in the special issues explores approaches for assessing tenant health amid social housing redevelopment. Also, having a sense of security, in terms of having a secure home, but also feeling truly included in society is really important, and is something addressed in the LGBTQIA+ paper.

What things do policy makers need to be more focused on or drive forward?

Jason Prior: Policy makers need to focus on driving three issues forward: developing evidence and tools for implementation and prioritisation, addressing equity, promoting cross-sectorial leadership and co-production,

Firstly, using urban planning and development as a platform to support human and planetary health requires us to continue to build evidence about the relationship between policy, environmental, economic, and social factors in urban environments and health outcomes. This includes tools that can readily assist with the appraisal and management of the relationship between urban environments, health, and health equity (for example, health impact assessment, risk assessment and system mapping tools).

Secondly, addressing inequalities is seen as essential to using urban planning and development as a platform to support human and planetary health due to unequal disease, mortality, and wellbeing burdens experienced by populations across urban environments as a product of the unfair distribution of the wider determinants of health.

Edgar Liu:  Finally, the promotion of sustained intersectoral actions between the health, planning and development, and other diverse sectors are seen as essential to using planning and development to manage the human and planetary health impacts of urban environments. Furthermore, policy makers need to promote coproduction models between researchers, healthcare professionals, consumers, and special population groups, including First Nations peoples. These are paramount to ensure appropriate translation and knowledge exchange. This approach comes across quite strongly in the LGBTQI+ paper and also the Indigenous paper, in terms of how do you address past history, but also the kind of inequalities right now. Because if you’re not part of those communities, you can only assume what the solutions might be. So bottom-up engagement is really important in working out the right solutions. Policy needs to be both directed but also facilitative: it needs to help people make things work rather than just doing something for people. 

These three areas that we suggest policy makers need to drive forward, and their relationship to the papers within the special issue, are discussed in greater detail within special issue’s editorial.

Is there enough research being done in this field? Do you have any messages to researchers in terms of how they should orientate their research?

Jason Prior: While there is a continuing need for research that develop evidence on how diverse aspects of our urban environments support and enable positive health outcomes, there is an increasing need to develop translation research that supports the development of effective urban planning interventions.  Furthermore, there is a need to develop techniques and tools for generating actionable pathways for prioritising these interventions within urban environments. An example of this research within this special issue is detailed in the paper that developed and piloted methods for longitudinal studies that can measure and assess how the redevelopment of a large social housing estate affects the health of its tenants and how to provide support appropriately.

While research in some areas of urban planning and development for health and wellbeing, such as active transport, are more highly developed, others – such as in the areas of climate change – remain nascent. Further research is required to better understand health-related outcomes in these less studies areas and effective interventions across urban contexts. An example of this type of research includes that detailed with the paper in the special issues that develops a Climate Change Inequality Health Impact Assessment framework to help guide planning of health services. A further example includes the paper within the special issue that is focused on research that seeks to identifies and pilots a tool to collect data within emergency departments, that can be used to better understand the relationship between environmental information and specific heatwave vulnerabilities.

It is important for the long-term sustainable of these interventions, that researchers properly engage key stakeholders from governments, communities, and academia in the developing of these interventions, and build their capacity to sustain and implement the interventions.

Do you feel optimistic that things are moving in the right direction?

Jason Prior: Over the past few decades, there has been an increased understanding across academia, government and industry, that urban planning and development can not only influence the health and wellbeing of urban populations, but also affect the health of the planet on which all human life depends. In the government context, we have seen this in the development of the Health Urban Development Checklist by NSW Health since 2007, and more recently in the Australian National Preventive Health Strategy, where urban form, that is, the shape, size, population, and density of our cities, are understood to play an integral role in shaping health and wellbeing in Australia. Similarly, in the academic context, we are seeing an increased focus on research into urban planning and development and health across Australian universities, and it is beginning to find a home in at least one of the 11 NHMRC-accredited Research Translation Centres in Australia – the Sydney Partnership for Health, Education, Research and Enterprise. These shifts in the Australian government and academic contexts reflect similar processes that are gaining pace across the globe. Given these changes I’m optimistic that things are moving in the right direction.

Edgar Liu: I’m also optimistic that things are moving in the right direction and that professionals responsible for the development of the built environment – urban and regional planners, urban designers, landscapers and architects – will overtime have an increasingly critical role to play in addressing health, in collaboration with health professionals and the communities they serve. The guidelines and frameworks that we’ve referenced in different parts of this special issue are part of the solution, putting pressure on industry and government to deliver on promises of healthier urban environments.

The special issue of PHRP on urban planning and development for health was produced in partnership with the Healthy Populations and Environments Platform within Maridulu Budyari Gumal (the Sydney Partnership for Health, Education, Research and Enterprise, SPHERE). Access the full issue here.

Public Health Research & Practice is an open-access, peer-reviewed quarterly online journal published by the Sax Institute. It is independently ranked by Scimago as Australia’s leading health policy journal. Click here to receive PHRP’s newsletter published with each new edition.