Annotated Table of Contents Making Healthy Places, Second Edition Designing and Building for Well-Being, Equity, and Sustainability Edited by Nisha D. Botchwey, Andrew Dannenberg, and Howard Frumkin
Chapter 1: An Introduction to Healthy, Equitable, and Sustainable Places By Howard Frumkin, Andrew L. Dannenberg, and Nisha Botchwey Key points •
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The environment consists of the external (or nongenetic) factors-physical, nutritional, social, behavioral, and others-that act on humans, and the built environment is made up of the many aspects of their surroundings created by humans, such as buildings, neighborhoods, and cities. Health is conventionally defined as complete physical, mental, and social well- being. This definition extends beyond the absence of disease to include many dimensions of comfort and well-being. Clinicians care for individual patients. Public health professionals aim to improve health at the level of populations. The design professions include urban planning, architecture, landscape architecture, interior design, and transportation planning. Each focuses on an aspect of the built environment. Both the public health profession and the design professions took modern form during the nineteenth century in response to rapid population growth, industrialization and urbanization, and the resulting problems of the urban environment. Public health practice is evidence-based, relying heavily on assessment, surveillance, and data collection.
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Leading causes of suffering and death include heart disease, cancer, diabetes, stroke, injuries, and mental illness. Many of these causes are related to community design and associated behavioral choices. Even though public health has evolved as a distinct field from planning and architecture, these domains have numerous opportunities to collaborate, and this collaboration can lead to improved health, well-being, and sustainability in many ways.
PART I: Health Impacts of the Built Environment Chapter 2: Physical Activity and the Built Environment By Nisha Botchwey, Meaghan Mcsorley, and M. Renée Umstattd Meyer Key Points • •
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Physical activity can help prevent numerous physical and mental health conditions, yet most people around the globe do not meet recommended physical activity levels. Some built environment attributes are associated with higher levels of physical activity. For example, people living in mixed-use communities with walkable destinations and accessible transit do more total physical activity than their counterparts living in residential-only neighborhoods. Promoting physical activity through the built environment is essential to public health and is also a sustainable climate change solution. Adding or improving recreation facilities is not enough to increase their use. Comprehensive interventions that include environmental changes, activity programs and marketing, and education have increased walking and biking to school and throughout cities. Living close to parks, trails, and recreation centers is related to greater use of facilities and more recreational physical activity. Access to recreation facilities, quality and safety of pedestrian facilities, and aesthetics are typically insufficient in areas with mostly low-income and racial/ethnic minority populations.
Chapter 3: Food, Nutrition, and Community Design By Roxanne Dupuis, Karen Glanz, and Carolyn Cannuscio Key Points •
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Individual-level interventions aimed at restricting calories and improving diet quality (and increasing activity levels) have failed to slow the obesity epidemic, leading researchers and practitioners to search for explanations and solutions in the food environment. Food environments—comprising food production, distribution, and marketing—vary dramatically within and across cities and from urban to rural areas. The toll of obesity is most evident in disadvantaged neighborhoods, which tend to lack supermarkets and fresh food yet have ample access to foods that are relatively inexpensive and calorie-dense but have little nutritional value. Various policy solutions are being launched on the local, regional, and national levels, with the promise of improved health as a rallying point for improvements in environments that include school food programs, changes in food marketing and nutrition labeling, and increased numbers of supermarkets and farmers’ markets. The health effects of these policy changes are often difficult to measure, and benefits may become evident only after extensive and sustained environmental changes. Recent data suggest that the steep rise in obesity witnessed in the late twentieth and early twenty-first centuries in the United States may finally be slowing among children and adolescents, perhaps in part because of changes to the food environment. The COVID-19 pandemic may undermine this public health progress.
Chapter 4: The Built Environment and Air Quality By Patrick Lott Kinney and Priyanka Nadia deSouza Key Points • • •
Air pollution remains a major healthchallenge facing cities throughout the world. Although ambient (outdoor) air pollution is the dominant concern, household (indoor) air pollution remains a significant global health burden as well. The health effects of air pollution are well established and depend on exposure levels.
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The spatial orientation of human activities and noxious sources within cities plays a key role in determining air pollution exposures that people and communities encounter. Air quality solutions are being successfully implemented by cities, many of which bring both health and climate benefits. Equitable access to clean air is an essential feature of a healthy city.
Chapter 5: Injury, Violence, and the Built Environment By Corinne Peek-Asa and Christopher N. Morrison Key Points • •
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Injuries and violence are two of the leading causes of premature life lost and disability globally. As described in the Haddon matrix, the public health approach to reducing the overall burden due to injuries involves preventing injury events, reducing injury severity, and supporting physical and psychological recovery. Modifying the built environment, including making physical changes to roadways, homes, workplaces, and public spaces, is a critical component of any comprehensive approach to injury prevention, especially for injuries related to transportation, falls, fire, drowning, and violence. Modifying the built environment is among the most effective, low-cost, and long-lasting prevention approaches available to prevent injuries.
Chapter 6: Water, Health, and the Built Environment By Charisma S. Acey and Emmanuel Frimpong Boamah Key Points • • • •
The design of the built environment can impact the availability of water and management of wastewater and stormwater in a community. Climate change and land use planning can aggravate or relieve the challenges of too little water, too much water, or poor water quality. Social inequality and vulnerability threaten the sustainability and resilience of water systems around the world. Innovative approaches to ensuring water quantity and quality involve cross-sector collaboration, community participation, and greater attention to natural ecosystems.
Chapter 7: Built Environments, Mental Health, and Well-Being By Xiangrong Jiang, Chia-Ching Wu, Chun-Yen Chang, and William C. Sullivan Key Points • •
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Built environments can promote or hinder mental health. Urbanization is often associated with poor mental health. It is not urbanization per se, however, but specific features of urban life that influence mental health. Good design, based on evidence, can promote mental health. Although urban settings with noise and traffic can increase stress, incorporating natural elements and beauty into the built environment can help people cope with stress. The conditions of modern life place great demands on—and often exhaust—our ability to pay attention. We can design settings to alleviate mental fatigue and restore people’s capacity to pay attention. Dilapidated, dangerous, and polluted places have a variety of negative impacts on people and their psychological states. Environmental injustice and inequity impact the mental health and well-being of individuals across the world. Planners, designers, and community leaders should work together to improve physical settings for everyone, but especially the most vulnerable among us.
Chapter 8: Social Capital and Community Design By Kasley Killam and Ichiro Kawachi Key Points • • •
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Social capital is broadly defined as the resources that individuals and groups can access through their social networks. Social capital affects health through the exchange of social support, collective action, and the maintenance of social norms to promote healthy behaviors. The built environment can affect social capital by providing opportunities for formal and informal social interactions, promoting investment and collaboration in a shared space, and conferring a sense of belonging. Examples from around the world support the notion that social capital can be fostered by thoughtful design decisions and modifications to the built environment. Opportunities for future research and application include more studies demonstrating causality and rapid responses to how the built environment can respond to evolving needs for social capital due to the loneliness epidemic and the COVID-19 pandemic.
Chapter 9: Inequity, Gentrification, and Urban Health By Helen V. S. Cole and Isabelle Anguelovski Key Points • • • •
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Urban environmental inequalities are often compounded and multifaceted. Deep, enduring histories of segregation and unequal urban development have structured and shaped urban inequalities. Neighborhood gentrification processes deepen existing urban inequities and lead to new patterns of spatial disinvestment with implications for health inequity. Environmental justice groups are increasingly facing a paradox whereby environmental improvements in historically marginalized neighborhoods contribute to displacement pressures, thereby complicating community activism and strategies for creating healthy urban places. Civic resistance, activism-driven neighborhood transformation, and policy and planning tools are all essential to achieve healthy urban places for all.
Chapter 10: Healthy Places Across the Life Span By Nisha Botchwey, Nsedu Obot Witherspoon, Jordana L. Maisel, and Howard Frumkin Key Points •
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The built environment “fits” different people differently. The concept of “personenvironment fit” focuses on the need for built environments to accommodate people across a range of personal characteristics. Certain life circumstances require particular attention to ensure that the built environment promotes safety, health, and thriving. These include childhood, old age, and disabilities such as reduced mobility, vision, hearing, or cognition. Everybody experiences one or more of these circumstances at some point in their life. Many design strategies serve the needs of all these populations and therefore offer multiple benefits. Accordingly, “universal design” aims to make buildings, products, and environments accessible to all people, regardless of age, disability, or other factors. The key to optimizing health and development via the built environment for children, seniors, and people with functional disabilities is through understanding the nature and vulnerabilities of these population(s) and the environments that they live within.
Solutions to vulnerabilities must be identified and implemented collaboratively with all the populations impacted.
PART II: Designing places for well-being, equity, and sustainability Chapter 11: Transportation, Land Use, and Health By Susan Handy Key Points • •
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Transportation and land use affect health through impacts on physical activity, air quality, injuries, social capital, mental health, and social equity. Transportation and land use are inextricably linked. Areas with good transportation access are more attractive for development, and developments with higher densities, a mix of land uses, and better street connectivity facilitate higher levels of walking, bicycling, and transit use, thereby promoting sustainability. Land use and transportation policies that can promote health and reduce automobile dependence include urban growth boundaries to promote compact development, upzoning to increase housing densities, incentives for transit-oriented development, elimination of minimum parking requirements, adoption of complete streets policies, and prioritization of funding for transit, bicycle, and pedestrian facilities. Planning for a “fifteen-minute city” or “twenty-minute neighborhood” promotes health by providing residents with access to goods and services within walking or bicycling distance of home.
Chapter 12: Healthy Homes By David E. Jacobs and Amanda Reddy Key Points •
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A major social determinant of health, housing is both a physical place where we spend most of our time, and a home is an expression of who we are individually and as a people. Housing and homes can support good physical and mental health and overall societal well-being or can contribute to disease and injury. Green healthy housing standards support sustainability by reducing energy and material use.
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Hazards in homes can include lead, allergens, mold, environmental tobacco smoke, carbon monoxide, asbestos, radon, volatile organic compounds, excessive heat and cold, crowding, barriers to accessibility, and conditions associated with falls and other injuries. These are linked to adverse health outcomes, including asthma, allergies, lung cancer, injuries, poor mental health, poisoning, fatalities, and neurodevelopmental disorders. Certain historic housing policies have contributed to inequities in health, wealth, opportunity, and community vitality through segregation, unaffordability, substandard housing quality, and shortages. Past and current racist and discriminatory housing practices have prevented communities of color and low-income households from building wealth and accessing healthy housing, worsening disparities in health and other outcomes. Examples of effective healthy housing interventions include improving ventilation and moisture control, diverting radon gas, controlling pests through integrated pest management, eliminating lead hazards, and installing smoke and carbon monoxide alarms. Strategies to promote healthy housing include implementation of healthy and green housing guidelines for new and existing construction, enhancement and enforcement of proactive housing code inspections, improved integration of healthy housing principles into disaster recovery/emergency preparedness and other home improvement programs, greater access to multicomponent home visit programs, increased public and private investment and policies that promote smoke-free homes, accessibility, and affordability. Healthy housing saves lives, reduces disease and injury, increases quality of life, reduces poverty, helps mitigate climate change, and contributes to the achievement of the United Nations’ Sustainable Development Goals.
Chapter 13: Healthy Workplaces By Jonathan A. Bach, Paul A. Schulte, L. Casey Chosewood, and Gregory R. Wagner Key Points •
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The design of the work environment contains opportunities to support and promote safety, health, and well-being while contributing to environmental, social, and economic sustainability. Work becomes safer through interventions such as reduced use of hazardous chemicals; ergonomically designed tools and workstations; built-in protection from hazards such as falls from heights; tools and equipment designed to be quieter; more effective controls of
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dust and vapor exposures; and other health-supportive designs, policies, and practices that mitigate risk and reduce stress. Improving indoor environmental quality through engineering involving heating and cooling systems, natural daylighting, and outdoor views has beneficial psychological effects on occupants. Workplace interventions such as layouts that encourage walking, attractive and wellplaced stairwells that encourage use, availability of healthier food options, and an active transportation infrastructure can increase worker health on and off the job and promote sustainability.
Chapter 14: Healthy Health Care Settings By Craig Zimring, Jennifer R. DuBose, and Bea Sennewald Key Points • •
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Health care settings represent a unique built environment because their primary function is maintaining and restoring health. The impacts of health care facility design on people and the environment are complex and operate at multiple scales from patients, family, and staff in the health care facility to communities and broader society. Although health care can be healing, it is costly and can cause harm to patients due to medical errors and infections, and health care facilities use considerable energy and water. Health care institutions using evidence-based design can offer direct benefits to patients, families, and staff, such as safety, and indirect benefits by facilitating teamwork and reducing medical errors. Health systems are significantly reducing their carbon footprint and resource use by innovative design. Principles of health care design apply to both high-income and low- and moderateincome countries by focusing on empowering patients and families, simplifying workflow, and making care safer. Health care design impacts communities and society by facilitating access to care and reducing use of energy, water, and other resources. Although much investment has been made in hospitals and clinics in the developed world, there is growing focus on providing good-quality, accessible, affordable care in low- and moderate-income countries that recognizes the dignity of all. The design of health care facilities ideally optimizes health of the individual, community, and ecosystems while reducing cost.
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Compliance with occupational safety and health regulations and use of consensus standards, sustainability reporting systems, and third-party building rating systems provide avenues for worker health and safety and environmental performance.
Chapter 15: Healthy Schools By Claire L. Barnett and Erika Sita Eitland Key Points •
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School buildings are unique indoor and outdoor environments. They are more densely occupied than offices or nursing homes. They have long hours of use and a multiplicity of indoor activities and functions. In the United States, 95 percent of the occupants are women and children. Children in prekindergarten through secondary (pre-K–12) schools are uniquely susceptible to environmental health hazards. Environmental exposures today can affect them for life, they breathe more air per pound of body weight than adults, they cannot recognize hazards, and they are undergoing rapid biological development and educational-social-emotional growth. Environmental hazards in and around schools are diverse and not well examined or addressed. Substandard physical conditions and hazards such as poor ventilation and sanitation, lead in paint and water, and asbestos are more prevalent in the poorest schools serving the poorest communities enrolling poor and minority children. Children with developmental and learning disabilities may be even more exposed and more vulnerable to hazards at school than their peers. Schools can prevent or control many physical health hazards affecting children’s health and learning. For example, they can maintain building systems and grounds and purchase safer products and equipment (often at equivalent prices). They can also take steps to address climate resiliency and mitigation.
Chapter 16: Contact with Nature By Howard Frumkin Key Points •
Nature contact promotes good health, a relationship supported by both theoretical and empirical considerations.
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In the built environment, nature contact may take many forms, such as plants in buildings, views out windows, biophilic building design, community gardens, street trees, and parks and green space. The benefits of such nature contact are wide-ranging, from stress reduction to improved birth outcomes, from recovery from illness and surgery to longer life. Access to nature is inequitably distributed; in many cities, low-income and minority neighborhoods lack nearby high-quality parks and green space. The response to the COVID-19 pandemic highlighted the value of nature contact for managing stress, anxiety, and depression. Much remains to be learned about the benefits of nature contact, such as what kinds of nature contact offer the greatest benefit, at what “dose” and frequency, and for which people. Providing nature contact may not only improve health but also yield co-benefits such as more disaster resilience, improved access to healthy foods, and conservation of natural resources.
Chapter 17: Climate Change, Cities, and Health By José G. Siri and Katherine Britt Indvik Key Points • • • • • •
Cities are a primary driver of climate change, including through the impacts of their built environments. Urban areas experience the most concentrated and extreme impacts of changing climate. Climate change affects the health and well-being of people in cities, and impacts will accelerate over time. Climate impacts are inequitably distributed, with marginalized and vulnerable populations experiencing the greatest health risks. Rethinking and restructuring the urban built environment can play a critical role in mitigating and adapting to climate change while maximizing health co-benefits. Creating healthy, sustainable, and equitable urban places in the context of a changing climate requires coordinated action across sectors and scales.
Chapter 18: Community Resilience and Healthy Places By José G. Siri, Katherine Britt Indvik, and Kimberley Clare O’Sullivan Key Points •
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Resilience is the capability of a person, structure, or system to withstand shocks or stressors while maintaining or recovering function and continuing to adapt and improve. Resilient built environments are critical to safeguarding health and health equity from social, economic, environmental, and other shocks and therefore to long-term health, safety, and sustainability. Resilience is multifactorial—it requires integrated actions by different stakeholders across sectors and scales. Individual elements or characteristics are not sufficient to predict resilience—it emerges from complex interactions within a socioecological system. A structure or system can be resilient to some risks for some people, but not for others— resilience is not always equitably distributed.
PART III: Strategies for Healthy Places: A Tool Kit Chapter 19: Healthy Behavioral Choices and the Built Environment By Christopher Coutts and Patrice C. Williams Key Points • • •
The design and conditions of the built environment can directly and indirectly affect health by influencing behavioral choices. The built environment acts together with other external factors—including historical and political context, economy, and social cues—to influence behavior. Current social trends include behavioral choices aimed at health (such as walking for physical activity) and behavioral choices aimed at environmental sustainability (such as driving less). The built environment can foster choices that advance both health and sustainability.
Chapter 20: Legislation, Policy, and Governance for Healthy Places By Eugenie L. Birch Key Points • •
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The public and private sectors, civil society, and professional organizations and residents individually and collectively create the built environment. The public sector plays a critical role in determining the form and contents of the built environment by establishing policies (statements that guide the courses of action for decision-makers to achieve desired goals) and legislating the rules and laws to realize policies. From the colonial period to the mid-twentieth century, local governments managed health issues within the built environment; thereafter, the federal government began to take responsibility for addressing certain concerns including environmental pollution but shared implementation with state and local governments. The United States Constitution outlines the form, roles, and responsibilities of the public sector, delegating specific powers for the national government and reserving those not delegated or prohibited in the Constitution to the states, and states through statutory provisions create local governments. As sprawling, automobile-dependent settlement patterns have contributed to physical inactivity, injuries, and air pollution, some localities have added health-supporting policies to their management of the built environment.
Chapter 21: Community Engagement for Health, Equity, and Sustainability By Manal J. Aboelata and Jasneet K. Bains Key Points •
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Community engagement entails relationship building, communication, and decisionmaking involving residents, the people most likely to be impacted by neighborhood change. Community engagement efforts employ a range of techniques to enable community members to participate in shaping strategies, processes, and outcomes. This chapter focuses on the land use, design, and built environment arenas, particularly as they pertain to health, equity, safety, and environmental sustainability. Community engagement should go beyond “usual suspects” to enlist the perspectives of diverse individuals who have typically been excluded from influencing neighborhood design, land use, and environmental decisions.
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Land use planning in the built environment is highly political, technical, and complicated; therefore, effective community engagement requires commitment to building knowledge, capacity, and relationships based on trust and shared understanding of historical and present-day factors impacting neighborhood health, equity, safety, and sustainability.
Chapter 22: Measuring, Assessing, and Certifying Healthy Places By Carolyn A. Fan and Andrew L. Dannenberg Key Points • • •
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Measurement, assessment, and certification are key processes for evaluating healthpromoting attributes of the built environment. Metrics, data, and tools are used to measure and assess the healthfulness of populations, places, and buildings. Tools such as health impact assessments can be used to assess the potential health outcomes of proposed projects and policies and to provide recommendations to promote healthy aspects and mitigate adverse aspects of proposals. Certification of buildings and communities facilitate improving designs to favor health and sustainability but may be subject to equity issues. Measurements, assessments, and certifications are conveyed to key decision-makers and community stakeholders to be translated into action through policies and projects.
PART IV: Looking forward, taking action Chapter 23: Training the Next Generation of Healthy Placemakers By Nisha Botchwey, Olivia E. Chatman, Matthew J. Trowbridge, and Yakut Gazi Key Points • •
Educating a new generation of healthy place-makers requires interdisciplinary training focused on team-based application of public health and design expertise. Academic training programs focused on the built environment and public health, ranging from cross-listed courses to dual-degree programs in planning and public health, are increasingly available.
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Better integration of public health and built environment competencies in interdisciplinary courses will be critical going forward and may require targeted offerings beyond the typical semester or quarter. The majority of professional education programs focus on understanding and communicating links between health and the built environment. However, there is growing demand for more applied built environment and health training tailored to specific disciplines (for example, public health, architecture, landscape architecture, urban planning, transportation engineering), as well as postgraduate professionals, particularly in the wake of more frequent natural disasters from climate change and the COVID-19 global pandemic. More work is needed to (1) define interdisciplinary competencies for healthy placemaking as the basis for better integrated training curricula; (2) produce and deliver accessible online training modules; (3) develop opportunities for collaboration between practitioners and academics across disciplines and diverse communities; and (4) expand funding support for multidisciplinary research, training, and practice.
Chapter 24: Innovative Technologies for Healthy Places By J. Aaron Hipp, Mariela Alfonzo, and Sonia Sequeira Key Points • • • • •
The use of technologies in urban spaces as related to the advancement of public health crosses scales and fields and is dynamic and continually expanding. The Smart Cities movement is one effort to capture the variety and use of technology across urban areas. The term Smart Cities might be better called Smart Places. Technologies produce the five V’s of big data: volume, velocity, veracity, variety, and value. The digital divide describes inequities in access to hardware (smartphones, laptop computers) and internet access (5G, fiber, broadband). Technological innovations for health challenge those developing and employing the technologies to ensure equity in the value of technology and data, as well as accessibility to visualizations and vernacular.
Chapter 25: Healthy Places Research: Emerging Opportunities By Andrew L. Dannenberg, Nisha Botchwey, and Howard Frumkin Key Points • • • •
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Empirical research provides a solid foundation for designing and building healthy places. Such research has not always been used in the design professions. Research performed to date can guide many health-promoting design choices now, although further research is needed to answer remaining questions. Many remaining questions concern equity, sustainability, and applications in low- and moderate-income countries. Numerous research opportunities are available for students, researchers, and practitioners in public health, planning, architecture, and other fields to advance the evidence base for creating healthy places. Data collected for purposes unrelated to health, including “big data,” can sometimes be used creatively to document links between health and the built environment. Natural experiments are a valuable approach to documenting the links between health and the built environment, especially because randomized controlled trials are rarely possible in community settings. Case studies of healthy and unhealthy places can be helpful for identifying areas in which further research would be useful.
Chapter 26: COVID and the Built Environment By Howard Frumkin Key Points •
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Throughout history, cities have confronted infectious disease outbreaks and have responded with a range of policies, practices, and design strategies. The COVID-19 pandemic that erupted in 2020 is the latest chapter of that history. Several features of the built environment increased the risk of COVID-19. They included crowding (as distinct from urban density), spatial patterns associated with poverty and racism, air pollution, and poor indoor air circulation. Responses to the pandemic included a range of built environment strategies. They included modifications to building design to permit physical distancing between people; working from home; reallocation of streets from vehicular traffic to walking, cycling, and commerce; a shift from mass transit to other travel modes; enhanced use of parks and green space; and residential relocation from cities to suburban and rural locations.
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The post-pandemic recovery presents many opportunities to advance health, equity, and sustainability in the built environment. The long-term impact of COVID-19 on cities is a story yet to be written.
