Health Promotion Journal of Australia, 2014, 25, 202–208 http://dx.doi.org/10.1071/HE14039
Capacity Building
Building partnerships for healthy environments: research, leadership and education Susan Thompson A,D, Jennifer Kent B and Claudine Lyons C A
City Futures Research Centre, University of New South Wales, Sydney, NSW 2052, Australia. Department of Environment and Geography, Macquarie University, Sydney, NSW 2109, Australia. C New South Wales Ministry of Health, 73 Miller Street, North Sydney, NSW 2060, Australia. D Corresponding author. Email: [email protected] B
Abstract As populations across the globe face an increasing health burden from rising rates of obesity, diabetes and other lifestyle-related diseases, health professionals are collaborating with urban planners to influence city design that supports healthy ways of living. This paper details the establishment and operation of an innovative, interdisciplinary collaboration that brings together urban planning and health. Situated in a built environment faculty at one of Australia’s most prestigious universities, the Healthy Built Environments Program (HBEP) partners planning academics, a health non-government organisation, local councils and private planning consultants in a state government health department funded consortium. The HBEP focuses on three strategic areas: research, workforce development and education, and leadership and advocacy. Interdisciplinary research includes a comprehensive literature review that establishes Australian-based evidence to support the development, prioritisation and implementation of healthy built environment policies and practices. Another ongoing study examines the design features, social interventions and locational qualities that positively benefit human health. Formal courses, workshops, public lectures and e-learning develop professional capacity, as well as skills in interdisciplinary practice to support productive collaborations between health professionals and planners. The third area involves working with government and non-government agencies, and the private sector and the community, to advocate closer links between health and the built environment. Our paper presents an overview of the HBEP’s major achievements. We conclude with a critical review of the challenges, revealing lessons in bringing health and planning closer together to create health-supportive cities for the 21st century.
Key words: collaboration, interdisciplinary, partnerships, planning, preventive health. Received 29 May 2014, accepted 10 August 2014, published online 1 December 2014
Introduction Planning, creating and managing built environments to encourage physical activity is a demanding health priority. It requires close partnership between researchers, practitioners and policymakers across many sectors.1,2 The fundamental importance of collaboration in this area was recently acknowledged by the American Journal of Health Promotion, which dedicated its first special issue for 2014 to the integration of research, policy and practice for active living.3 This special issue followed the 2013 conference of the Active Living Research program, which explored a similar theme. A common message in these various commentaries is the need to map and record the emergence of synergies between the ‘processes, policies, politics, and people’1(pS1) required to generate active-living environments. This paper contributes to these records by detailing an Australian initiative based in New South Wales (NSW) – the Healthy Built Journal compilation Ó Australian Health Promotion Association 2014
Environments Program (HBEP). Initiated by a state health agency, the Program is uniquely situated within an urban planning and design context, and has a strong environmental sustainability focus. We begin our paper by situating the HBEP in the broader theoretical terrain and then shift to an overview of how it came into existence. In the section that follows, we briefly describe the main activities and achievements of the Program. The paper finishes with a critical discussion of the challenges in this interdisciplinary arena, exposing lessons for others working to create healthy built environments.
The theoretical terrain: the relationship between health and the built environment Over the last generation there has been a shift in conceptualisations of health and disease, from the treatment of illness in the individual to disease prevention and health promotion in populations. This has included increased focus on the impact of environments on CSIRO Publishing
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collective well being4,5 and on the interdependence of environments and individual behaviour.4,6–8 Built environments have subsequently emerged as a focus in health research. This reinvigoration of the health-built environment interdisciplinary relationship embraces a range of themes. These include the built environment’s impact on opportunities for utilitarian and recreational physical activity;9–12 healthy food access;13,14 exposure to nature and green space;15,16 community building;17,18 noise abatement;19 air pollution20 and crime.21 Theoretically, this shift reflects the growing ecological orientation of the health promotion field.4,5,22,23 Ecological models of health promotion are underpinned by the understanding that healthpromoting and preventing interventions need to be considered across multiple levels and contexts. The ecological orientation emphasises that the most effective health interventions will be tailored to place24and the people living in that place. It acknowledges that individuals of different ages,25 socio-economic and cultural backgrounds26–28 and genders29 will respond to health-promoting interventions in varying ways. Ecological theories also recognise the role of educational programs, policy change and economic incentives,30 and work with more targeted medical interventions by providing supportive environments for change. In short, ecological models are based on the idea that comprehensive approaches to health promotion need to consider interventions at multiple policy and practice scales and in different geographical and demographic contexts. The ecological orientation has been used to demonstrate links between the modern epidemics of chronic non-communicable diseases and the way we live in cities. As a result, health professionals increasingly recognise that the built environment directly affects people’s health. Further, and most importantly, there is growing appreciation of the central role that urban planners play in providing environments that support healthy behaviour. Indeed, and perhaps ironically, this goes back to the origins of the planning discipline, which arose out of concerns for human health.31 A century ago, planning was strongly aligned with public health objectives to prevent the spread of contagious diseases. Nevertheless, this close relationship was not sustained as planning moved to focus on urban policy development, design and environmental sustainability – away from a focus on public health–related concerns.32
Healthy built environments in Australia In Australia, the health sector has spearheaded policy initiatives to bridge health and the environment. In 2009, the Australian Government undertook national assessments of health promotion and the health system more generally.33 The opinions of urban planners and designers informed key recommendations emerging from these reviews. While both state and federal governments in Australia look after different parts of the health care system, the state has primary responsibility for hospitals. This can provide an incentive
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for investment in preventive health to reduce the cost burden of hospital-based care. Keeping people well, however, is very much about providing environments that support healthy behaviour. Over the past two decades, the NSW state health agency, NSW Health, has intensified its engagement in bringing this about. The aim has been to increase the agency’s influence over the shape of the urban environment to sustain health and well being. The need to engage with the systems and processes that determine built environments was identified as a key priority for the NSW Government in the first NSW State Plan.34 Further clarification about the role that urban planning plays in relation to health was also contained in the NSW State Health Plan 2006–2010.35 In addition, the 2007 health-prevention strategy Healthy People NSW prioritised action to ‘create environments that promote health and well being’.36(p17) This strategy identified health impact assessment (HIA) as a key ‘tool to strengthen health input into planning decisions’.36(p18) This focus on health and planning issues has been maintained throughout government electoral changes and significant structural health reforms at both state and federal levels. The most recent health prevention strategy, 2012–2017, includes action to be taken on building and maintaining healthy environments as a key priority.37 Workforce development is key to bridging the theoretical and practical differences between the disciplines of planning and health professionals. NSW Health has invested in a capacity-building program for its staff on the use of HIA,38 and during the last ten years HIAs have successfully been used on several projects with local and regional partners (for an example, see Neville et al.39). To further support the development of NSW Health staff’s capacity to influence healthy design and the built environment, the Healthy Urban Development Checklist was created.40 The Checklist assists health staff in providing feedback and advice on development policies, plans and proposals. In addition, it facilitates partnerships and collaboration between NSW Health, planners and developers. NSW Health has also focused on inter and intrasectoral partnership building. From 2004 as a founding member of the NSW Premier’s Council for Active Living (PCAL), NSW Health championed projects to strengthen the physical and social environments in which communities engage in active living.41 As well, NSW Health entered into a partnership with the NSW Commission for Children and Young People in 2011 to look at a range of age-specific, built-environment concerns.42 In summary, the provision and promotion of healthy built environments is now one of NSW Health’s key preventive health priorities. With the built environment increasingly viewed as an important determinant of health, and the evidence base continuing to grow, NSW Health realised that more was required. This extended to supporting a comprehensive framework for building workforce capacity, as well as a strategic method of supporting policy-relevant,
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built-environment research. Knowing that this is a cross-sectoral issue with significant complexity, it was considered that an innovative and different approach was required to increase the integration between the health and planning sectors. In the next section we describe this approach.
The Healthy Built Environments Program In 2009, and following a formal tender process, NSW Health selected the City Futures Research Centre, situated in the Faculty of the Built Environment at The University of NSW (UNSW), to establish the Healthy Built Environments Program (HBEP). Under the leadership of an urban planner and public health physician, a five-year contract was awarded to an interdisciplinary consortium from academic, government, private and non-government organisations with expertise across health, urban planning and design. Core funding from NSW Health totalled AUD1.5million over the five-year period 2010–14, with infrastructural support from UNSW. The Program was established to spearhead a fresh approach to the integration of the health and planning sectors in NSW. Situated in one of Australia’s largest faculties of the built environment, the HBEP includes all of the design and planning disciplines concerned with individual buildings (their interiors and what is between them), through neighbourhoods, to the urban region, city and beyond. Positioning the Program within a built environment faculty offers the opportunity to influence the builtenvironment professions to incorporate healthy-planning provisions in their training, strategic direction, policy formulations and decision making. The overarching aim of the HBEP is to revitalise the relationship between the built environment and health professions so they can work together to create places – which embrace physical, social and cultural aspects – that support people being healthy in their everyday lives. The Program’s vision is that built environments will be planned, designed, developed and managed to promote and protect health for all people. This vision is realised through the HBEP’s three strategic areas of operation involving its key stakeholders and partners:
(1) Interdisciplinary research on the relationship between health and the built environment (2) Capacity building, education and workforce development (3) Leadership and advocacy on health and the built environment. Outlined below is each strategic area that exemplifies the Program’s interconnected ways of working. These bring the interdisciplinary efforts of researchers, educators, practitioners and policymakers from the built environment and health sectors together in the prevention of contemporary chronic disease. We also provide examples of the results of the HBEP’s work, illustrating how it has been translated into policy and practice, as well as building the capacity of students and professionals to implement healthy built environments. More information, together with access to the resources mentioned below,
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is available from the comprehensive Healthy Built Environments Program website.43
1. Research The HBEP fosters interdisciplinary research which is policy relevant for professionals working in urban planning, design and public health. A Research Strategy to facilitate the development of such priorities was completed in 2012. The Strategy was informed by the research gaps identified in the comprehensive Literature Review undertaken by the HBEP.44 This scholarly work examines the role of the built environment in supporting human health as part of everyday living. The principal aim was to establish a robust evidence base to support the development, prioritisation and implementation of healthy builtenvironment policies and practices. The Literature Review proposes three key built-environment ‘domains’ to support health and well being:
(i) The built environment and getting people active (ii) The built environment and connecting and strengthening communities (iii) The built environment and providing healthy food options. These domains address three of the major risk factors that cause chronic disease in the Australian community – physical inactivity, obesity and social isolation. In 2012, supplementing the lengthy Literature Review, a set of concise Fact Sheets was released to facilitate enhanced practitioner engagement with the research. In recognition of its successful research–policy interface, the project won an Excellence Award from the NSW Division of the Planning Institute of Australia. The HBEP is engaged in other research projects supported by a range of institutions. An Australian Research Council Linkage Grant has funded an examination of how different urban environments sustain health and well being. A detailed built environmental audit instrument has been developed as part of this study.45 Healthy food availability has also been investigated,46 and in-depth interviews about how the diverse residential environments support everyday healthy behaviour are currently underway. In 2011, the HBEP completed a smaller project funded by the Australian Housing and Urban Research Institute. This work involved a focused examination of the health impacts of housing, with an emphasis on exploring interdisciplinary policy–practice relationships across health and housing disciplines.47 The HBEP is contributing to building the research evidence to influence policy and practice. It has informed policy development and implementation at the state government level in two key areas: initiatives instigated by the NSW Ministry of Health; and guiding the Ministry’s collaborations with other government agencies such as the NSW Commission for Children and Young People.42 As an example, the NSW Healthy Eating and Active Living Strategy48 includes ‘environments to support healthy eating and active living’ as its number one strategic direction. Under this cross-government initiative, Transport for NSW has committed to create public
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infrastructure for active travel. In addition, the NSW Department of Planning and Environment plan to deliver healthy built environments through incorporating active-living principles into infrastructure development and design, as well as providing accessible open spaces. Research is used by Local Health Districts for evidence-based policy development and to assist in making informed responses on state and local planning proposals. The HBEP Literature Review also featured in the 2011 State of Australian Cities Report49 prepared by the then federal government’s Major Cities Unit. The Review was also cited by the NSW Department of Planning and Infrastructure in its consultation papers for the development of a new Sydney Metropolitan Strategy, a key state planning document.50
2. Capacity building, education and workforce development The HBEP undertakes innovative, cross-disciplinary educational activities to build the capacity of practitioners to deliver healthy built environments. While the focus is on the NSW health workforce, urban planners and community workers, together with medical practitioners, have attended a raft of diverse HBEP educational programs. During 2013 the HBEP presented a series of day-long workshops across 12 rural and metropolitan regions, with just under 260 enrolments. Participants learnt about the NSW planning system and how to consider the health implications of policies, plans and development proposals to influence decision making in planning, taking this knowledge back to the workplace. A variety of shorter seminars, public lectures, interactive forums and e-learning opportunities also feature in the HBEP’s educational portfolio. The HBEP’s education remit extends to tertiary courses at UNSW. In the first year of its operation, HBEP established a postgraduate interdisciplinary elective called Healthy Built Environments, complementing the existing undergraduate course Healthy Planning. The HBEP has made it possible for up to six health professionals to take part in the course each year, further enhancing the opportunities for interdisciplinary exchange and learning. Doctoral research is also conducted under the umbrella of the HBEP. To date, research topics have encompassed cultural barriers to the uptake of active transport, planning for healthy ageing in a supportive built environment, the implications of hotter temperatures for activities in public spaces, and the importance of local neighbourhood green space and connecting walkways for older residents.
3. Leadership and advocacy Leadership and advocacy to bring health and the built environment closer together is the third area of focus for the HBEP. This has involved stakeholder partnerships with government and nongovernment agencies, the private sector and the community. Of particular note is the Program’s Advisory Board comprising healthy built-environment stakeholders representing academia, government, and the not-for-profit and private sectors.
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An important aspect of the HBEP’s leadership and advocacy activities are its regular submissions to major inquiries that review planning and health regulation and policy. We have made submissions on Australia’s National Urban Policy, different stages of the NSW Planning System Review and several reviews of the Sydney Metropolitan Strategy. In every case, the HBEP’s submissions argue for inclusion of health as a foundation of a sustainable environment. A particularly significant outcome of this work has been the inclusion of a specific health objective in the NSW Planning Bill 2013 – the first time that such an objective has appeared in state planning legislation. While subject to the parliamentary process and potential amendment, if successful it will put the State at the vanguard of national and international best practice. Together with other key stakeholders, HBEP has had an important role in the inclusion of the health objective. In addition to these initiatives, presentations are frequently given to health and built-environment professionals, including at conferences and industry meetings. Information is also regularly disseminated via the HBEP’s quarterly e-newsletter, and other professional, industry and community magazines (for example, Thompson and Capon;51 Thompson52). Since its inception, a regular ‘Healthy Built Environments’ column in the Planning Institute of Australia’s NSW journal New Planner has made a significant contribution to the knowledge base of the urban planning profession in NSW. This column provides an excellent platform to inform planning practitioners and city policy makers about the latest research and policy in healthy built environments, inspiring the profession to plan healthy and sustainable spaces and places. All columns are placed on the HBEP website.
Challenges in moving forward Progression of the healthy built-environments agenda requires formation of strong interdisciplinary relationships. This process will inevitably encounter practical and theoretical discord that needs to be acknowledged and addressed. Common themes of friction identified through our experience relate to different understandings of the complexity of context, different ways of thinking about the nature of evidence required to justify policy change, and more general misconstructions about ways to mix policies and disciplines. A further complicating factor is the political context in which policy is developed and implemented. These themes highlight some of the practical challenges to planning for healthy built environments, revealing lessons for others working to create healthy and resilient cities for the 21st century.
Context The need for consistent and objective measurement of built environment and physical activity variables is a commonly cited weakness in research on the built environment and health. As an example, Kirk et al.53 recommend standardisation of measurement in seeking to characterise ‘obesogenic’ environments. This
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comprehensive review of 146 primary studies concludes that the ‘environment may play a critical role in obesity development, prevention and management, but we have yet to determine the best method for measuring that effect accurately and consistently, or develop an appropriate theory to encompass this very complex and dynamic system’.53(p116) Other studies recommend consistency in measurement of built environment variables (see for example Heinen et al.,12 Cunningham and Michael,54 and Davison and Lawson55); nevertheless, there are disadvantages in waiting until there are no gaps or inconsistencies in our knowledge. It will be difficult to obtain consensus as to when, if ever, this point has arrived. There will be differing interpretations about the evidence and how it should translate into policy. Government priorities will also shift in an evolving political climate. Further, policy responses will differ according to spatial context, demographic, social and cultural character, environmental quality and temporality. As an example, NSW covers an area of ~800,628 km2, and while the population is highly urbanised, the distances between regional centres create significant practical issues. These range from the need to respond and work with communities from diverse cultural backgrounds and in a variety of social contexts, to the requirement to take into account the health impacts of different bio-physical geographies. Distance, in itself, presents difficulties; it isolates professionals, limits opportunities for education and acts as an impediment to workforce retention. Recommendations for standardised measurements risk underestimating NSW’s geographical and cultural diversity and the complexity of people in place. This is particularly the case when attempts are made to compare results between and across populations and locations. And while there is a role for standardising some variables (such as the use of body mass index (BMI) as a way to define the healthy weight range), standardised measures should not be viewed as a prerequisite to prove the relationship between the built environment and health. Acknowledging contextuality in relation to research into the health determinants of place must not be viewed as an impediment to the search for elements of commonality but needs to be taken seriously in both the application of research to policy, and the design of future research agendas. Research on health and the built environment has addressed ways to avoid the ‘excuse’ of context (see, for example, Black and Macinko56), with the strongest recommendation being that methods should be transparent and at least situated within, but not necessarily echoing, the existing research agenda. This implies that future research should build on the findings of previous work, and comprehensively detail the measures and methods used.
Evidence of causality Linked to the common call for standardisation is an identified need to establish that the relationship between the built environment and health is a causal relationship. Studies have consistently found a
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significant association between health and the built environment; however. associations are insufficient to establish true causality. A failure to account for confounding variables (such as residential selfselection) is often cited as a major weakness in research on the healthbuilt environment relationship.10,57–59 The lack of longitudinal research required to prove time precedence is also identified as another missing element of causal proof.11,12,58,60–62 This inability of the research agenda to date to establish true causality is a ‘weakness’ perhaps not of the research itself but of the seemingly unpredictable way people relate to their environments. Juxtaposed to the call for causality is research accepting that the randomised-controlled trials often underpinning causal proof are impractical for studies on the built environment and health simply because it is impossible to randomly assign exposure to built-environment modifications.63,64 This scholarship suggests that the constant focus on causality is a weakness of the research agenda in itself. Further, attention would be better directed towards the establishment of a more practical standard of proof acceptable in the absence of causality.59,65–67 This standard would need to incorporate the results of qualitative as well as quantitative research. The question about evidence cuts to a core division between the health and urban planning disciplines. Traditionally, the nature of evidence used by planners to develop policy is different from that used by public health officials. Australian urban planning’s early- to mid-20th century focus on greenbelt cities, for example, was based on an historical appreciation of the health benefits of open space for overcrowded and dirty cities.68 Schemes such as Sydney’s County of Cumberland Plan and Perth’s Endowment Lands project reflect this appreciation. Basing policy change on an ‘appreciation’, rather than hard evidence, poses a problem for a public health–based intervention.
Mixing policies and disciplines Research on the links between health and the built environment often concludes with the acknowledgement that structural modifications to the built environment need to be part of a policy mix if they are to be successful. For example, Ewing and Cervero’s10 ‘elasticity’ theory gives quantifiable justification that active transport behaviour is unresponsive to small-scale, built-environment modifications but responsive to an integrated range of builtenvironment modifications, educational programs, incentives and restrictions. Theoretically, this conceptualisation reflects the increasingly ecological orientation of the health promotion field described in this paper’s introduction. To change practices, however, an ecological approach requires consistent and meaningful interdisciplinary collaboration. This necessitates seeking new, potentially more comprehensive ways of understanding the impacts of policy development, amendment and implementation. It also demands that both researchers and practitioners from the built environment and health recognise that their accepted wisdoms and assumptions are not necessarily shared, nor understood, beyond
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their own disciplinary boundaries. Successful healthy builtenvironment partnerships rest on deliberative interdisciplinary engagement. At its heart is an eagerness to listen and learn about the other. This extends from disciplinary culture to ways of collecting and measuring data, reporting results and the subsequent translation into policy. The complexity of health prevention in modern society demands interdisciplinary collaboration. However, perhaps the biggest challenge facing planning for healthy built environments is the ongoing need to appeal to economic and political agendas, including the timeframes laid down by the electoral cycle. The economic imperative was highlighted in our research with health and built-environment policy makers who identified cost–benefit analysis tools as critical in enabling better advocacy for the provision of built-environment interventions to improve health.69 Nevertheless, it is not an easy task to provide the ‘proof’ to justify action. The need for healthy built environments to recognise context problematises the provision of such proof. Ongoing success in this area requires the adoption of a long-term perspective in assessing possible health, social and economic outcomes.
Conclusion There is a strong relationship between people’s health and the built environment. This relationship is complex and contextual, and translating this framework into action requires the development of interdisciplinary working relationships. These relationships must be based on mutual understanding and respect. Our paper has detailed the development of an innovative, interdisciplinary collaboration that has achieved significant research-policy translation and education outcomes by bringing urban planning and health together. The experiences of the HBEP demonstrate that very real differences exist in the research and practical traditions unique to professionals working in this area. While these disparities are not insurmountable, they do indicate that this is a discipline area that is in its infancy. A fuller evaluation of the Program, which is currently underway, will no doubt further elaborate on these issues. The HBEP is proud to be playing a part in the development of the discipline in Australia, contributing to the creation of built environments that promote the health and well being of all communities.
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Acknowledgements An earlier version of this paper was presented to the joint Association of European Schools of Planning (AESOP) and the American Association of Collegiate Schools of Planning (ACSP) Congress, Planning for Resilient Cities and Regions, Dublin, Ireland, 15–19 July 2013.
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29. Bonham J, Wilson A. Bicycling and the life course: the start-stop-start experiences of women cycling. Int J Sustain Transp 2012; 6(4): 195–213. doi:10.1080/ 15568318.2011.585219 30. Rodríguez DA, Evenson KR, Diez Roux AV, Brines SJ. Land use, residential density, and walking. The multi-ethnic study of atherosclerosis. Am J Prev Med 2009; 37(5): 397–404. doi:10.1016/j.amepre.2009.07.008 31. Thompson S. A planner’s perspective on the health impacts of urban settings. NSW Public Health Bull 2007; 18(9–10): 157–60. doi:10.1071/NB07093 32. Botchwey ND, Hobson SE, Dannenberg AL, Mumford KG, Contant CK, Mcmillan TE, et al. A model curriculum for a course on the built environment and public health training for an interdisciplinary workforce. Am J Prev Med 2009; 36(2): S63–71. doi:10.1016/j.amepre.2008.10.003 33. National Preventative Health Taskforce. Australia: the healthiest country by 2020 – National Preventative Health Strategy. Canberra: Commonwealth of Australia; 2009. 34. State Government of NSW. NSW State Plan: a new direction for NSW. Sydney: Premier’s Department; 2006. 35. NSW Department of Health. State Health Plan: towards 2010 – a new direction for NSW. North Sydney: NSW Department of Health; 2007. 36. NSW Department of Health. Healthy People NSW. North Sydney: NSW Department of Health; 2007. 37. NSW Ministry of Health (Population and Public Health Division). Population health priorities for NSW: 2012–2017. Sydney: NSW Ministry of Health; 2012. 38. Harris-Roxas B, Simpson S. The NSW Health Impact Assessment Project. N S W Public Health Bull 2005; 16(7–8): 120–3. 39. Neville L, Furber S, Thackway S, Gray E, Mayne D. A health impact assessment of an environmental management plan: The impacts on physical activity and social cohesion. Health Promot J Austr 2005; 16(3): 194–200. 40. NSW Department of Health. Healthy Urban Development Checklist: a guide for health services when commenting on development policies, plans and proposals. North Sydney: NSW Department of Health; 2009. 41. PCAL. Premier’s Council for Active Living website [Internet]. Sydney: PCAL; 2014. Available from: http://www.pcal.nsw.gov.au/ [Verified 23 May 2014]. 42. NSW Office of Communities. NSW Commission for Young People, Children and the Built Environment [Internet]. Sydney: NSW Office of Communities; 2014. Available from: http://kids.nsw.gov.au/kids/advocacyresearch/builtenvironment. cfm [Verified 23 May 2014]. 43. HBEP. Healthy Built Environments Program [Internet]. Sydney: Healthy Built Environments Program; 2014. Available from: http://www.be.unsw.edu.au/ programmes/healthy-built-environments-program/about [Verified 26 May 2014]. 44. Kent JL, Thompson SM, Jalaludin BB. Healthy built environments: a review of the literature. Sydney: Healthy Built Environments Program, City Futures Research Centre, University of NSW; 2011. 45. Mitchell E, Thompson SM. The Healthy Neighbourhood Audit Instrument: understanding the environmental and socio-cultural conditions to support healthy, happy and resilient residential communities. In Rowley S, Ong R, Markannen S, editors. Proceedings of the 7th Australasian Housing Researchers Conference. Fremantle, Western Australia; 2013. 46. Thompson SM, Mitchell E, Crawford B. Planning and Building Healthy Communities. In: Ruming K, Randolph B, Gurran N, eds. State of Australian Cities Conference 2013: Refereed Proceedings; 2013, Sydney, AU. 47. Phibbs P, Thompson SM. The Health Impacts of Housing: Toward a policy relevant research agenda. AHURI Final Report No. 173. Melbourne: Australian Housing and Urban Research Institute; 2011. 48. NSW Ministry of Health. NSW Healthy Eating and Active Living Strategy: Preventing overweight and obesity in NSW 2013–2018, North Sydney: NSW Ministry of Health; 2013 Available from: http://www.health.nsw.gov.au/obesity/Publications/nswhealthy-eating-strategy.pdf [Verified 7 August 2014]. 49. Department of Infrastructure and Transport. Major Cities Unit. State of Australian Cities 2011. Canberra: Major Cities Unit, Department of Infrastructure and Transport; 2011.
50. State Government of New South Wales. Sydney over the next 20 years: a discussion paper. NSW Government; 2012 Available from: http://strategies.planning.nsw. gov.au/Portals/0/Documents/Metro_strategy_discussion_May_2012.pdf [Verified 7 August 2014]. 51. Thompson SM, Capon A. Designing for health. Landscape Archit Austr 2012; 134: 26. 52. Thompson SM. Creating healthy built environments. Inner Sydney Voice 2014; Winter: 14–17. 53. Kirk SFL, Penney TL, McHugh TLF. Characterizing the obesogenic environment: the state of the evidence with directions for future research. Obes Rev 2010; 11(2): 109–17. doi:10.1111/j.1467-789X.2009.00611.x 54. Cunningham GO, Michael YL. Concepts guiding the study of the impact of the built environment on physical activity for older adults: a review of the literature. Am J Health Promot 2004; 18(6): 435–43. doi:10.4278/0890-1171-18.6.435 55. Davison KK, Lawson CT. Do attributes in the physical environment influence children’s physical activity? A review of the literature. Int J Behav Nutr Phy 2006; 3(1): 19. doi:10.1186/1479-5868-3-19 56. Black JL, Macinko J. Neighborhoods and obesity. Nutr Rev 2008; 66(1): 2–20. doi:10.1111/j.1753-4887.2007.00001.x 57. Tzoulas K, Korpela K, Venn S, Tli-Pelkonen V, Kaźmierczak A, Niemela J, et al. Promoting ecosystem and human health in urban areas using green infrastructure: a literature review. Landscape Urban Plan 2007; 81(3): 167–78. doi:10.1016/ j.landurbplan.2007.02.001 58. Reynolds CCO, Harris MA, Teschke K, Cripton PA, Winters M. The impact of transportation infrastructure on bicycling injuries and crashes: a review of the literature. Environ Health 2009; 8(1): 47. doi:10.1186/1476-069X-8-47 59. Story M, Giles-Corti B, Yaroch AL, Cummins S, Frank LD, Huang TT, et al. Work groups IV: future directions for measures of the food and physical activity environments. Am J Prev Med 2009; 36(Suppl 4): S182–8. doi:10.1016/j.amepre.2009.01.008 60. Faulkner GEJ, Buliung RN, Flora PK, Fusco C. Active school transport, physical activity levels and body weight of children and youth: a systematic review. Prev Med 2009; 48(1): 3–8. doi:10.1016/j.ypmed.2008.10.017 61. Handy S, Cao X, Mokhtarian P. Active travel: the role of self-selection in explaining the effect of built environment on active travel. California: Active Living Research, Robert Wood Johnson Foundation; 2009. 62. Renalds A, Smith TH, Hale PJ. A systematic review of built environment and health. Fam Community Health 2010; 33(1): 68–78. doi:10.1097/FCH.0b013e3181c4e2e5 63. Brownson RC, Haire-Joshu D, Luke DA. Shaping the context of health: a review of environmental and policy approaches in the prevention of chronic diseases. Annu Rev Public Health 2006; 27: 341–70. doi:10.1146/annurev.publhealth.27.021405. 102137 64. Bauman A, Bull F. Environmental correlates of physical activity and walking in adults and children: a review of reviews. London: National Institute of Health and Clinical Excellence; 2007. 65. Gebel K, King L, Bauman A, Vita P, Gill T, Rigby A. et al. Creating healthy environments: a review of links between the physical environment, physical activity and obesity. Sydney: NSW Health Department and NSW Centre for Overweight and Obesity; 2005. 66. Ogilvie D, Mitchell R, Mutrie N, Petticrew M, Platt S. Evaluating health effects of transport interventions – methodologic case study. Am J Prev Med 2006; 31(2): 118–26. doi:10.1016/j.amepre.2006.03.030 67. Cavill N, Kahlmeier S, Rutter H, Racioppi F, Oja P. Economic analyses of transport infrastructure and policies including health effects related to cycling and walking: a systematic review. Transport Policy 2008; 15(5): 291–304. doi:10.1016/j.tranpol. 2008.11.001 68. Cullingworth B, Nadin V. Town and country planning in the UK (14th edition). London: Routledge; 2006. 69. HBEP (Healthy Built Environments Program). Stakeholder consultation report: informing a research strategy in NSW. Sydney: The Healthy Built Environments Program; 2011 Available from: http://www.be.unsw.edu.au/sites/default/files/ upload/research/centres/cf/researchprograms/healthy_built_environments_program/research/Stakeholder_Consultation_Report2011.pdf [Verified 23 May 2014].
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Capacity Building
Building partnerships for healthy environments: research, leadership and education Susan Thompson A,D, Jennifer Kent B and Claudine Lyons C A
City Futures Research Centre, University of New South Wales, Sydney, NSW 2052, Australia. Department of Environment and Geography, Macquarie University, Sydney, NSW 2109, Australia. C New South Wales Ministry of Health, 73 Miller Street, North Sydney, NSW 2060, Australia. D Corresponding author. Email: [email protected] B
Abstract As populations across the globe face an increasing health burden from rising rates of obesity, diabetes and other lifestyle-related diseases, health professionals are collaborating with urban planners to influence city design that supports healthy ways of living. This paper details the establishment and operation of an innovative, interdisciplinary collaboration that brings together urban planning and health. Situated in a built environment faculty at one of Australia’s most prestigious universities, the Healthy Built Environments Program (HBEP) partners planning academics, a health non-government organisation, local councils and private planning consultants in a state government health department funded consortium. The HBEP focuses on three strategic areas: research, workforce development and education, and leadership and advocacy. Interdisciplinary research includes a comprehensive literature review that establishes Australian-based evidence to support the development, prioritisation and implementation of healthy built environment policies and practices. Another ongoing study examines the design features, social interventions and locational qualities that positively benefit human health. Formal courses, workshops, public lectures and e-learning develop professional capacity, as well as skills in interdisciplinary practice to support productive collaborations between health professionals and planners. The third area involves working with government and non-government agencies, and the private sector and the community, to advocate closer links between health and the built environment. Our paper presents an overview of the HBEP’s major achievements. We conclude with a critical review of the challenges, revealing lessons in bringing health and planning closer together to create health-supportive cities for the 21st century.
Key words: collaboration, interdisciplinary, partnerships, planning, preventive health. Received 29 May 2014, accepted 10 August 2014, published online 1 December 2014
Introduction Planning, creating and managing built environments to encourage physical activity is a demanding health priority. It requires close partnership between researchers, practitioners and policymakers across many sectors.1,2 The fundamental importance of collaboration in this area was recently acknowledged by the American Journal of Health Promotion, which dedicated its first special issue for 2014 to the integration of research, policy and practice for active living.3 This special issue followed the 2013 conference of the Active Living Research program, which explored a similar theme. A common message in these various commentaries is the need to map and record the emergence of synergies between the ‘processes, policies, politics, and people’1(pS1) required to generate active-living environments. This paper contributes to these records by detailing an Australian initiative based in New South Wales (NSW) – the Healthy Built Journal compilation Ó Australian Health Promotion Association 2014
Environments Program (HBEP). Initiated by a state health agency, the Program is uniquely situated within an urban planning and design context, and has a strong environmental sustainability focus. We begin our paper by situating the HBEP in the broader theoretical terrain and then shift to an overview of how it came into existence. In the section that follows, we briefly describe the main activities and achievements of the Program. The paper finishes with a critical discussion of the challenges in this interdisciplinary arena, exposing lessons for others working to create healthy built environments.
The theoretical terrain: the relationship between health and the built environment Over the last generation there has been a shift in conceptualisations of health and disease, from the treatment of illness in the individual to disease prevention and health promotion in populations. This has included increased focus on the impact of environments on CSIRO Publishing
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collective well being4,5 and on the interdependence of environments and individual behaviour.4,6–8 Built environments have subsequently emerged as a focus in health research. This reinvigoration of the health-built environment interdisciplinary relationship embraces a range of themes. These include the built environment’s impact on opportunities for utilitarian and recreational physical activity;9–12 healthy food access;13,14 exposure to nature and green space;15,16 community building;17,18 noise abatement;19 air pollution20 and crime.21 Theoretically, this shift reflects the growing ecological orientation of the health promotion field.4,5,22,23 Ecological models of health promotion are underpinned by the understanding that healthpromoting and preventing interventions need to be considered across multiple levels and contexts. The ecological orientation emphasises that the most effective health interventions will be tailored to place24and the people living in that place. It acknowledges that individuals of different ages,25 socio-economic and cultural backgrounds26–28 and genders29 will respond to health-promoting interventions in varying ways. Ecological theories also recognise the role of educational programs, policy change and economic incentives,30 and work with more targeted medical interventions by providing supportive environments for change. In short, ecological models are based on the idea that comprehensive approaches to health promotion need to consider interventions at multiple policy and practice scales and in different geographical and demographic contexts. The ecological orientation has been used to demonstrate links between the modern epidemics of chronic non-communicable diseases and the way we live in cities. As a result, health professionals increasingly recognise that the built environment directly affects people’s health. Further, and most importantly, there is growing appreciation of the central role that urban planners play in providing environments that support healthy behaviour. Indeed, and perhaps ironically, this goes back to the origins of the planning discipline, which arose out of concerns for human health.31 A century ago, planning was strongly aligned with public health objectives to prevent the spread of contagious diseases. Nevertheless, this close relationship was not sustained as planning moved to focus on urban policy development, design and environmental sustainability – away from a focus on public health–related concerns.32
Healthy built environments in Australia In Australia, the health sector has spearheaded policy initiatives to bridge health and the environment. In 2009, the Australian Government undertook national assessments of health promotion and the health system more generally.33 The opinions of urban planners and designers informed key recommendations emerging from these reviews. While both state and federal governments in Australia look after different parts of the health care system, the state has primary responsibility for hospitals. This can provide an incentive
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for investment in preventive health to reduce the cost burden of hospital-based care. Keeping people well, however, is very much about providing environments that support healthy behaviour. Over the past two decades, the NSW state health agency, NSW Health, has intensified its engagement in bringing this about. The aim has been to increase the agency’s influence over the shape of the urban environment to sustain health and well being. The need to engage with the systems and processes that determine built environments was identified as a key priority for the NSW Government in the first NSW State Plan.34 Further clarification about the role that urban planning plays in relation to health was also contained in the NSW State Health Plan 2006–2010.35 In addition, the 2007 health-prevention strategy Healthy People NSW prioritised action to ‘create environments that promote health and well being’.36(p17) This strategy identified health impact assessment (HIA) as a key ‘tool to strengthen health input into planning decisions’.36(p18) This focus on health and planning issues has been maintained throughout government electoral changes and significant structural health reforms at both state and federal levels. The most recent health prevention strategy, 2012–2017, includes action to be taken on building and maintaining healthy environments as a key priority.37 Workforce development is key to bridging the theoretical and practical differences between the disciplines of planning and health professionals. NSW Health has invested in a capacity-building program for its staff on the use of HIA,38 and during the last ten years HIAs have successfully been used on several projects with local and regional partners (for an example, see Neville et al.39). To further support the development of NSW Health staff’s capacity to influence healthy design and the built environment, the Healthy Urban Development Checklist was created.40 The Checklist assists health staff in providing feedback and advice on development policies, plans and proposals. In addition, it facilitates partnerships and collaboration between NSW Health, planners and developers. NSW Health has also focused on inter and intrasectoral partnership building. From 2004 as a founding member of the NSW Premier’s Council for Active Living (PCAL), NSW Health championed projects to strengthen the physical and social environments in which communities engage in active living.41 As well, NSW Health entered into a partnership with the NSW Commission for Children and Young People in 2011 to look at a range of age-specific, built-environment concerns.42 In summary, the provision and promotion of healthy built environments is now one of NSW Health’s key preventive health priorities. With the built environment increasingly viewed as an important determinant of health, and the evidence base continuing to grow, NSW Health realised that more was required. This extended to supporting a comprehensive framework for building workforce capacity, as well as a strategic method of supporting policy-relevant,
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built-environment research. Knowing that this is a cross-sectoral issue with significant complexity, it was considered that an innovative and different approach was required to increase the integration between the health and planning sectors. In the next section we describe this approach.
The Healthy Built Environments Program In 2009, and following a formal tender process, NSW Health selected the City Futures Research Centre, situated in the Faculty of the Built Environment at The University of NSW (UNSW), to establish the Healthy Built Environments Program (HBEP). Under the leadership of an urban planner and public health physician, a five-year contract was awarded to an interdisciplinary consortium from academic, government, private and non-government organisations with expertise across health, urban planning and design. Core funding from NSW Health totalled AUD1.5million over the five-year period 2010–14, with infrastructural support from UNSW. The Program was established to spearhead a fresh approach to the integration of the health and planning sectors in NSW. Situated in one of Australia’s largest faculties of the built environment, the HBEP includes all of the design and planning disciplines concerned with individual buildings (their interiors and what is between them), through neighbourhoods, to the urban region, city and beyond. Positioning the Program within a built environment faculty offers the opportunity to influence the builtenvironment professions to incorporate healthy-planning provisions in their training, strategic direction, policy formulations and decision making. The overarching aim of the HBEP is to revitalise the relationship between the built environment and health professions so they can work together to create places – which embrace physical, social and cultural aspects – that support people being healthy in their everyday lives. The Program’s vision is that built environments will be planned, designed, developed and managed to promote and protect health for all people. This vision is realised through the HBEP’s three strategic areas of operation involving its key stakeholders and partners:
(1) Interdisciplinary research on the relationship between health and the built environment (2) Capacity building, education and workforce development (3) Leadership and advocacy on health and the built environment. Outlined below is each strategic area that exemplifies the Program’s interconnected ways of working. These bring the interdisciplinary efforts of researchers, educators, practitioners and policymakers from the built environment and health sectors together in the prevention of contemporary chronic disease. We also provide examples of the results of the HBEP’s work, illustrating how it has been translated into policy and practice, as well as building the capacity of students and professionals to implement healthy built environments. More information, together with access to the resources mentioned below,
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is available from the comprehensive Healthy Built Environments Program website.43
1. Research The HBEP fosters interdisciplinary research which is policy relevant for professionals working in urban planning, design and public health. A Research Strategy to facilitate the development of such priorities was completed in 2012. The Strategy was informed by the research gaps identified in the comprehensive Literature Review undertaken by the HBEP.44 This scholarly work examines the role of the built environment in supporting human health as part of everyday living. The principal aim was to establish a robust evidence base to support the development, prioritisation and implementation of healthy builtenvironment policies and practices. The Literature Review proposes three key built-environment ‘domains’ to support health and well being:
(i) The built environment and getting people active (ii) The built environment and connecting and strengthening communities (iii) The built environment and providing healthy food options. These domains address three of the major risk factors that cause chronic disease in the Australian community – physical inactivity, obesity and social isolation. In 2012, supplementing the lengthy Literature Review, a set of concise Fact Sheets was released to facilitate enhanced practitioner engagement with the research. In recognition of its successful research–policy interface, the project won an Excellence Award from the NSW Division of the Planning Institute of Australia. The HBEP is engaged in other research projects supported by a range of institutions. An Australian Research Council Linkage Grant has funded an examination of how different urban environments sustain health and well being. A detailed built environmental audit instrument has been developed as part of this study.45 Healthy food availability has also been investigated,46 and in-depth interviews about how the diverse residential environments support everyday healthy behaviour are currently underway. In 2011, the HBEP completed a smaller project funded by the Australian Housing and Urban Research Institute. This work involved a focused examination of the health impacts of housing, with an emphasis on exploring interdisciplinary policy–practice relationships across health and housing disciplines.47 The HBEP is contributing to building the research evidence to influence policy and practice. It has informed policy development and implementation at the state government level in two key areas: initiatives instigated by the NSW Ministry of Health; and guiding the Ministry’s collaborations with other government agencies such as the NSW Commission for Children and Young People.42 As an example, the NSW Healthy Eating and Active Living Strategy48 includes ‘environments to support healthy eating and active living’ as its number one strategic direction. Under this cross-government initiative, Transport for NSW has committed to create public
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infrastructure for active travel. In addition, the NSW Department of Planning and Environment plan to deliver healthy built environments through incorporating active-living principles into infrastructure development and design, as well as providing accessible open spaces. Research is used by Local Health Districts for evidence-based policy development and to assist in making informed responses on state and local planning proposals. The HBEP Literature Review also featured in the 2011 State of Australian Cities Report49 prepared by the then federal government’s Major Cities Unit. The Review was also cited by the NSW Department of Planning and Infrastructure in its consultation papers for the development of a new Sydney Metropolitan Strategy, a key state planning document.50
2. Capacity building, education and workforce development The HBEP undertakes innovative, cross-disciplinary educational activities to build the capacity of practitioners to deliver healthy built environments. While the focus is on the NSW health workforce, urban planners and community workers, together with medical practitioners, have attended a raft of diverse HBEP educational programs. During 2013 the HBEP presented a series of day-long workshops across 12 rural and metropolitan regions, with just under 260 enrolments. Participants learnt about the NSW planning system and how to consider the health implications of policies, plans and development proposals to influence decision making in planning, taking this knowledge back to the workplace. A variety of shorter seminars, public lectures, interactive forums and e-learning opportunities also feature in the HBEP’s educational portfolio. The HBEP’s education remit extends to tertiary courses at UNSW. In the first year of its operation, HBEP established a postgraduate interdisciplinary elective called Healthy Built Environments, complementing the existing undergraduate course Healthy Planning. The HBEP has made it possible for up to six health professionals to take part in the course each year, further enhancing the opportunities for interdisciplinary exchange and learning. Doctoral research is also conducted under the umbrella of the HBEP. To date, research topics have encompassed cultural barriers to the uptake of active transport, planning for healthy ageing in a supportive built environment, the implications of hotter temperatures for activities in public spaces, and the importance of local neighbourhood green space and connecting walkways for older residents.
3. Leadership and advocacy Leadership and advocacy to bring health and the built environment closer together is the third area of focus for the HBEP. This has involved stakeholder partnerships with government and nongovernment agencies, the private sector and the community. Of particular note is the Program’s Advisory Board comprising healthy built-environment stakeholders representing academia, government, and the not-for-profit and private sectors.
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An important aspect of the HBEP’s leadership and advocacy activities are its regular submissions to major inquiries that review planning and health regulation and policy. We have made submissions on Australia’s National Urban Policy, different stages of the NSW Planning System Review and several reviews of the Sydney Metropolitan Strategy. In every case, the HBEP’s submissions argue for inclusion of health as a foundation of a sustainable environment. A particularly significant outcome of this work has been the inclusion of a specific health objective in the NSW Planning Bill 2013 – the first time that such an objective has appeared in state planning legislation. While subject to the parliamentary process and potential amendment, if successful it will put the State at the vanguard of national and international best practice. Together with other key stakeholders, HBEP has had an important role in the inclusion of the health objective. In addition to these initiatives, presentations are frequently given to health and built-environment professionals, including at conferences and industry meetings. Information is also regularly disseminated via the HBEP’s quarterly e-newsletter, and other professional, industry and community magazines (for example, Thompson and Capon;51 Thompson52). Since its inception, a regular ‘Healthy Built Environments’ column in the Planning Institute of Australia’s NSW journal New Planner has made a significant contribution to the knowledge base of the urban planning profession in NSW. This column provides an excellent platform to inform planning practitioners and city policy makers about the latest research and policy in healthy built environments, inspiring the profession to plan healthy and sustainable spaces and places. All columns are placed on the HBEP website.
Challenges in moving forward Progression of the healthy built-environments agenda requires formation of strong interdisciplinary relationships. This process will inevitably encounter practical and theoretical discord that needs to be acknowledged and addressed. Common themes of friction identified through our experience relate to different understandings of the complexity of context, different ways of thinking about the nature of evidence required to justify policy change, and more general misconstructions about ways to mix policies and disciplines. A further complicating factor is the political context in which policy is developed and implemented. These themes highlight some of the practical challenges to planning for healthy built environments, revealing lessons for others working to create healthy and resilient cities for the 21st century.
Context The need for consistent and objective measurement of built environment and physical activity variables is a commonly cited weakness in research on the built environment and health. As an example, Kirk et al.53 recommend standardisation of measurement in seeking to characterise ‘obesogenic’ environments. This
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comprehensive review of 146 primary studies concludes that the ‘environment may play a critical role in obesity development, prevention and management, but we have yet to determine the best method for measuring that effect accurately and consistently, or develop an appropriate theory to encompass this very complex and dynamic system’.53(p116) Other studies recommend consistency in measurement of built environment variables (see for example Heinen et al.,12 Cunningham and Michael,54 and Davison and Lawson55); nevertheless, there are disadvantages in waiting until there are no gaps or inconsistencies in our knowledge. It will be difficult to obtain consensus as to when, if ever, this point has arrived. There will be differing interpretations about the evidence and how it should translate into policy. Government priorities will also shift in an evolving political climate. Further, policy responses will differ according to spatial context, demographic, social and cultural character, environmental quality and temporality. As an example, NSW covers an area of ~800,628 km2, and while the population is highly urbanised, the distances between regional centres create significant practical issues. These range from the need to respond and work with communities from diverse cultural backgrounds and in a variety of social contexts, to the requirement to take into account the health impacts of different bio-physical geographies. Distance, in itself, presents difficulties; it isolates professionals, limits opportunities for education and acts as an impediment to workforce retention. Recommendations for standardised measurements risk underestimating NSW’s geographical and cultural diversity and the complexity of people in place. This is particularly the case when attempts are made to compare results between and across populations and locations. And while there is a role for standardising some variables (such as the use of body mass index (BMI) as a way to define the healthy weight range), standardised measures should not be viewed as a prerequisite to prove the relationship between the built environment and health. Acknowledging contextuality in relation to research into the health determinants of place must not be viewed as an impediment to the search for elements of commonality but needs to be taken seriously in both the application of research to policy, and the design of future research agendas. Research on health and the built environment has addressed ways to avoid the ‘excuse’ of context (see, for example, Black and Macinko56), with the strongest recommendation being that methods should be transparent and at least situated within, but not necessarily echoing, the existing research agenda. This implies that future research should build on the findings of previous work, and comprehensively detail the measures and methods used.
Evidence of causality Linked to the common call for standardisation is an identified need to establish that the relationship between the built environment and health is a causal relationship. Studies have consistently found a
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significant association between health and the built environment; however. associations are insufficient to establish true causality. A failure to account for confounding variables (such as residential selfselection) is often cited as a major weakness in research on the healthbuilt environment relationship.10,57–59 The lack of longitudinal research required to prove time precedence is also identified as another missing element of causal proof.11,12,58,60–62 This inability of the research agenda to date to establish true causality is a ‘weakness’ perhaps not of the research itself but of the seemingly unpredictable way people relate to their environments. Juxtaposed to the call for causality is research accepting that the randomised-controlled trials often underpinning causal proof are impractical for studies on the built environment and health simply because it is impossible to randomly assign exposure to built-environment modifications.63,64 This scholarship suggests that the constant focus on causality is a weakness of the research agenda in itself. Further, attention would be better directed towards the establishment of a more practical standard of proof acceptable in the absence of causality.59,65–67 This standard would need to incorporate the results of qualitative as well as quantitative research. The question about evidence cuts to a core division between the health and urban planning disciplines. Traditionally, the nature of evidence used by planners to develop policy is different from that used by public health officials. Australian urban planning’s early- to mid-20th century focus on greenbelt cities, for example, was based on an historical appreciation of the health benefits of open space for overcrowded and dirty cities.68 Schemes such as Sydney’s County of Cumberland Plan and Perth’s Endowment Lands project reflect this appreciation. Basing policy change on an ‘appreciation’, rather than hard evidence, poses a problem for a public health–based intervention.
Mixing policies and disciplines Research on the links between health and the built environment often concludes with the acknowledgement that structural modifications to the built environment need to be part of a policy mix if they are to be successful. For example, Ewing and Cervero’s10 ‘elasticity’ theory gives quantifiable justification that active transport behaviour is unresponsive to small-scale, built-environment modifications but responsive to an integrated range of builtenvironment modifications, educational programs, incentives and restrictions. Theoretically, this conceptualisation reflects the increasingly ecological orientation of the health promotion field described in this paper’s introduction. To change practices, however, an ecological approach requires consistent and meaningful interdisciplinary collaboration. This necessitates seeking new, potentially more comprehensive ways of understanding the impacts of policy development, amendment and implementation. It also demands that both researchers and practitioners from the built environment and health recognise that their accepted wisdoms and assumptions are not necessarily shared, nor understood, beyond
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their own disciplinary boundaries. Successful healthy builtenvironment partnerships rest on deliberative interdisciplinary engagement. At its heart is an eagerness to listen and learn about the other. This extends from disciplinary culture to ways of collecting and measuring data, reporting results and the subsequent translation into policy. The complexity of health prevention in modern society demands interdisciplinary collaboration. However, perhaps the biggest challenge facing planning for healthy built environments is the ongoing need to appeal to economic and political agendas, including the timeframes laid down by the electoral cycle. The economic imperative was highlighted in our research with health and built-environment policy makers who identified cost–benefit analysis tools as critical in enabling better advocacy for the provision of built-environment interventions to improve health.69 Nevertheless, it is not an easy task to provide the ‘proof’ to justify action. The need for healthy built environments to recognise context problematises the provision of such proof. Ongoing success in this area requires the adoption of a long-term perspective in assessing possible health, social and economic outcomes.
Conclusion There is a strong relationship between people’s health and the built environment. This relationship is complex and contextual, and translating this framework into action requires the development of interdisciplinary working relationships. These relationships must be based on mutual understanding and respect. Our paper has detailed the development of an innovative, interdisciplinary collaboration that has achieved significant research-policy translation and education outcomes by bringing urban planning and health together. The experiences of the HBEP demonstrate that very real differences exist in the research and practical traditions unique to professionals working in this area. While these disparities are not insurmountable, they do indicate that this is a discipline area that is in its infancy. A fuller evaluation of the Program, which is currently underway, will no doubt further elaborate on these issues. The HBEP is proud to be playing a part in the development of the discipline in Australia, contributing to the creation of built environments that promote the health and well being of all communities.
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Acknowledgements An earlier version of this paper was presented to the joint Association of European Schools of Planning (AESOP) and the American Association of Collegiate Schools of Planning (ACSP) Congress, Planning for Resilient Cities and Regions, Dublin, Ireland, 15–19 July 2013.
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