Planning, implementing and governing systems-based co-creation: the DISCOVER framework.

BACKGROUND: Increasingly, public health faces challenges requiring complex, multifaceted and multi-sectoral responses. This calls for systems-based approaches that facilitate the kind of collective and collaborative thinking and working required to address complexity. While the literature on systems thinking, system dynamics and the associated methodologies is extensive, there remains little clear guidance on how to plan, govern and implement participatory systems approaches within a co-creation process. METHODS: We used a three-step process to develop DISCOVER, a framework for implementing, and governing systems-based co-creation: Stage 1: We conducted a literature analysis of key texts to identify well-documented methods and phases for co-creation using a systems approach, as well as areas where gaps existed. Stage 2: We looked for the most appropriate methods and approaches to fill the gaps in the knowledge production chain. Stage 3: We developed the framework, identifying how the different tools and approaches fit together end-to-end, from sampling and recruiting participants all the way through to responding with an action plan. RESULTS: We devised DISCOVER to help guide researchers and stakeholders to collectively respond to complex social, health and wider problems. DISCOVER is a strategic research planning and governance framework that provides an actionable, systematic way to conceptualise complex problems and move from evidence to action, using systems approaches and co-creation. In this article, we introduce the eight-step framework and provide an illustrative case study showcasing its potential. The framework integrates complementary approaches and methods from social network analysis, systems thinking and co-creation literature. The eight steps are followed sequentially but can overlap. CONCLUSIONS: DISCOVER increases rigour and transparency in system approaches to tackling complex issues going from planning to action. It is being piloted in environmental health research but may be suitable to address other complex challenges and could be incorporated into research proposals and protocols for future projects.

Factors influencing usage of urban blue spaces: A systems-based approach to identify leverage points.

Urban blue spaces may have salutogenic health benefits. It is crucial to understand the factors that influence the use of urban blue spaces so that urban populations can benefit equitably. A system map of factors influencing usage was developed by qualitatively analysing 203 intercept interviews conducted with people actively using the towpath along the canal in North Glasgow, Scotland. Network analysis was used to analyse the system map's structure identifying Exercise & Health and Urban Nature as key leverage points and Cleanliness & Maintenance as the key area for improvement. Findings could be used to inform the management, governance and revitalisation of urban blue spaces with the ultimate aim of maximising their potential to be equitable, sustainable and salutogenic.

Investigating the association between regeneration of urban blue spaces and risk of incident chronic health conditions stratified by neighbourhood deprivation: A population-based retrospective study, 2000-2018.

Chronic non-communicable diseases are leading causes of poor health and mortality worldwide, disproportionately affecting people in highly deprived areas. We undertook a population-based, retrospective study of 137,032 residents in Glasgow, Scotland, to investigate the association between proximity to urban blue spaces and incident chronic health conditions during a canal regeneration programme. Hazard ratios (HRs) were estimated using Cox proportional hazards models adjusted for age and sex, with the incidence of a given health condition as the dependent variable. The analyses were stratified by socioeconomic deprivation tertiles. We found that, in areas in the highest deprivation tertile, proximity to blue space was associated with a lower risk of incident cardiovascular disease (HR 0.85, 95% Confidence Interval (CI) 0.76-0.95), hypertension (HR 0.85, 95% CI 0.79-0.92), diabetes (HR 0.88, 95% CI 0.83-0.94), stroke (HR 0.85, 95% CI 0.77-0.94) and obesity (HR 0.90, 95% CI 0.86-0.94), but not chronic pulmonary disease, after adjusting for age and sex covariates. In middle and low deprivation tertiles, living closer to the canal was associated with a higher risk of incident chronic pulmonary disease (middle: HR 1.56, 95% CI 1.24-1.97, low: HR 1.34, 95% CI 1.05-1.73). Moreover, in the middle deprivation tertile, a higher risk of stroke (HR 1.36, 95% CI 1.02-1.81) and obesity (HR 1.14, 95% CI 1.01-1.29) was observed. We conclude that exposure to blue infrastructure could be leveraged to mitigate some of the health inequalities in cities.

Urban Blue Spaces as Therapeutic Landscapes: "A Slice of Nature in the City".

Urban blue spaces are defined as all natural and manmade surface water in urban environments. This paper draws on how the concepts of experienced, symbolic, social, and activity space combine to position urban blue spaces as therapeutic landscapes. We conducted 203 intercept interviews between 12 October 2019 and 10 November 2019. Although safety concerns had health-limiting impacts, interacting with the Glasgow Canal and surrounding landscape was predominantly perceived as health-enhancing. Our findings build on current evidence, which has suggested that urban blue spaces, particularly canals, may foster therapeutic properties, contributing to healthier city environments. Further research is required to understand better the interconnectedness of urban blue spaces and health and how such spaces can be best developed and managed to improve the health outcomes of local populations.

A population-based retrospective study of the modifying effect of urban blue space on the impact of socioeconomic deprivation on mental health, 2009-2018.

The incidence of mental health disorders in urban areas is increasing and there is a growing interest in using urban blue spaces (urban waterways, canals, lakes, ponds, coasts, etc.) as a tool to manage and mitigate mental health inequalities in the population. However, there is a dearth of longitudinal evidence of the mechanisms and impact of blue spaces on clinical markers of mental health to support and inform such interventions. We conducted a 10-year retrospective study, following STROBE guidelines, using routinely collected population primary care health data within the National Health Service (NHS) administrative area of Greater Glasgow and Clyde for the North of Glasgow city area. We explored whether living near blue space modifies the negative effect of socio-economic deprivation on mental health during the regeneration of an urban blue space (canal) from complete dereliction and closure. A total of 132,788 people (65,351 female) fulfilling the inclusion criteria were entered in the analysis. We established a base model estimating the effect of deprivation on the risk of mental health disorders using a Cox proportional hazards model, adjusted for age, sex and pre-existing comorbidities. We then investigated the modifying effect of living near blue space by computing a second model which included distance to blue space as an additional predicting variable and compared the results to the base model. Living near blue space modified the risk of mental health disorders deriving from socio-economic deprivation by 6% (hazard ratio 2.48, 95% confidence interval 2.39-2.57) for those living in the most deprived tertile (T1) and by 4% (hazard ratio 1.66, 95% confidence interval 1.60-1.72) for those in the medium deprivation tertile (T2). Our findings support the notion that living near blue space could play an important role in reducing the burden of mental health inequalities in urban populations.

Mechanisms of Impact of Blue Spaces on Human Health: A Systematic Literature Review and Meta-Analysis.

Blue spaces have been found to have significant salutogenic effects. However, little is known about the mechanisms and pathways that link blue spaces and health. The purpose of this systematic review and meta-analysis is to summarise the evidence and quantify the effect of blue spaces on four hypothesised mediating pathways: physical activity, restoration, social interaction and environmental factors. Following the PRISMA guidelines, a literature search was conducted using six databases (PubMed, Scopus, PsycInfo, Web of Science, Cochrane Library, EBSCOHOST/CINAHL). Fifty studies were included in our systematic review. The overall quality of the included articles, evaluated with the Qualsyst tool, was judged to be very good, as no mediating pathway had an average article quality lower than 70%. Random-effects meta-analyses were conducted for physical activity, restoration and social interaction. Living closer to blue space was associated with statistically significantly higher physical activity levels (Cohen's d = 0.122, 95% CI: 0.065, 0.179). Shorter distance to blue space was not associated with restoration (Cohen's d = 0.123, 95% CI: -0.037, 0.284) or social interaction (Cohen's d = -0.214, 95% CI: -0.55, 0.122). Larger amounts of blue space within a geographical area were significantly associated with higher physical activity levels (Cohen's d = 0.144, 95% CI: 0.024, 0.264) and higher levels of restoration (Cohen's d = 0.339, 95% CI: 0.072, 0.606). Being in more contact with blue space was significantly associated with higher levels of restoration (Cohen's d = 0.191, 95% CI: 0.084, 0.298). There is also evidence that blue spaces improve environmental factors, but more studies are necessary for meta-analyses to be conducted. Evidence is conflicting on the mediating effects of social interaction and further research is required on this hypothesised pathway. Blue spaces may offer part of a solution to public health concerns faced by growing global urban populations.

The Impact of Regeneration and Climate Adaptations of Urban Green-Blue Assets on All-Cause Mortality: A 17-Year Longitudinal Study.

Urban waterways are underutilised assets, which can provide benefits ranging from climate-change mitigation and adaptation (e.g., reducing flood risks) to promoting health and well-being in urban settings. Indeed, urban waterways provide green and blue spaces, which have increasingly been associated with health benefits. The present observational study used a unique 17-year longitudinal natural experiment of canal regeneration from complete closure and dereliction in North Glasgow in Scotland, U.K. to explore the impact of green and blue canal assets on all-cause mortality as a widely used indicator of general health and health inequalities. Official data on deaths and socioeconomic deprivation for small areas (data zones) for the period 2001-2017 were analysed. Distances between data zone population-weighted centroids to the canal were calculated to create three 500 m distance buffers. Spatiotemporal associations between proximity to the canal and mortality were estimated using linear mixed models, unadjusted and adjusted for small-area measures of deprivation. The results showed an overall decrease in mortality over time (ß = -0.032, 95% confidence interval (CI) [-0.046, -0.017]) with a closing of the gap in mortality between less and more affluent areas. The annual rate of decrease in mortality rates was largest in the 0-500 m buffer zone closest to the canal (-3.12%, 95% CI [-4.50, -1.73]), with smaller decreases found in buffer zones further removed from the canal (500-1000 m: -3.01%, 95% CI [-6.52, 0.62]), and 1000-1500 m: -1.23%, 95% CI [-5.01, 2.71]). A similar pattern of results was found following adjustment for deprivation. The findings support the notion that regeneration of disused blue and green assets and climate adaptions can have a positive impact on health and health inequalities. Future studies are now needed using larger samples of individual-level data, including environmental, socioeconomic, and health variables to ascertain which specific elements of regeneration are the most effective in promoting health and health equity.