What are the lessons from COVID-19 for creating healthy, sustainable, resilient future cities?

The COVID-19 pandemic has disrupted lives and the economy, reminding the global community of the devastating health and economic impacts of uncontrolled infectious disease. It has affected how and where people live, work, shop, and play, and exposed our cities' vulnerabilities, leading to calls for a health lens to be applied in designing, approving, and evaluating city plans. Socioeconomic, spatial and health inequities have been amplified, particularly for those living in inadequate or poorly designed housing, neighbourhoods, and cities. Hence, city mayors have committed to 'build back better' with all daily living amenities within a 15-min walking or cycling trip. Designed well, these cities have the potential to be healthier, more sustainable, equitable, and resilient. Yet their delivery requires a rethink of city planning. Drawing on lessons from the COVID-19 pandemic, we argue that to reduce the risk of future pandemics, we must mitigate climate change, limit urban expansion, and use nature-based solutions to protect natural habitats and biodiversity. We then explore how healthy, sustainable, and resilient 15-minute cities could be planned to reduce emissions and ensure our cities are more resilient in the event of future crises. Given that higher density housing underpins the success of 15-minute cities, we also examine how to create more resilient housing stock, through well-implemented health-supportive apartment design standards. Finally, we argue that to achieve all this, cross-sector leadership and investment will be vital.

Spatial and socioeconomic inequities in liveability in Australia's 21 largest cities: Does city size matter?

Spatial and area-level socioeconomic variation in urban liveability (access to social infrastructure, public transport, open space, healthy food choices, local employment, street connectivity, dwelling density, and housing affordability) was examined and mapped across 39,967 residential statistical areas in Australia's metropolitan (n = 7) and largest regional cities (n = 14). Urban liveability varied spatially, with inner-city areas more liveable than outer suburbs. Disadvantaged areas in larger metropolitan cities were less liveable than advantaged areas, but this pattern was reversed in smaller cities. Local data could inform policies to redress inequities, including those designed to avoid disadvantage being suburbanised as cities grow and gentrify.

City planning policies to support health and sustainability: an international comparison of policy indicators for 25 cities.

City planning policies influence urban lifestyles, health, and sustainability. We assessed policy frameworks for city planning for 25 cities across 19 lower-middle-income countries, upper-middle-income countries, and high-income countries to identify whether these policies supported the creation of healthy and sustainable cities. We systematically collected policy data for evidence-informed indicators related to integrated city planning, air pollution, destination accessibility, distribution of employment, demand management, design, density, distance to public transport, and transport infrastructure investment. Content analysis identified strengths, limitations, and gaps in policies, allowing us to draw comparisons between cities. We found that despite common policy rhetoric endorsing healthy and sustainable cities, there was a paucity of measurable policy targets in place to achieve these aspirations. Some policies were inconsistent with public health evidence, which sets up barriers to achieving healthy and sustainable urban environments. There is an urgent need to build capacity for health-enhancing city planning policy and governance, particularly in low-income and middle-income countries.

Using open data and open-source software to develop spatial indicators of urban design and transport features for achieving healthy and sustainable cities.

Benchmarking and monitoring of urban design and transport features is crucial to achieving local and international health and sustainability goals. However, most urban indicator frameworks use coarse spatial scales that either only allow between-city comparisons, or require expensive, technical, local spatial analyses for within-city comparisons. This study developed a reusable, open-source urban indicator computational framework using open data to enable consistent local and global comparative analyses. We show this framework by calculating spatial indicators-for 25 diverse cities in 19 countries-of urban design and transport features that support health and sustainability. We link these indicators to cities' policy contexts, and identify populations living above and below critical thresholds for physical activity through walking. Efforts to broaden participation in crowdsourcing data and to calculate globally consistent indicators are essential for planning evidence-informed urban interventions, monitoring policy effects, and learning lessons from peer cities to achieve health, equity, and sustainability goals.

What next? Expanding our view of city planning and global health, and implementing and monitoring evidence-informed policy.

This Series on urban design, transport, and health aimed to facilitate development of a global system of health-related policy and spatial indicators to assess achievements and deficiencies in urban and transport policies and features. This final paper in the Series summarises key findings, considers what to do next, and outlines urgent key actions. Our study of 25 cities in 19 countries found that, despite many well intentioned policies, few cities had measurable standards and policy targets to achieve healthy and sustainable cities. Available standards and targets were often insufficient to promote health and wellbeing, and health-supportive urban design and transport features were often inadequate or inequitably distributed. City planning decisions affect human and planetary health and amplify city vulnerabilities, as the COVID-19 pandemic has highlighted. Hence, we offer an expanded framework of pathways through which city planning affects health, incorporating 11 integrated urban system policies and 11 integrated urban and transport interventions addressing current and emerging issues. Our call to action recommends widespread uptake and further development of our methods and open-source tools to create upstream policy and spatial indicators to benchmark and track progress; unmask spatial inequities; inform interventions and investments; and accelerate transitions to net zero, healthy, and sustainable cities.

Australia in 2030: what is our path to health for all?

CHAPTER 1: HOW AUSTRALIA IMPROVED HEALTH EQUITY THROUGH ACTION ON THE SOCIAL DETERMINANTS OF HEALTH: Do not think that the social determinants of health equity are old hat. In reality, Australia is very far away from addressing the societal level drivers of health inequity. There is little progressive policy that touches on the conditions of daily life that matter for health, and action to redress inequities in power, money and resources is almost non-existent. In this chapter we ask you to pause this reality and come on a fantastic journey where we envisage how COVID-19 was a great disruptor and accelerator of positive progressive action. We offer glimmers of what life could be like if there was committed and real policy action on the social determinants of health equity. It is vital that the health sector assists in convening the multisectoral stakeholders necessary to turn this fantasy into reality. CHAPTER 2: ABORIGINAL AND TORRES STRAIT ISLANDER CONNECTION TO CULTURE: BUILDING STRONGER INDIVIDUAL AND COLLECTIVE WELLBEING: Aboriginal and Torres Strait Islander peoples have long maintained that culture (ie, practising, maintaining and reclaiming it) is vital to good health and wellbeing. However, this knowledge and understanding has been dismissed or described as anecdotal or intangible by Western research methods and science. As a result, Aboriginal and Torres Strait Islander culture is a poorly acknowledged determinant of health and wellbeing, despite its significant role in shaping individuals, communities and societies. By extension, the cultural determinants of health have been poorly defined until recently. However, an increasing amount of scientific evidence supports what Aboriginal and Torres Strait Islander people have always said - that strong culture plays a significant and positive role in improved health and wellbeing. Owing to known gaps in knowledge, we aim to define the cultural determinants of health and describe their relationship with the social determinants of health, to provide a full understanding of Aboriginal and Torres Strait Islander wellbeing. We provide examples of evidence on cultural determinants of health and links to improved Aboriginal and Torres Strait Islander health and wellbeing. We also discuss future research directions that will enable a deeper understanding of the cultural determinants of health for Aboriginal and Torres Strait Islander people. CHAPTER 3: PHYSICAL DETERMINANTS OF HEALTH: HEALTHY, LIVEABLE AND SUSTAINABLE COMMUNITIES: Good city planning is essential for protecting and improving human and planetary health. Until recently, however, collaboration between city planners and the public health sector has languished. We review the evidence on the health benefits of good city planning and propose an agenda for public health advocacy relating to health-promoting city planning for all by 2030. Over the next 10 years, there is an urgent need for public health leaders to collaborate with city planners - to advocate for evidence-informed policy, and to evaluate the health effects of city planning efforts. Importantly, we need integrated planning across and between all levels of government and sectors, to create healthy, liveable and sustainable cities for all. CHAPTER 4: HEALTH PROMOTION IN THE ANTHROPOCENE: THE ECOLOGICAL DETERMINANTS OF HEALTH: Human health is inextricably linked to the health of the natural environment. In this chapter, we focus on ecological determinants of health, including the urgent and critical threats to the natural environment, and opportunities for health promotion arising from the human health co-benefits of actions to protect the health of the planet. We characterise ecological determinants in the Anthropocene and provide a sobering snapshot of planetary health science, particularly the momentous climate change health impacts in Australia. We highlight Australia's position as a major fossil fuel producer and exporter, and a country lacking cohesive and timely emissions reduction policy. We offer a roadmap for action, with four priority directions, and point to a scaffold of guiding approaches - planetary health, Indigenous people's knowledge systems, ecological economics, health co-benefits and climate-resilient development. Our situation requires a paradigm shift, and this demands a recalibration of health promotion education, research and practice in Australia over the coming decade. CHAPTER 5: DISRUPTING THE COMMERCIAL DETERMINANTS OF HEALTH: Our vision for 2030 is an Australian economy that promotes optimal human and planetary health for current and future generations. To achieve this, current patterns of corporate practice and consumption of harmful commodities and services need to change. In this chapter, we suggest ways forward for Australia, focusing on pragmatic actions that can be taken now to redress the power imbalances between corporations and Australian governments and citizens. We begin by exploring how the terms of health policy making must change to protect it from conflicted commercial interests. We also examine how marketing unhealthy products and services can be more effectively regulated, and how healthier business practices can be incentivised. Finally, we make recommendations on how various public health stakeholders can hold corporations to account, to ensure that people come before profits in a healthy and prosperous future Australia. CHAPTER 6: DIGITAL DETERMINANTS OF HEALTH: THE DIGITAL TRANSFORMATION: We live in an age of rapid and exponential technological change. Extraordinary digital advancements and the fusion of technologies, such as artificial intelligence, robotics, the Internet of Things and quantum computing constitute what is often referred to as the digital revolution or the Fourth Industrial Revolution (Industry 4.0). Reflections on the future of public health and health promotion require thorough consideration of the role of digital technologies and the systems they influence. Just how the digital revolution will unfold is unknown, but it is clear that advancements and integrations of technologies will fundamentally influence our health and wellbeing in the future. The public health response must be proactive, involving many stakeholders, and thoughtfully considered to ensure equitable and ethical applications and use. CHAPTER 7: GOVERNANCE FOR HEALTH AND EQUITY: A VISION FOR OUR FUTURE: Coronavirus disease 2019 has caused many people and communities to take stock on Australia's direction in relation to health, community, jobs, environmental sustainability, income and wealth. A desire for change is in the air. This chapter imagines how changes in the way we govern our lives and what we value as a society could solve many of the issues Australia is facing - most pressingly, the climate crisis and growing economic and health inequities. We present an imagined future for 2030 where governance structures are designed to ensure transparent and fair behaviour from those in power and to increase the involvement of citizens in these decisions, including a constitutional voice for Indigenous peoples. We imagine that these changes were made by measuring social progress in new ways, ensuring taxation for public good, enshrining human rights (including to health) in legislation, and protecting and encouraging an independent media. Measures to overcome the climate crisis were adopted and democratic processes introduced in the provision of housing, education and community development.

An ecosystem service perspective on urban nature, physical activity, and health.

Nature underpins human well-being in critical ways, especially in health. Nature provides pollination of nutritious crops, purification of drinking water, protection from floods, and climate security, among other well-studied health benefits. A crucial, yet challenging, research frontier is clarifying how nature promotes physical activity for its many mental and physical health benefits, particularly in densely populated cities with scarce and dwindling access to nature. Here we frame this frontier by conceptually developing a spatial decision-support tool that shows where, how, and for whom urban nature promotes physical activity, to inform urban greening efforts and broader health assessments. We synthesize what is known, present a model framework, and detail the model steps and data needs that can yield generalizable spatial models and an effective tool for assessing the urban nature-physical activity relationship. Current knowledge supports an initial model that can distinguish broad trends and enrich urban planning, spatial policy, and public health decisions. New, iterative research and application will reveal the importance of different types of urban nature, the different subpopulations who will benefit from it, and nature's potential contribution to creating more equitable, green, livable cities with active inhabitants.

Defining pathways to healthy sustainable urban development.

Goals and pathways to achieve sustainable urban development have multiple interlinkages with human health and wellbeing. However, these interlinkages have not been examined in depth in recent discussions on urban sustainability and global urban science. This paper fills that gap by elaborating in detail the multiple links between urban sustainability and human health and by mapping research gaps at the interface of health and urban sustainability sciences. As researchers from a broad range of disciplines, we aimed to: 1) define the process of urbanization, highlighting distinctions from related concepts to support improved conceptual rigour in health research; 2) review the evidence linking health with urbanization, urbanicity, and cities and identify cross-cutting issues; and 3) highlight new research approaches needed to study complex urban systems and their links with health. This novel, comprehensive knowledge synthesis addresses issue of interest across multiple disciplines. Our review of concepts of urban development should be of particular value to researchers and practitioners in the health sciences, while our review of the links between urban environments and health should be of particular interest to those outside of public health. We identify specific actions to promote health through sustainable urban development that leaves no one behind, including: integrated planning; evidence-informed policy-making; and monitoring the implementation of policies. We also highlight the critical role of effective governance and equity-driven planning in progress towards sustainable, healthy, and just urban development.

Achieving the SDGs: Evaluating indicators to be used to benchmark and monitor progress towards creating healthy and sustainable cities.

In 2016, the World Health Organization declared that 'Health is one of the most effective markers of any city's successful sustainable development' (World Health Organisation, 2016). With estimates that around 6.7 billion people will live in cities by 2050, 21st century city planning decisions will play a critical role in achieving the United Nations (UN) Sustainable Development Goals (SDGs). They will determine the city structure and access to health-enhancing (or health-damaging) urban environments, and ultimately lifestyle choices that impact both individual and planetary health. Benchmarking, monitoring and evaluating city planning policies and interventions is therefore critical to optimise urban outcomes. In 2017, the UN adopted a global SDG indicator framework, calling for complementary national and regional indicators to be collected by member countries. UN Habitat has also developed an indicator action framework specifically for cities. This paper examined the extent to which the UN indicators will help cities evaluate their efforts to deliver sustainability and health outcomes. It identified inconsistencies between the two UN indicator frameworks. Many of the SDG indicators assess outcomes, rather than the comprehensive and integrated 'upstream' policies and interventions required to deliver outcomes on-the-ground. Conversely, the UN Habitat framework incorporates intervention indicators, but excludes health outcome indicators. A more comprehensive approach to benchmarking, monitoring and evaluating policies designed to achieve healthy and sustainable cities and assessing spatial inequities is proposed.

Daily Walking among Commuters: A Cross-Sectional Study of Associations with Residential, Work, and Regional Accessibility in Melbourne, Australia (2012-2014).

BACKGROUND: Most research on walking for transport has focused on the walkability of residential neighborhoods, overlooking the contribution of places of work/study and the ease with which destinations outside the immediate neighborhood can be accessed, referred to as regional accessibility. OBJECTIVES: We aimed to examine if local accessibility/walkability around place of work/study and regional accessibility are independently and interactively associated with walking. METHODS: A sample of 4,913 adult commuters was derived from a household travel survey in Melbourne, Australia (2012-2014). Local accessibility was measured as the availability of destinations within an 800-m pedestrian network from homes and places of work/education using a local living index [LLI; 0-3 (low), 4-6, 7-9, and 10-12 (high) destinations]. Regional accessibility was estimated using employment opportunity, commute travel time by mode, and public transport accessibility. Every individual's potential minutes of walking for each level of exposure (observed and counter to fact) were predicted using multivariable regression models including confounders and interaction terms. For each contrast of exposure levels of interest, the corresponding within-individual differences in predicted walking were averaged across individuals to estimate marginal effects. RESULTS: High LLI at home and work/education was associated with more minutes walking than low LLI by 3.9 [95% confidence interval (CI): 2.3, 5.5] and 8.3 (95% CI: 7.3, 9.3) min, respectively, in mutually adjusted models. Across regional accessibility measures, an independent association with walking and an interactive association with LLI at work/education was observed. To take one example, the regional accessibility measure of "Jobs within 30 min by public transport" was associated with 4.3 (95% CI: 2.9, 5.7) more mins walking for high (≥30,000 jobs) compared with low (<4,000 jobs) accessibility in adjusted models. The estimated difference for high vs. low LLI (work/education) (among those with low regional accessibility) was 3.6 min (95% CI: 2.3, 4.8), while the difference for high vs. low regional accessibility (among those with low LLI) was negligible (-0.01; 95% CI: -1.2, 1.2). However, the combined effect estimate for high LLI and high regional accessibility, compared with low on both, was 12.8 min (95% CI: 11.1, 14.5), or 9.3 (95% CI: 6.7, 11.8) min/d walking more than expected based on the separate effect estimates. CONCLUSIONS: High local living (work/education) and regional accessibility, regardless of the regional accessibility measure used, are positively associated with physical activity. High exposure to both is associated with greater benefit than exposure to one or the other alone. https://doi.org/10.1289/EHP3395.

High Life Study protocol: a cross-sectional investigation of the influence of apartment building design policy on resident health and well-being.

INTRODUCTION: The rapid increase in apartment construction in Australia has raised concerns about the impacts of poorly designed and located buildings on resident health and well-being. While apartment design policies exist, their content varies across jurisdictions and evidence on their impact on health and well-being is lacking. This cross-sectional observational study (2017-2021) aims to generate empirical evidence to guide policy decisions on apartment development and help to create healthy, equitable higher-density communities. Objectives include to benchmark the implementation of health-promoting apartment design requirements and to identify associations between requirements and resident health and well-being outcomes. METHODS AND ANALYSIS: Eligible buildings in three Australian cities with different apartment design guidelines will be stratified by area disadvantage and randomly selected (~n=99). Building architects, developers and local governments will be approached to provide endorsed development plans from which apartment and building design features will be extracted. Additional data collection includes a resident survey (~n=1000) to assess environmental stressors and health and well-being impacts and outcomes, and geographic information systems measures of the neighbourhood. The study has 85% power to detect a difference of 0.5 SD in the primary outcome of mental well-being (Warwick-Edinburgh Mental Well-being Scale) at a 5% level of significance. Analyses will compare policy compliance and health-promoting design features between cities and area disadvantage groups. Regression models will test whether higher policy compliance (overall and by design theme) is associated with better health and well-being, and the relative contribution of the neighbourhood context. ETHICS AND DISSEMINATION: Human Research Ethics Committees of RMIT University (CHEAN B 21146-10/17) and the University of Western Australia (RA/4/1/8735) approved the study protocol. In addition to academic publications, the collaboration will develop specific health-promoting indicators to embed into the monitoring of apartment design policy implementation and impact, and co-design research dissemination materials to facilitate uptake by decision makers.

A Case Study of a Natural Experiment Bridging the 'Research into Policy' and 'Evidence-Based Policy' Gap for Active-Living Science.

The translation of research into tangible health benefits via changes to urban planning policy and practice is a key intended outcome of academic active-living research endeavours. Conversely, policy-makers and planners identify the need for policy-specific evidence to ensure policy decisions and practices are informed and validated by rigorously established evidence. In practice, however, these two aspirations rarely meet and a research-translation gap remains. The RESIDE project is a unique longitudinal natural experiment designed to evaluate the health impacts of the 'Liveable Neighbourhoods' planning policy, which was introduced by the Western Australian Government to create more walkable suburbs. This commentary provides an overview and discussion of the policy-specific study methodologies undertaken to quantitatively assess the implementation of the policy and assess its active living and health impacts. It outlines the key research-translation successes and impact of the findings on the Liveable Neighbourhoods policy and discusses lessons learnt from the RESIDE project to inform future natural experiments of policy evaluation.

The impact of a park refurbishment in a low socioeconomic area on physical activity: a cost-effectiveness study.

BACKGROUND: Physical inactivity is the fourth highest cause of death globally and is a major contributor to increases in healthcare expenditure. Improving public open spaces such as parks in areas of low socio-economic position (SEP) may increase recreational physical activity in disadvantaged populations. We assessed the cost-effectiveness of the installation of a play-space in a large metropolitan park in a low socioeconomic area based on changes in physical activity. METHODS: Observational data of visitor counts and activities undertaken in the park before the installation of the new play-scape (T1), at two months (T2) and 14 months post-installation (T3) were obtained for the intervention and a control park (with no refurbishment) located in a high SEP metropolitan area. Observed sitting, standing, and moderate and vigorous-intensity physical activity were converted to yearly MET-h according to age. Costs of the play-scape and ongoing maintenance were obtained from the organisation managing the refurbishment. The incremental cost-effectiveness ratio (ICER) (ratio of incremental cost to incremental effect) was calculated based on the incremental increase in MET-h from T1 to T3 assuming a 20-year lifetime of the play-scape. Observation counts combining moderate and vigorous activity were used in the sensitivity analysis. RESULTS: When compared with T1, at T3 the new play-scape resulted in an overall incremental net gain of 114,114 MET-h (95% UI: 80,476 - 146,096) compared with the control park and an incremental cost effectiveness ratio (or cost per MET-h gained per park visitor) of AUD $0.58 (95% UI: $0.44-$0.80). The sensitivity analysis combining moderate and vigorous activity into one category showed an increase in estimated incremental MET-h of 118,190 (95% CI: 83,528 - 149,583) and a lower incremental cost per MET-h gained of AUD $0.56 (95% UI: $0.43-$0.77). CONCLUSIONS: Using a benchmark of cost-effectiveness for physical activity interventions of AUD $0.60-$1.30, this study suggests that the installation of a play-scape located in a low SEP area is cost-effective based on its potential to facilitate increases in MET-h. It provides much needed preliminary evidence and requires replication elsewhere.

Physical activity-related health and economic benefits of building walkable neighbourhoods: a modelled comparison between brownfield and greenfield developments.

BACKGROUND: A consensus is emerging in the literature that urban form can impact health by either facilitating or deterring physical activity (PA). However, there is a lack of evidence measuring population health and the economic benefits relating to alternative urban forms. We examined the issue of housing people within two distinct types of urban development forms: a medium-density brownfield development in an established area with existing amenities (e.g. daily living destinations, transit), and a low-density suburban greenfield development. We predicted the health and economic benefits of a brownfield development compared with a greenfield development through their influence on PA. METHODS: We combined a new Walkability Planning Support System (Walkability PSS) with a quantitative health impact assessment model. We used the Walkability PSS to estimate the probability of residents' transport walking, based on their exposure to urban form in the brownfield and greenfield developments. We developed the underlying algorithms of the Walkability PSS using multi-level multivariate logistic regression analysis based on self-reported data for transport walking from the Victorian Integrated Survey of Transport and Activity 2009-10 and objectively measured urban form in the developments. We derived the difference in transport walking minutes per week based on the probability of transport walking in each of the developments and the average transport walking time per week among those who reported any transport walking. We then used the well-established method of the proportional multi-cohort multi-state life table model to translate the difference in transport walking minutes per week into health and economic benefits. RESULTS: If adult residents living in the greenfield neighbourhood were instead exposed to the urban development form observed in a brownfield neighbourhood, the incidence and mortality of physical inactivity-related chronic diseases would decrease. Over the life course of the exposed population (21,000), we estimated 1600 health-adjusted life years gained and economic benefits of A$94 million. DISCUSSION: Our findings indicate that planning policies that create walkable neighbourhoods with access to shops, services and public transport will lead to substantial health and economic benefits associated with reduced incidence of physical inactivity related diseases and premature death.

'Punching above their weight': a qualitative examination of local governments' organisational efficacy to improve the social determinants of health.

OBJECTIVE: The World Health Organization calls upon local government worldwide to play a greater role in improving public health by improving the social determinants of health. This research aimed to determine how local governments in Victoria, Australia, conceptualised their organisational efficacy to address public health with reference to their statutory obligations. METHODS: Sixteen in-depth interviews were conducted with Victorian local government health planners. Thematic analysis was used to determine the importance of state health priorities and the perceived organisational efficacy of local government to address health via social determinants. RESULTS: While there were disparities between state and local priorities for health, local government believes it can make an important contribution to improving health through 'upstream' approaches. CONCLUSIONS: Victorian local government has strongly adopted the socio-ecological model of health and is aware of the important role that its diverse policy and program areas play in creating healthy communities. The Victorian State Government's priorities, which adopted a more 'downstream' approach, were less influential. Implications for public health: State governments' priority settings should be responsive to local governments' unique local knowledge of health priorities. There is value in legislating a social determinants role for local government, provided it is supported by state and national government policies that facilitate public health.

A Longitudinal Study Examining Changes in Street Connectivity, Land Use, and Density of Dwellings and Walking for Transport in Brisbane, Australia.

BACKGROUND: Societies face the challenge of keeping people active as they age. Walkable neighborhoods have been associated with physical activity, but more rigorous analytical approaches are needed. OBJECTIVES: We used longitudinal data from adult residents of Brisbane, Australia (40-65 years of age at baseline) to estimate effects of changes in neighborhood characteristics over a 6-y period on the likelihood of walking for transport. METHODS: Analyses included 2,789-9,747 How Areas Influence Health and Activity (HABITAT) cohort participants from 200 neighborhoods at baseline (2007) who completed up to three follow-up questionnaires (through 2013). Principal components analysis was used to derive a proxy measure of walkability preference. Environmental predictors were changes in street connectivity, residential density, and land use mix within a one-kilometer network buffer. Associations with any walking and minutes of walking were estimated using logistic and linear regression, including random effects models adjusted for time-varying confounders and a measure of walkability preference, and fixed effects models of changes in individuals to eliminate confounding by time-invariant characteristics. RESULTS: Any walking for transport (vs. none) was increased in association with an increase in street connectivity (+10 intersections, fixed effects OR=1.19; 95% confidence interval (CI): 1.07, 1.32), residential density (+5 dwellings/hectare, OR=1.10; 95% CI: 1.05, 1.15), and land-use mix (10% increase, OR=1.12; 95% CI: 1.00, 1.26). Associations with minutes of walking were positive based on random effects models, but null for fixed effects models. The association between land-use mix and any walking appeared to be limited to participants in the highest tertile of increased street connectivity (fixed effects OR=1.17; 95% CI: 0.99, 1.35 for a 1-unit increase in land-use mix; interaction p-value=0.05). CONCLUSIONS: Increases in street connectivity, residential density, and land-use heterogeneity were associated with walking for transport among middle-age residents of Brisbane, Australia. https://doi.org/10.1289/EHP2080.

A method for the inclusion of physical activity-related health benefits in cost-benefit analysis of built environment initiatives.

The built environment has a significant influence on population levels of physical activity (PA) and therefore health. However, PA-related health benefits are seldom considered in transport and urban planning (i.e. built environment interventions) cost-benefit analysis. Cost-benefit analysis implies that the benefits of any initiative are valued in monetary terms to make them commensurable with costs. This leads to the need for monetised values of the health benefits of PA. The aim of this study was to explore a method for the incorporation of monetised PA-related health benefits in cost-benefit analysis of built environment interventions. Firstly, we estimated the change in population level of PA attributable to a change in the built environment due to the intervention. Then, changes in population levels of PA were translated into monetary values. For the first step we used estimates from the literature for the association of built environment features with physical activity outcomes. For the second step we used the multi-cohort proportional multi-state life table model to predict changes in health-adjusted life years and health care costs as a function of changes in PA. Finally, we monetised health-adjusted life years using the value of a statistical life year. Future research could adapt these methods to assess the health and economic impacts of specific urban development scenarios by working in collaboration with urban planners.

Designing healthy communities: creating evidence on metrics for built environment features associated with walkable neighbourhood activity centres.

BACKGROUND: Evidence-based metrics are needed to inform urban policy to create healthy walkable communities. Most active living research has developed metrics of the environment around residential addresses, ignoring other important walking locations. Therefore, this study examined: metrics for built environment features surrounding local shopping centres, (known in Melbourne, Australia as neighbourhood activity centres (NACs) which are typically anchored by a supermarket); the association between NACs and transport walking; and, policy compliance for supermarket provision. METHODS: In this observational study, cluster analysis was used to categorize 534 NACs in Melbourne, Australia by their built environment features. The NACS were linked to eligible Victorian Integrated Survey of Travel Activity 2009-2010 (VISTA) survey participants (n=19,984). Adjusted multilevel logistic regressions estimated associations between each cluster typology and two outcomes of daily walking: any transport walking; and, any 'neighbourhood' transport walking. Distance between residential dwellings and closest NAC was assessed to evaluate compliance with local planning policy on supermarket locations. RESULTS: Metrics for 19 built environment features were estimated and three NAC clusters associated with walkability were identified. NACs with significantly higher street connectivity (mean:161, SD:20), destination diversity (mean:16, SD:0.4); and net residential density (mean:77, SD:65) were interpreted as being 'highly walkable' when compared with 'low walkable' NACs, which had lower street connectivity (mean:57, SD:15); destination diversity (mean:11, SD:3); and net residential density (mean:10, SD:3). The odds of any daily transport walking was 5.85 times higher (95% CI: 4.22, 8.11), and for any 'neighborhood' transport walking 8.66 (95% CI: 5.89, 12.72) times higher, for residents whose closest NAC was highly walkable compared with those living near low walkable NACs. Only highly walkable NACs met the policy requirement that residents live within 1km of a local supermarket. CONCLUSIONS: Built environment features surrounding NACs must reach certain levels to encourage walking and deliver walkable communities. Research and metrics about the type and quantity of built environment features around both walking trip origins and destinations is needed to inform urban planning policies and urban design guidelines.

Comparisons of depression, anxiety, well-being, and perceptions of the built environment amongst adults seeking social, intermediate and market-rent accommodation in the former London Olympic Athletes' Village.

The Examining Neighbourhood Activities in Built Living Environments in London (ENABLE London) study provides a unique opportunity to examine differences in mental health and well-being amongst adults seeking social, intermediate (affordable rent), and market-rent housing in a purpose built neighbourhood (East Village, the former London 2012 Olympic Athletes' Village), specifically designed to encourage positive health behaviours. Multi-level logistic regression models examined baseline differences in levels of depression, anxiety and well-being across the housing groups. Compared with the intermediate group, those seeking social housing were more likely to be depressed, anxious and had poorer well-being after adjustment for demographic and health status variables. Further adjustments for neighbourhood perceptions suggest that compared with the intermediate group, perceived neighbourhood characteristics may be an important determinant of depression amongst those seeking social housing, and lower levels of happiness the previous day amongst those seeking market-rent housing. These findings add to the extensive literature on inequalities in health, and provide a strong basis for future longitudinal work that will examine change in depression, anxiety and well-being after moving into East Village, where those seeking social housing potentially have the most to gain.