More People, More Active, More Often for Heart Health - Taking Action on Physical Activity.

Physical inactivity is a leading contributor to increased cardiovascular morbidity and mortality. Almost 500 million new cases of preventable noncommunicable diseases (NCDs) will occur globally between 2020 and 2030 due to physical inactivity, costing just over US$300 billion, or around US$ 27 billion annually (WHO 2022). Active adults can achieve a reduction of up to 35% in risk of death from cardiovascular disease. Physical activity also helps in moderating cardiovascular disease risk factors such as high blood pressure, unhealthy weight and type 2 diabetes. For people with cardiovascular disease, hypertension, type 2 diabetes and many cancers, physical activity is an established and evidence-based part of treatment and management. For children and young people, physical activity affords important health benefits. Physical activity can also achieve important cross-sector goals. Increased walking and cycling can reduce journeys by vehicles, air pollution, and traffic congestion and contribute to increased safety and liveability in cities.

Changes in neighbourhood walkability and body mass index: An analysis of residential mobility from a longitudinal multilevel study in Brisbane, Australia.

This study examined associations between changes in neighbourhood walkability and body mass index (BMI) among 1041 residents who relocated within Brisbane, Australia between 2007 and 2016 over five waves of the HABITAT study. Measures included spatially-derived neighbourhood walkability (dwelling density, street connectivity, and land use mix) and self-reported height and weight. No associations were found between any neighbourhood walkability characteristics and BMI. Examining these associations over the life course, and the impact of residential relocation in the younger years, remains a priority for future research.

Residential density and 20-minute neighbourhoods: A multi-neighbourhood destination location optimisation approach.

The concept of 20-min neighbourhoods, a planning intervention to promote local living and active travel, has recently become a key urban planning priority in Melbourne, Australia. The Victorian Government defines this concept as being able to reach daily local living destinations within a 20-min round-trip walk from home, which is approximately 800m of walking for each trip leg. Similar concepts, such as 10- or 15-min cities, have been explored in other cities worldwide. However, research to date has largely focused on measuring accessibility to destinations in developed areas, with few studies examining what is needed to build a city of 20-min neighbourhoods, i.e., investigating multiple neighbourhoods, shared destinations, and the role of residential density. In this study, we used optimisation models to examine the relationship between residential density and the targets of 20-min neighbourhoods in a hypothetical greenfield development scenario. We defined different targets for various destinations in terms of the percentage of the population aimed to have access to that destination within 800 m, ranging from 95% for the smallest destinations to 70% for the largest. Our results demonstrate that at least 25 dwellings per hectare (assuming 2.6 persons per dwelling) are needed to provide access to the destinations within 1.2 km and 35 dwellings per hectare to provide access within 1 km. Furthermore, we show that the cost of building destinations and the land required for them when delivering 20-min neighbourhoods at 30 dwellings per hectare is almost half of what is required when building at 15 dwellings per hectare.

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.

Policy relevant health related liveability indicator datasets for addresses in Australia's 21 largest cities.

Measuring and monitoring the spatial distribution of liveability is crucial to ensure that implemented urban and transport planning decisions support health and wellbeing. Spatial liveability indicators can be used to ensure these decisions are effective, equitable and tracked across time. The 2018 Australian National Liveability Study datasets comprise a suite of policy-relevant health-related spatial indicators of local neighbourhood liveability and amenity access estimated for residential address points and administrative areas across Australia's 21 most populous cities. The indicators and measures encompass access to community and health services, social infrastructure, employment, food, housing, public open space, transportation, walkability and overall liveability. This national 'baseline' liveability indicators dataset for residential address points and areas can be further linked with surveys containing geocoded participant locations, as well as Census data for areas from the Australian Statistical Geography Standard. The datasets will be of interest to planners, policy makers and researchers interested in modelling and mapping the spatial distribution of urban environmental exposures and their relationship with health and other outcomes.

Mapping and analysis of laws influencing built environments for walking and cycling in Australia.

BACKGROUND: Physical inactivity is a significant public health concern, with limited signs of improvement despite a global commitment to achieving the World Health Organization's target of 15% reduction by 2030. A systems approach is required to tackle this issue, involving the creation of environments that are conducive to physical activity. Laws represent an important tool for regulating the built environment for physical activity, are a mechanism for systems change, and have the capacity to reorient the goals and rules of a system. However, they are understudied and potentially underutilised for physical activity. Scientific legal mapping is a first step towards understanding how laws could impact the built environment to facilitate greater population physical activity. METHOD: We conducted a legal assessment of state and territory laws in Australia, to systematically characterise how they address built environment considerations with specific relevance to walking and cycling. An interdisciplinary team of researchers with public health, law and urban planning expertise was formed to complete the multistage process. Key steps included a systematic search of laws using a combination of original legal research, consultation of secondary sources, and review and verification by an urban planning expert; development of a coding scheme; and completion of coding and quality control procedures. RESULTS: Most jurisdictions in Australia do not currently embed objectives in primary legislation that would promote physical activity and support an integrated approach to land use and transport planning that encourages active and sustainable lifestyles. Only two jurisdictions addressed the large majority of evidence-based standards that promote active living. Of the standards addressed in law, few fully met evidence-based recommendations. While most jurisdictions legislated responsibility for enforcement of planning law, few legislated obligations for monitoring implementation. CONCLUSION: Increasing physical activity is a systems issue, requiring actions across multiple sectors. An in-depth examination of the legal environment is an important step towards understanding and influencing the existing physical activity system, why it may not be generating desired outcomes, and potential opportunities for improvement. Our findings reveal opportunities where laws could be strengthened to promote more active environments. Updating this dataset periodically will generate longitudinal data that could be used to evaluate the impact of these laws on the built environment and physical activity behaviours.

The Built Environment and Population Physical Activity: Methods for Mapping the Relevant Laws.

BACKGROUND: The development of policies that promote and enable physical activity (PA) is a global health priority. Laws are an important policy instrument that can enable enduring beneficial outcomes for individuals, organizations, and environments through multiple mechanisms. This article presents a systematic process for mapping laws relevant to PA, which can be used to understand the role of laws as a powerful PA policy lever. METHODS: Building on methods used in public health law research, we developed a protocol for scientific mapping of laws influencing the built environment for PA in Australia. The MonQcle online legal research platform was used for data coding, analysis, and presentation. RESULTS: We describe the 10 key stages of legal mapping that we applied to examine state and territory laws that influence walking and cycling in Australia. CONCLUSIONS: Law is a neglected element of policy research for PA. There is a need for accessible legal data to drive the design, investment, and implementation of legal interventions to improve population PA. Legal mapping is a first step toward evaluation of such laws for PA. This paper provides a practical case study and guidance for the 10 stages in legal mapping of laws that influence the built environment for PA.

An analysis of the legal framework influencing walking in Australia.

AIM: Although walking is a priority in many strategic plans in Australian cities, there is limited understanding of the statutory components for delivering this. Confusion still exists despite substantial evidence about the built environment elements that promote walking and the availability of tools to assess walkability outcomes. This paper examines the characteristics and components of the legal framework that influence the walkability of built environments in Australian states and territories. METHODS: We audited the form and nature of statutory components regulating the design of the built environment and used framework analysis to identify and compare the main statutory instrument/s that address walkability design considerations in each state and territory. RESULTS: Lawmaking for planning may involve the state/territory parliament, executive, ministers, government departments and/or statutory authorities. The state/territory planning Act is the primary legislation that sets out the framework for the prevailing planning systems. Its relevance to walkability arises from its planning objectives, the legal effect it confers to statutory instruments that support the Act's implementation, and any processes or mechanisms to promote high-quality design outcomes. Most states and territories have developed jurisdiction-wide statutory tools that contain relevant design considerations for walking. These instruments influence walkability through objectives set for planning zones and aspects of development, and through criteria established to achieve the goals. Many jurisdictions use a combination of outcome and rules-based standards to achieve desired design objectives. CONCLUSIONS: The variability in jurisdictional approaches poses challenges, and raises uncertainty, about the scope and strength of legal support for creating walkable environments at the national level. Future policy surveillance and epidemiological analysis are needed to refine the specifications of laws that influence walking in Australia.

Grand designs for design policy: Associations between apartment policy standards, perceptions of good design and mental wellbeing.

Comprehensive apartment design policies have been legislated by Australian state governments to address concerns about poor design in residential buildings. These policies aim to improve apartment design and promote good health. This study examined whether: (1) residents living in apartments that implemented more minimum design requirements perceived better apartment design and amenity; and (2) increased implementation of minimum requirements and better perceptions of design were associated with positive mental wellbeing. Apartment complexes (n = 114, built 2006-2016) were sampled from Sydney, Perth, and Melbourne. Building plans and elevations were used to measure and score apartments for their implementation of 96 quantifiable policy-specific requirements and residents (n = 1072) completed a self-report survey on their apartment design and health. Multi-level linear regression models were used to account for clustered data. Residents in apartments with greater implementation of requirements for solar and daylight, indoor space, private open space, communal space and parking had more positive perceptions of their apartment in terms of natural light and winter thermal comfort, indoor space and layout, private open space, communal area quality, and parking, respectively (all p < 0.05). Perceptions of natural ventilation, summer thermal comfort, indoor space, and communal area quality were independently associated with positive mental wellbeing (all p < 0.05), but the objective implementation scores had no direct association. When implemented as intended, minimum requirements had a positive impact on perceptions of design, which were associated with mental wellbeing. The study underscores the importance of planning instruments and design review processes that increase industry uptake of minimum policy standards.

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.

Determining thresholds for spatial urban design and transport features that support walking to create healthy and sustainable cities: findings from the IPEN Adult study.

An essential characteristic of a healthy and sustainable city is a physically active population. Effective policies for healthy and sustainable cities require evidence-informed quantitative targets. We aimed to identify the minimum thresholds for urban design and transport features associated with two physical activity criteria: at least 80% probability of engaging in any walking for transport and WHO's target of at least 15% relative reduction in insufficient physical activity through walking. The International Physical Activity and the Environment Network Adult (known as IPEN) study (N=11 615; 14 cities across ten countries) provided data on local urban design and transport features linked to walking. Associations of these features with the probability of engaging in any walking for transport and sufficient physical activity (≥150 min/week) by walking were estimated, and thresholds associated with the physical activity criteria were determined. Curvilinear associations of population, street intersection, and public transport densities with walking were found. Neighbourhoods exceeding around 5700 people per km2, 100 intersections per km2, and 25 public transport stops per km2 were associated with meeting one or both physical activity criteria. Shorter distances to the nearest park were associated with more physical activity. We use the results to suggest specific target values for each feature as benchmarks for progression towards creating healthy and sustainable cities.

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.

Findings from the Kids in Communities Study (KiCS): A mixed methods study examining community-level influences on early childhood development.

There is increasing international interest in place-based approaches to improve early childhood development (ECD) outcomes. The available data and evidence are limited and precludes well informed policy and practice change. Developing the evidence-base for community-level effects on ECD is one way to facilitate more informed and targeted community action. This paper presents overall final findings from the Kids in Communities Study (KiCS), an Australian mixed methods investigation into community-level effects on ECD in five domains of influence-physical, social, governance, service, and sociodemographic. Twenty five local communities (suburbs) across Australia were selected based on 'diagonality type' i.e. whether they performed better (off-diagonal positive), worse (off-diagonal negative), or 'as expected' (on-diagonal) on the Australian Early Development Census (AEDC) relative to their socioeconomic profile. The approach was designed to determine replicable and modifiable factors that were separate to socioeconomic status. Between 2015-2017, stakeholder interviews (n = 146), parent and service provider focus groups (n = 51), and existing socio-economic and early childhood education and care administrative data were collected. Qualitative and quantitative data analyses were undertaken to understand differences between 14 paired disadvantaged local communities (i.e. on versus off-diagonal). Further analysis of qualitative data elicited important factors for all 25 local communities. From this, we developed a draft set of 'Foundational Community Factors' (FCFs); these are the factors that lay the foundations of a good community for young children.

Supporting pandemic disease preparedness: Development of a composite index of area vulnerability.

Although pandemics are rare, planning and preparation for responding to them plays a crucial role in preventing their spread. The management and control of pandemics such as COVID-19 relies heavily on a country's health capacity. Measuring vulnerability to pandemics in geographical areas could potentially delay a pandemic's exponential growth and reduce the number of cases, which would alleviate the disease impact on communities and the health care sector. The aim of this study is to generate an area-level COVID-19 Pandemic Vulnerability Index (CPVI) and to assess its correlation with COVID-19 cases. Data were collected for Local Government Areas (LGAs) across Australia from different sources including Australia Bureau of Statistics, Australian Institute of Health and Welfare, and General Transit Feed Specification. Based on recent official reports about the COVID-19 outbreak, 18 factors were identified as influencing vulnerability to the disease within LGAs. Using factor analysis, four latent factors were identified and named as sociodemographic, medical conditions, transportation, and land use. Predicted factor scores were summed to generate a CPVI for each LGA. The CPVI was evaluated by correlating with confirmed cases of COVID-19 standardised by adult population in New South Wales and Victoria, the two Australian states with the highest numbers of confirmed cases. There was a statistically significant correlation between the CPVI and COVID-19 in New South Wales (r = 0.49) and Victoria (r = 0.48). LGAs scoring higher on the CPVI also had a higher absolute number of cases. The CPVI could be used by policymakers to identify at-risk areas and to develop preparedness and response plans to help mitigate the spread of COVID-19 and future pandemics.

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.