Designing the built environment to support physical ...

(Re)Designing the built environment to support physical activity: Bringing public health into urban design and planning

MOHAMMAD JAVAD KOOHSARI*, PhD McCaughey VicHealth Centre for Community Wellbeing, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia Behavioural Epidemiology Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia [email protected]; [email protected]

HANNAH BADLAND, PhD McCaughey VicHealth Centre for Community Wellbeing, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia [email protected] BILLIE GILES-CORTI, PhD McCaughey VicHealth Centre for Community Wellbeing, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia [email protected]

* Corresponding author     Acknowledgments  We would like to acknowledge Professor Neville Owen and Dr Takemi Sugiyama (Baker IDI Heart and  Diabetes Institute, Melbourne) for their constructive comments on an earlier version of this paper.  BGC is supported by an NHMRC Principal Research Fellow Award (#1004900). 

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(Re)Designing the built environment to support physical activity: Bringing public health back into urban design and planning Abstract: While public health and urban planning fields worked closely to tackle communicable disease outbreaks in the 19th century, this collaboration faded during the 20th century. Over the last few decades, engagement in physical activity – even walking - has declined substantially, with serious impacts on population health. Recently there has been an emerging body of literature and guidance illustrating the role the built environment has in shaping health outcomes; much of this has focussed on physical activity behaviours. Associations between built environment attributes and physical activity have been reported by many studies, however the geographic scales at which these built environment attributes need to be measured and the magnitude of the built environment attributes required to support physical activity are not clear. Further studying these geographical scales and thresholds will facilitate development of specific guidance to urban designers and planners to create supportive built environments to facilitate physical activity engagement. This is an important addition for re-connecting the fields of public health and urban design and planning.

The built environment and health outcomes Recognition that the design, form, amenities and utilities of cities (i.e., the planning of cities) impacts on the health of residents was formally established in the 19th century in response communicable disease outbreaks (Snow, 1855). As such, urban planning was recognised as an important tool to enhance public health. The focus of urban planning within public health waned during the 20th century; however, recently there have been calls for these two disciplines to reconnect (Boarnet & Takahashi, 2011; Frank & Kavage, 2008; Giles-Corti & Whitzman, 2012; Hoehner, Brennan, Brownson, Handy, & Killingsworth, 2003; Malizia, 2006; Sloane, 2006; Vernez Moudon, 2005), and a series of documents have been produced to stimulate the discussion (e.g., National Heart Foundation of Australia, 2009; The City of New York, 2010). These have emerged from the growing evidence base showing lower residential densities, singular land uses, inadequate health and social service infrastructure, limited public transport access, and poorer quality public open space are associated with several risk factors for major non-communicable diseases, such as physical inactivity, overweight and obesity, and poorer mental health (Planning Institute of Australia, 2009; 2  

Public Health Advisory Committee, 2010; World Health Organization, 2010b). This emerging body of research parallels a range of reports, enquiries, and planning resources emphasising the importance of urban planning and design for building efficient, resilient, and sustainable cities (e.g., National Heart Foundation of Australia, 2009; The City of New York, 2010; World Health Organization Centre for Health Development, 2011); whereby “urban planning can, and should, play a role in making the impact of urbanisation on health beneficial for people” (World Health Organization Centre for Health Development, 2011, p. 2). Promoting regular physical activity has become a public health priority worldwide (Beaglehole et al., 2011; World Health Organization, 2010a). Physical activity is defined as “any bodily movement produced by skeletal muscle that results in energy expenditure”(Caspersen, Powell, & Christenson, 1985, p. 126) and includes a wide range of activities, such as walking, exercise, swimming, dancing. Physical activity can broadly be categorised into several domains: recreational, occupational, transport, and household activities. Recreation and transport physical activity are frequently compared with built environment attributes (Saelens & Handy, 2008). Recreational physical activity refers to “those [physical activities] undertaken for discretionary reasons in someone’s leisure time”, while transport physical activities are “undertaken in order to accomplish another purpose [such as transporting the person to another place using active modes (e.g., walking or cycling)]” (Frank, Engelke, & Schmid, 2003, p. 56). Playing tennis and walking within a park are examples of recreational physical activities, and walking or bicycling to stores or workplaces are examples of transport-related physical activities. There is a vast body of evidence demonstrating substantial health benefits from engaging in regular physical activity (Janssen & LeBlanc, 2010; Vogel et al., 2009; Warburton, Nicol, & Bredin, 2006), including reducing the risk factors for many major chronic diseases – particularly type 2 diabetes and cardiovascular disease (U.S. Department of Health and Human Services, 1996). Internationally, inadequate physical activity causes approximately 3 million deaths annually, or 8% of all deaths per year attributed to noncommunicable diseases (Beaglehole, et al., 2011). It is estimated that 0.68 (range 0.41–0.95) years will be added to the life expectancy of the world’s population through eliminating physical inactivity (Lee et al., 2012). Despite the benefits of physical activity, overall engagement in the behaviour has shown substantial, and continued declines over the last few decades, with the greatest reductions occurring for occupational and transport-related physical activity (Brownson, 3  

Boehmer, & Luke, 2004). For example, data from 122 countries show that a third of adults are physically inactive, ranging from 17% in southeast Asia to about 43% in the Americas and the eastern Mediterranean (Hallal et al., 2012). Given the limited success of individualbased approaches (e.g., targeting people individually through behaviour change strategies) to health behaviour change (Sallis & Kerr, 2006; Sallis, Owen, & Fisher, 2008), socioecological models are gaining popularity as the theoretical underpinnings for interventions designed to encourage adoption of healthy behaviours, including physical activity (Sallis, Floyd, Rodríguez, & Saelens, 2012). Socioecological models suggest that behaviours are influenced at multiple levels, including: biological, psychological, social/cultural, physical environment, and policy levels. Studies using socioecological frameworks to understand the determinants of physical activity emphasise the importance of the built environment as a potential facilitator or barrier (Handy, Boarnet, Ewing, & Killingsworth, 2002; Saelens & Handy, 2008). Within this body of research, the built environment is generally defined as “the part of the physical environment that is constructed by human activity” (Saelens & Handy, 2008, p. 2) and it includes “homes, schools, workplaces, parks/recreation areas, greenways, business areas and transportation systems” (National Institute of Environmental Health Sciences, 2004, p. 2). It refers to a context in which people’s behaviours occur, thus environmental interventions might influence individual physical activity (Boarnet & Takahashi, 2011). The emphasis on the role of the built environment is necessary as encouraging people to change a behaviour (such as physical activity) in an environment that is not supportive of behaviour change is less likely to be effective. Moreover, modifying the built environment has the potential to have a long-term impact on the health and wellbeing at the population-level (Sallis, Floyd, Rodríguez, & Saelens, 2012). Although, built environment interventions are generally initially expensive because of their construction costs, the longevity and ability to influence a large population make these cost-effective in the long-term if done correctly from the outset. Moreover, they generally serve multiple purposes, and there are co-benefits across multiple sectors including traffic management, environmental protection, and safety and community (Giles-Corti, Foster, Shilton, & Falconer, 2010). A wide range of built environment features have been investigated in relation to recreation- and transport-related physical activity. Specific built environment attributes such as street connectivity, residential density and land use mix have been consistently associated with walking for recreation and transportation (Saelens & Handy, 2008; Sallis, et al., 2012; Sugiyama, Neuhaus, Cole, Giles-Corti, & Owen, 2012). For example, availability and access 4  

to destinations such as local shops, green spaces, services, and transit stations have been found as potential predictor factors in walking for transport (Forsyth & Krizek, 2010; Sugiyama, et al., 2012). Although these associations exist, it remains challenging to create and retrofit built environments that support health and wellbeing outcomes. This is largely because prescriptive evidence for planners and policy-makers about ‘how much’ and ‘what types’ of infrastructure is required to support health and wellbeing is lacking (Fig 1). Developing clear, evidence-based guidance for various built environment attribute thresholds and scales will provide urban designers and planners with specific criteria about the amount and mix of built environment attributes required to support diverse health outcomes and behaviours such as physical activity. Providing these tools will substantially assist with progressing research translation from public health through to urban design and planning.

Identifying appropriate geographical scales Geographical scale refers to the area at which the associations between the built environment and physical activity are investigated. Predefined administrative boundaries (e.g., census tracts) have been the most-commonly applied scale (Riva, Gauvin, & Barnett, 2007), with more recent work utilising different buffer sizes generated from residential addresses (Fig. 2) (Colabianchi et al., 2007; Feng, Glass, Curriero, Stewart, & Schwartz, 2010). Yet, when different geographical scales are applied, different associations with physical activity are shown. For example, one study (Learnihan, Van Niel, Giles-Corti, & Knuiman, 2011) demonstrated street connectivity, residential density, land use mix, and retail floor area calculated at a 15-minute street network walking distance from home predicted walking for transport; however, these associations became non-significant when the measures were calculated at the suburb or census collection district scales. This is known as the Modifiable Areal Unit Problem (MAUP). MAUP refers to the sensitivity of results to the spatial units from which data are collected, and it includes two distinctive but related problems: the scale and the zoning (Openshaw, 1984; Openshaw & Taylor, 1979). The scale problem is defined as changes in results because of the number of units of analysis in a certain area and the zoning problem refers to differences in results when the same number of units is regrouped differently (Openshaw & Taylor, 1979). MAUP has received much attention in statistical and geographical literature, while its implications in studies examining the built environment attributes supporting physical activity, health and wellbeing is in its infancy. There have recently been a number of studies exploring the concept of activity 5  

spaces and neighbourhood definitions in relation to physical activity (Boruff, Nathan, & Nijenstein, 2012; Chaix et al., 2012; Mitra & Buliung, 2012; Perchoux, Chaix, Cummins, & Kestens, 2013; Villanueva et al., 2012). For example, Villanueva et al. (2012) examined how far children actively travel from their homes, and whether built environment attributes within these activity spaces influence children’s active travelling to schools. They found factors including freedom, the number of local destinations and traffic safety can influence the size of children’s activity spaces. In another study, Boruff et al. (2012) compared associations between land-use calculated for several buffers with walking for transport or leisure; buffers derived from Global Positioning Systems (GPS) provided a better model fit than traditional circular and polygon network buffers. The optimal geographical scales for built environment attributes supporting physical activity likely differs by population, type of physical activity, and the attribute being investigated. For instance, it is probable elderly people and children will walk for a shorter distances compared with functioning adults, and it has been shown that people will walk further to access a high speed, high quality public transport network (e.g., train) than when accessing a lower speed public transport mode (e.g., bus). Future studies should examine the effects of various geographical scales on different types of physical activity among specific population sub-groups. New tracking technology, such as GPS, can also be applied to identify the real activity space for different populations, and identify the built environment attributes supporting physical activity within these areas.

Generating valid thresholds Existing research on the built environment and physical activity has been mainly concerned with linear relationships between built environmental attributes and walking; e.g., a shorter network distance between destinations is associated with more walking. However, these associations may not be linear. Moreover, there may be ‘optimal’ or ‘threshold’ values (Kaczynski, Potwarka, Smale, & Havitz, 2009) which would provide urban designers with information to inform planning guidance (Sugiyama, et al., 2012). The shape of associations between built environment attributes and physical activity has been neglected in previous studies, and threshold values for various built environment attributes needed to promote different types of physical activity are not known; that is, ‘how much’ of a particular attribute is needed to generate behaviour change. For example, the negative effect of distance to a park on residents’ walking might only become evident when parks are located beyond 400 meters of residents’ home. In this case, 400 metres can be applied as the threshold for green open 6  

space allocation in planning and design practice. Similarly, understanding the optimal range of residential density to support walking for transport can guide planners and policy-makers, both for ensuring the appropriate infrastructure is present (Fig. 3). This is an important issue, which researchers have only just begun to address. For instance, Van Dyck et al. (2013) examined the strength, direction and shape of the associations of neighbourhood perceptions with adult’s recreational walking and leisure-time moderate-to-vigorous physical activity living in metropolitan areas in the USA, Australia and Belgium. They found positive associations of neighbourhood perceptions with both outcome measures, and all curvilinear effects and site-specific interactions were identified.

Conclusion After several decades of separation, the collaboration between urban design and planning and public health is necessary to facilitate physical activity within an socioecological framework; whereby “the key ingredient toward designing an environment to promote physical activity is to reconnect the two fields, as they did to prevent the spread of infectious diseases a century ago in the US” (Oka, 2011, p. 294). The field of urban design and planning contributes concepts and measures for the built environment (Sallis, 2009) and public health provides an understanding of the broader impacts of the built environment on health and high quality data to establish the associations between the built environment and health outcomes. However, public health researchers and policy-makers must rely on urban design and planning professionals to translate the findings into practice. Future research on geographical scales and thresholds provides a promising point to re-connect public health and urban design and planning, and the forthcoming evidence-based guidance will be critical in establishing built environments that support physical activity.

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Figure 1. Conceptual framework

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Figure 2. Different geographical scale around people’s home to capture the built environment measures

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Figure 3. Hypothetical diagram showing thresholds that support walking for access to park and residential density

 

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