Placemaking for Public Health
Reframing Place & Health
A report by
Araceli Camargo, Daniel Akinola-Odusola, and Josh Artus
We are a grant and citizen supported lab, we use our funding to create free scientific reports, which provide foundational knowledge about health, health inequities, and health justice. We prioritise the hiring of scientists and researchers from marginalised communities to ensure that the lived experience is covered in an ethical, inclusive, and accurate manner.
Our goal is to be an open lab that is “for the people by the people”.
Issues with Current Framing
There are two ways to approach the current issue of health and place: as a citizen and as a built environment authority or practitioner. The current framing for citizens does not make it easy to understand the long-term contributions of the places people inhabit to their health. People have more resources and measures on factors related to individual decisions, such as diet and exercise, but do not have the same capacity in terms of factors such as environmental pollutants.
This report will focus primarily on the role of the built environment because practitioners have a significant influence on the ability of citizens to build healthy relationships between health and place. As a neuroscience lab our focus and perspective will be from a biological and health lense. Even when practitioners have the right intentions, the initiatives proposed, such as planting trees and creating low traffic neighbourhoods, are rarely determined by the actual environmental or psychosocial quality of the location and thus do not solve fundamental problems or give citizens agency.
Upgrading cities from merely places of commerce to habitats that can support human health will require a biological approach.
Objective
This report will:
Create a robust profile of the relationship between place and health.
Present how we can use this profile to better approach current health crises.
Present a resilience framework that has practical use for the built environment.
Elements of the Relationship Between Health & Place
Before introducing the specific tools, processes, and suggestions regarding the relationship between health and place, there are some key principles worth mentioning that should always be considered.
Exposure
Exposure is a key principle because accurately understanding the effect of exposure involves more nuance and investigation than simply presenting where environmental pollutants and other place based (produced by the lived experience of a place) stressors are present. People can live in the same general location but have different exposure due to different jobs, family dynamics, social discriminants, and socioeconomic differences that are reflected in their urban footprint.
For instance, a street can be heavily congested and polluted. On one side of the street, there are people with private greenery behind their houses who generally take a car when they are going out and can afford the right filtering systems in their house. On the other side of the street are flats with the only greenery being public and by the road. If they often walk and spend social time by the street to get to greenery then they experience more exposure to the pollutants than the first group. It is therefore important that representations of health and place factor in a representation of exposure when addressing individuals or are transparent in acknowledging that individual exposure was not taken into account.
Access
Access refers to both the physical and mental ability to engage, participate, and consume a product, service, or activity. The access principle goes against the idea that “if you build it, they will come” when it comes to built environment mitigations for health.
As an example, suppose you wanted to make sure that a neighbourhood has greenery, food venues, and health clinics. If these places are only located in dense and noisy locations, this might create a physical boundary for those on the neurodiverse spectrum or if the location is only accessible with a car it might reduce who can and cannot access the resources. These obstacles can in turn have health consequences.
Perception
Many analytical and scientific evaluations ignore the importance of lived experience to health solutions. This approach is counterintuitive if the goal is to have healthy citizens. Perception as a key principle can refer to the perception of access, safety, equity, or other personal or community benefits. If a small park is situated in an area that is not perceived as healthy or safe, people may have less motivation to use the park to stay healthy.
Why Neuroscience?
Neuroscience is a multidisciplinary branch of biology and is the scientific study of the brain and nervous system. The main neuroscientific approach which can begin to explain how urban environments interact with the human biological system is by looking at the stress response, which is one of the key pathways linking the internal human biological environment with the external environment. In this case, the interest is in how the biological system adapts to urban pollutants such as air, noise, thermal, and light. The use of neuroscience in refining the relationship of place and health comes in three parts.
The first is the generation of insights related to mental disorders such as depression, anxiety or PTSD and how they interact with metabolic disorders such as obesity and diabetes.
The second is knowledge of how urban environments create a health risk for the aforementioned disorders.
Finally, neuroscience can be used to identify areas that pose a health risk.
A major neuroscientific approach which can begin to explain how urban environments interact with the human biological system is by looking at the stress response, which is one of the key pathways linking the internal human biological environment with the external environment. In this case, the interest is in how the biological system adapts to urban pollutants such as air, noise, thermal and light.
Stress Response
The stress response is mitigated by the hypothalamic-pituitary-adrenal axis (HPA-Axis) which is a series of hormonal responses that help the body adapt to stressors. The system engages regardless of whether it is a psychological stressor such as losing a job, financial insecurity, witnessing a crime, or a physical stressor such as illness, environmental changes
or external pollutants. The HPA-Axis activation starts in the brain when the stressor — in this case a pollutant — triggers the hypothalamic production of corticotropin-releasing hormone (CRH). This trigger signals to the pituitary gland, which is also located in the brain, to synthesise the adrenal-corticotropin releasing hormone (ACTH). ACTH is then released into the circulation system where it reaches the adrenal glands, which are located above the kidneys. Once it reaches the adrenal glands ACTH stimulates the release of cortisol, which is another regulatory hormone. Finally, cortisol circulates back to the brain through the circulation system, creating a negative feedback loop that repeats until the body comes to homeostasis or equilibrium.
Chronic Stress
Despite the role the HPA-Axis plays in providing the biological system with the means to adapt to stressors by mobilising energy reserves and regulating necessary immune responses, the majority of stressors we experience in urban environments are chronic in nature and overly engage this system. A continual activation of the HPA-Axis can result in its dysregulation and a subsequent cascade of damage to human bodily systems through a process known as ‘allostatic load’ predisposing people to a range of health complications. The dysregulation of the HPA-Axis is a feature of many disease processes associated with chronic stress, such as diabetes, obesity, depression, PTSD, and anxiety.
Environmental Factors of Chronic Stress
The average citizen does not often have the ability to actively investigate the role their environment has in contributing to their health. This is especially true of factors they have no personal control over or are not directly related to their personal activities. Environmental risk factors are often a result of larger infrastructure and activity, such as construction, traffic activity, population density, and presence of green and blue space. A goal of urban health and environmental justice must be to make these factors easier for the average citizen to understand and navigate.
One example of where this information can be useful is visiting the doctor. If someone was able to accurately give insight into the types of environments they are exposed to, it would help a practitioner understand further factors potentially involved in the patient’s health outcomes.
Environmental risk factors are often a result of larger infrastructure and activity, such as construction, traffic activity, population density, and presence of green and blue space. A goal of urban health and environmental justice must be to make these factors easier for the average citizen to understand and navigate.
The Stress Risk Score
Given the aforementioned disparity for the average citizen, the Stress Risk Score (SRS) is a scale used to measure and present the environmental stress risk factors based on proxies for noise, air, light, and thermal pollution. These measures were established using a meta-analysis of how each stressor engages with the stress response system, specifically allostatic load. It was created to begin the culture of understanding concepts such as systemic and ecological health when understanding how your environment influences your lived experience (source). In other words, the SRS is not an acute diagnostic tool but a tool for understanding the general risk of an environment in a way that can lead to further action and investigation.
While each pollutant presents its own health risks — for example, light pollution has the potential to disrupt melatonin production, linking it to sleep disorders and depression — it is the composite exposure to these pollutants which needs to be addressed, especially as research is indicating that when found together they become more acute and present a higher risk to human biological systems. (source)
Why These Four Risk Factors?
The relationship between place and health is complicated, so it is important to be intentional and clear when it comes to creating a tool such as the SRS. While there is no official set of criteria to determine what makes a “good” factor to score, there are several considerations we took when deciding on the four pollutants represented in the SRS.
The first is understanding the previous research relating to health. Each of the four factors has research suggesting a contribution to chronic stress-related health outcomes. Following the literature review, the factor must have available annual data related to the specific metric presented in the research. For instance, the chronic stress research involving air pollution referred to particulate matter (PM 2.5). To represent the relationship between place and health involving air pollution and to draw conclusions we must use particulate matter data.
The selection of the four factors in the SRS does not belittle the importance of understanding other factors such as cold and hay fever nor the presence of certain diseases or disorders. The SRS intentionally focuses on less personalised environmental measures that are influenced by infrastructure and regional activity and should be treated as a pre-measure to understanding individual exposure and susceptibility
Air Pollution
All factors listed here are regulated by the planning sector. Therefore, if, as directed by government policy, urban planning policy is to improve health it should regulate the activities according to a health based measurement process. For example, if an area such as the Surrey Quays train station has an annual average SRS score of 3.5 (Air = 1, Heat = 0.7, Light = 1, Noise = 0.8) local planning should set development and management based objectives that seek to actively lower these values. These can be through regulation of activity or through materiality that absorbs particulate matter or dampen sound, most of which tend to be from the natural world.
The importance of directing health to be centred around a biological assessment of place is that it is universal. We all breathe the same air and hear the same sounds. Therefore, reducing exposure ensures that not only do all benefit but those who are more susceptible to stressors do not face further inequities. Equally, it is integral to focus on cleaning the environment from stressors before integrating more lifestyle health qualities such as encouraging active transport or outdoor seating areas. Exercise in polluted areas can cause unintended dysregulation of your stress system and elderly people dwelling in areas of high stress run health risks of complications at elevated heart rates.
Therefore, before introducing health and wellbeing initiatives to communities, authorities need better regulation of stressors in order to not exacerbate health inequities prevalent in society coming from historical classism and structural racism. It is wrong to place blame for poor health on individuals not exercising outdoors enough when their only choice is to be biologically impacted.
Case Study 1: Mobility and Health
Using the SRS with Infrastructure Data: PTAL
Organisation Types
Transport for London
Council making mobility improvements
Planning officer making decisions about transport policy
Challenge
What is the relationship between public transport access, density and exposure to environmental pollutants?
Significance
There is now an understanding that the longer a person is exposed to environmental pollutants such as air pollution, the more impact on their health. Therefore, cities looking to increase equatable mobility zones, should consider how healthy it is for a person to move from point A to point B. It is also an effective method to identify nodes of health inequity within the transport system and prioritise change.
Methods
Using publicly available data source is the public transport accessibility level (PTAL), a method that suggests how well a place is connected to public transport services based on distance to public transport stops and the frequency of use from those stops. To look at density, population density from 2011 was used.
the SRS averaged at the Lower Supported Output Area (LSOA)
the public transport accessibility level (PTAL) which had a 0.64 positive correlation with the SRS (medium correlation)
the population density from 2011 which had a 0.52 positive correlation with the SRS (medium correlation)
Results
The SRS to PTAL analysis resulted in a 0.64 correlation coefficient. This level of correlation signifies a medium correlation between the increase in environmental stressors and the increase in public transport accessibility. This result makes sense as frequent transport is a main contributor to environmental pollutants in urban environments. The SRS to pollution density analysis resulted in a 0.52 correlation coefficient. This level of correlation signifies a medium correlation between a high presence of environmental stressors and high population density. This result also follows the same principle relating to densely populated areas and the pollutants from transport and human activity.
Discussion
These datasets can also be used to determine hotspots by identifying locations that pass a certain threshold in each dataset. In this case, it would be finding a location that has reasonably high environmental stressors, low transport access, and a possibly denser population.
This data can be used to find areas that pose a health risk and help create more equatable and health transport systems. Mobility is more than just transporting people, it also has to be healthy.
Using SRS Summary
What becomes clear is that the SRS works best in correlation with other infrastructure led data as opposed to health data. This is because health involves the principles of exposure, access, and perceived value, factors not represented in annual environmental averages. Health, therefore, does not translate directly to macro infrastructure in the same way and significant correlations are not expected to the SRS. Both infrastructure and health data can be used accompanying the SRS to begin identifying hotspots worth investigating, and this is the recommended use of the SRS.
Limitations
An important consideration in any tool or process designed to help people is the acknowledgement of limitations. The limitations of the SRS are both temporal and from a source analysis perspective. In an ideal world, people would have local monitors on their persons or in every environment they frequent that would detail exposure. But without that level of detail, we rely on annual environmental averages and modelling. So a particular score on a road may not be the lived experience on a given day or week. The dynamic of exposure is also better left to more localised investigations within a community. In other words, the SRS presents “what risk is present” rather than “what risk you will personally experience”.
Psychological Factors of Stress
Our body does not only suffer chronic stress due to pollutants. Psychosocial factors also play a part in our long-term health. The psychosocial relationship to health is a widely investigated field. We refer to two areas of investigation relevant to our work.
The Weathering Hypothesis
The weathering hypothesis was proposed to account for early health deterioration as a result of cumulative exposure to experiences of social, economic and political adversity. It is well documented that minority groups and marginalized communities suffer from poorer health outcomes. This may be due to a multitude of stressors including prejudice, social alienation, institutional bias, political oppression, economic exclusion and racial discrimination. The weathering hypothesis proposes that the cumulative burden of these stressors as individuals age is "weathering," and the increased weathering experienced by minority groups compared to others can account for differences in health outcomes.
Robert Sapolsky
As a neuroendocrinologist, Sapolsky’s work has focused his research on issues of stress and neuronal degeneration. Sapolsky’s work looks into factors such as non-life-threatening stressors, such as constantly worrying about money or pleasing your boss, and how they trigger the release of adrenalin and other stress hormones, which, over time, can have devastating consequences to your health; "If you turn on the stress response chronically for purely psychological reasons, you increase your risk of adult onset diabetes and high blood pressure. If you're chronically shutting down the digestive system, there's a bunch of gastrointestinal disorders you're more at risk for as well."
The IMD
The Index of Multiple Deprivation (IMD) follows an established methodological framework in broadly defining deprivation to encompass a wide range of an individual’s living conditions and is collected every four years (source). The Ministry of Housing, Communities and Local Government makes it clear in the documentation for the IMD that the tool is not to specifically identify individuals as affluent or deprived. According to their documentation, people may be considered to be living in poverty if they lack the financial resources to meet their needs, whereas people can be regarded as deprived if they lack any kind of resources, not just income.
The IoD2019 (the most recent version of the IMD) is comprised of seven distinct domains of deprivation which, when combined and appropriately weighted, are; Income (22.5%), Employment (22.5%), Health Deprivation and Disability (13.5%), Education, Skills Training (13.5%), Crime (9.3%), Barriers to Housing and Services (9.3%), Living Environment (9.3%).
The IMD is an effective tool to use as a proxy for evaluating whether a person regularly engaging in these environments will be exposed to sustained psychosocial stressors.
Biological Inequity & The Urban Health Index
Biological Inequity refers to the unequal distribution, exposure and vulnerability to health-threatening pollution levels within urban environments.
When people live in neighbourhoods that have high levels of pollutants, their systems become more exposed, which over time may cause them to develop long-term physical degradation to muscles and lung tissue as well as changes to insulin and metabolic functions.
Research indicates that those who live in impoverished urban environments are presented with higher levels of psychosocial stressors linked to poverty such as housing, economic and food insecurity, lack of high-quality healthcare, neglect, domestic abuse, etc. They are also at a higher risk of experiencing acute trauma, which is linked to PTSD. This suggests those living in poverty may already have a dysregulated HPA-Axis due to psychosocial stressors, which may leave them with compromised immune and metabolic systems. When these vulnerable systems are exposed to pollutants, this can create a further burden on their biological functions, thereby increasing their vulnerability to disease. In short, deprived environments can impose a double burden on a person’s biological system, resulting in a higher risk of disease. This insight is supported by population data which shows low SES demographics having a higher prevalence of metabolic and mental disorders.
Following the understanding of biological inequality and deprivation, the Urban Health Index (UHI) was created as a way to present the psychosocial and environmental stress risks in one score to reflect the urban health experience. When following the definition of deprivation proposed by the IMD, the SRS provides greater depth into the role the environment plays in the overall assessment. The UHI, therefore, shares the representation of each to create a score from 0.0-2.0 where 0 is worse and 2 is best.
Case Study 2: Health Hotspots
How do we learn to identify places that have the potential of making people sick.
Scale: 0.2 (worst) - 1.88 (best)
Top 20 worst scoring Wards in London
Stonebridge (Brent)
Golborne (Kensington and Chelsea)
St. Pancras and Somers Town (Camden)
Hackney Wick (Hackney)
Church Street (City of Westminster)
Notting Dale (Kensington and Chelsea)
Northumberland Park (Haringey)
Woodberry Down (Hackney)
Hackney Central (Hackney)
Homerton (Hackney)
Lansbury (Tower Hamlets)
North Walworth (Southwark)
Poplar (Tower Hamlets)
Hoxton West (Hackney)
Bromley North (Tower Hamlets)
Shepherd's Bush Green (Hammersmith and Fulham)
St. George's (Southwark)
Prince's (Lambeth)
College Park and Old Oak (Hammersmith and Fulham)
Finsbury Park (Islington)
Top 20 Best scoring Wards in London
Petts Wood and Knoll (Bromley)
Hayes and Coney Hall (Bromley)
West Wickham (Bromley)
Upminster (Havering)
Chelsfield and Pratts Bottom (Bromley)
Farnborough and Crofton (Bromley)
Shortlands (Bromley)
Biggin Hill (Bromley)
East Sheen (Richmond upon Thames)
Hacton (Havering)
Sanderstead (Croydon)
Emerson Park (Havering)
Bickley (Bromley)
Carshalton South and Clockhouse (Sutton)
Cheam (Sutton)
Cranham (Havering)
Teddington (Richmond upon Thames)
Eastcote and East Ruislip (Hillingdon)
Crook Log (Bexley)
Nonsuch (Sutton)
Understanding which areas pose a health risk can help practitioners make better decisions at a systemic level. Whether it is which areas need environmental pollutant reduction or which areas need more health support. Additionally, it can help GP’s identify which patients could be at a health risk due to environmental pollutants to better prepare their health programmes. Finally, citizens, can use this information to campaign for better urban planning strategies that affect their health.
Limitations
Despite adding another layer to the information provided by the SRS, the UHI displays the same general limitations as the SRS in that it is based on aggregate averages and is not a tool for referencing the exposure of specific individuals. It also shares the weight between environmental and psychosocial factors when displaying a score (meaning each is 50% of the total score) when that is not proven to reflect the real, much more complicated dynamics and influence of these factors that researchers and local authorities are still trying to comprehend. It may be the case that there’s a threshold for both to reach together, that they grow exponentially, or that a threshold of one amplifies the other. For simplicity, we have kept them equal.
Climate Change x City Infrastructure x Health
People line up to get dry ice from a Con Edison truck in a neighbourhood without power in the Brooklyn borough of New York, Monday, July 22, 2019. Seth Wenig / AP Photo
Climate change will exacerbate pollutants and likely create different ones, given how it is already wreaking havoc on poorly planned and tired infrastructure. There are many case studies to learn from, such as the New York City heatwave of 2019, which caused Con Edison to take pre-emptive measures to protect vital equipment due to the unprecedented usage brought on by the high temperatures. This resulted in Con Edison turning off the power to a neighbourhood in southeast Brooklyn. The problem with the decision was it took power away in an area that scores a 4 out 5 in the Heat Vulnerability Index (HVI). The HVI is a metric developed by Columbia University to estimate the risk of heat-related deaths across different New York City neighbourhoods. Con Edison’s pre-emptive action could have potentially put people’s health at risk as the neighbourhood where the outage took place was already vulnerable to the effects of heat.
While urban regeneration cannot make direct decisions about power grids, it can incorporate built environment interventions to bring the urban heat index down, such as planning for more green infrastructure, creating housing regulations that require homes to be built with heatwave considerations, reducing the amount of concrete, etc. The health risks associated with heat can range from instant death or lifelong injury due to heatstroke. The hyperthermic element of heatstroke can also bring long-lasting neurological damage, which can lead to memory and attention differences.
Heat is only one of the many pollutants that affect people living in cities; therefore, a key question is what happens when people are exposed to multiple pollutants and what effect this has on their biological systems? Furthermore, who are the demographics that are the most vulnerable due to levels of exposure? Understanding which areas are more vulnerable to health risks can help make more effective urban regeneration decisions related to urban health, especially as climate change puts new strains on urban infrastructure.
We also need to consider what biological inequality will look like in the face of climate change. For example, low SES communities already experience higher levels of UHI effect due to poor green infrastructure; when a heatwave occurs, they experience higher micro- environmental temperatures, which puts them at a higher risk for heatstroke effects. Finally, climate change can be a source of further stressors for those living in poverty. This can range from living in cold or hot homes due to poor insulation and inability to acquire resources due to income shortages, to living in environments with mould due to wetter winters and poor ventilation. Additionally, living with mould is not just a psychological stressor of living in a visibly dilapidated environment, it can also have an effect on mental health as it is linked to both anxiety and depression.
With this understanding, it is important for urban planning, development and management to include biological measures into their strategies, starting with insight from neuroscience.
Health, Place, and Resilience
Introduction
Previously, we have identified how the invisible outputs of the built environment coalesce to create a biological impact. It should be taken as fact that an overarching aim is to reduce these stressors through active monitoring and local development and management policies. However simply removing the stressors from the local environment will not absolutely reduce health inequities. There are many non-urban places with poor health outcomes where exposure to environmental stressors are low. This is where we need to address the built environment as a relational and ecological system. Centric do not prescribe an overt framework for health, as this runs the risk of top-down behaviours that ignore what exists. Instead, we believe that communities know what contributes to health but need barriers removed. By looking at built environments from a position of resilience, we can see whether people in their community on a given day have access to goods, resources, and services to build a platform. This platform will become more important through the challenges of climate change and disruptions such as the Covid-19 pandemic and government enforced lockdowns.
Resilience is defined as the capacity to recover quickly from difficulties; toughness. The objective of this next section is to present a framework for identifying resilience in communities and their relationship to health.
A Framework
A Comment on the Framework
This framework intentionally does not include a scoring system. A scoring system is best used when the premise and relationships are well understood and there’s a clear pathway to change. An over-reliance on numerical metrics in an assessment can sometimes distract from further insight that highlights nuances that lived experience would readily identify. For example, when comparing two London locations (Islip Street, NW5 and Beaconsfield Road, UB1) the total scores were relatively similar and quite “good”. However, when looking at Beaconsfield Road, a street where multiple health injustices are occurring due to a neighbouring gasworks redevelopment, the issues contributing to poorer health outcomes lie in the Housing and Local Governance domains.
The trespassing of toxic air pollutants from soil to sofa made the home an unsafe place for residents. Equally, the low levels of governance has forced the relatively low-income community to establish their own representation groups; at the opportunity cost of either additional work or simple wellbeing time.
Had this framework been converted into a totalised scoring system it would fall foul to Goodharts Law; Any observed statistical regularity will tend to collapse once pressure is placed upon it for control purposes, and as the British anthropologist Marilyn Strathern later boiled it down: “When a measure becomes a target, it ceases to be a good measure.”
It is of Centric Lab’s own opinion that too much focus is placed on achieving scoring systems and not nuanced problem solving, listening and community sovereignty. There are many global and national indexes that exist to support the delivery of good infrastructure however it can be argued that they support a culture of self-congratulating rather than addressing inequities communities are experiencing rather than how cities compare to each other. One addresses who might move there in the future, the other cares what happened yesterday to make tomorrow better.
A lens on the UK National Planning Policy Framework
Following a review of the NPPF we would make the following edits to embed a process of equitable health in the planning system
DEFINITIONS
Biological Inequality
The chronic and disproportionate exposure to environmental and psychosocial stressors arising from the built environment.
Community Health
A baseline health assessment performed annually to determine the vulnerability of the community to stressors in the built environment.
Health
Health is the ability for our biological systems to enter stability after experiencing trauma or stress throughout our entire lifetime
Stressors
Stressors are elements arising from the building environment that threaten to cause physiological or psychological stress upon a person, namely by engaging the stress-response system.
Susceptibility
Susceptibility refers to the effects of biological inequality on the human immune response, specifically the fact that persistent environmental stressors on a community place these individuals at a heightened risk of developing severe symptoms and chronic illnesses compared to a normative population, not exposed to significant stressors.
The following are chapter updates based on these definitions:
+ Chapter 2. Achieving sustainable development
[8] Achieving sustainable development means that the planning system has 3 overarching objectives, which are interdependent and need to be pursued in mutually supportive ways (so that opportunities can be taken to secure net gains across each of the different objectives):
A health objective; to actively target the reduction of chronic health issues prevalent in the local area. This involves collaboration with local NHS Trusts and health specialists to determine realistic objects to be achieved through planning. The process ensures that plans are written targeting the promotion of uses and activities that mitigate stressors and build long term positive health outcomes relative to existing communities and those potentially faced by future citizens.
+ Chapter 3. Plan-making
[15] The planning system should be genuinely plan-led. Succinct and up-to-date plans should provide a positive vision for the future of each area; a framework for addressing housing needs and other health, economic, social and environmental priorities; and a platform for local people to shape their surroundings.
[16] Plans should:
(g) Provide a clear process to baseline Community Health and how any intervention will improve or impact this level.
(h) Incorporate knowledge and processes that encourage the interaction of broader local authority health targets.
Maintaining effective cooperation
[25] Strategic policy-making authorities should collaborate to identify the relevant strategic matters which they need to address in their plans. They should also engage with their local communities and relevant bodies including Local Enterprise Partnerships, Local Nature Partnerships, the Marine Management Organisation, county councils, infrastructure providers, elected Mayors and combined authorities (in cases where Mayors or combined authorities do not have plan-making powers), and local NHS Trusts or relevant bodies.
Preparing and reviewing plans
[32] Local plans and spatial development strategies should be informed throughout their preparation by a sustainability appraisal that meets the relevant legal requirements. This should demonstrate how the plan has addressed relevant health, economic, social and environmental objectives (including opportunities for net gains). Significant adverse impacts on these objectives should be avoided and, wherever possible, alternative options which reduce or eliminate such impacts should be pursued. Where significant adverse impacts are unavoidable, suitable mitigation measures should be proposed (or, where this is not possible, compensatory measures should be considered).
Development contributions
[34] Plans should set out the contributions expected from development. This should include setting out the levels and types of affordable housing provision required, along with other infrastructure (such as that needed for education, Community Health, transport, flood and water management, green and digital infrastructure). Such policies should not undermine the deliverability of the plan.
+ Chapter 8. Promoting healthy and safe communities
[91] Planning policies and decisions should aim to achieve healthy, inclusive and safe places which: (d) target the reduction of Stressors existing in the local area.
[93] Planning policies and decisions should consider the social, economic and environmental benefits of estate regeneration. Local planning authorities should use their planning powers to help deliver estate regeneration to a high standard, prioritising estates in areas high in Stressors.
[96] Access to a network of a high and varied quality of open spaces, as determined by local ecologists, and opportunities for sport and physical activity is important for the health and well-being of communities. Planning policies should be based on robust and up-to-date assessments of the need for open space, sport and recreation facilities (including quantitative or qualitative deficits or surpluses) and opportunities for new provision. Information gained from the assessments should be used to determine what open space, sport and recreational provision is needed, which plans should then seek to accommodate.
+ Chapter 9. Promoting sustainable transport
[102] Transport issues should be considered from the earliest stages of plan-making and development proposals, so that:
(f) a full Community Health assessment is taken into consideration when evaluating the potential temporary or permanent increase in stressors resulting from the proposal.
(g) there are no adverse effects as a result of climate change on walkability, cycling or vehicle based traffic.
[108] In assessing sites that may be allocated for development in plans, or specific applications for development, it should be ensured that:
(c) any significant impacts from the development on the transport network (in terms of capacity and congestion), or on highway safety, can be cost effectively mitigated to an acceptable degree relative to the Community Health baseline.
[110] Within this context, applications for development should:
(f) demonstrate climate change preparedness.
+ Chapter 12. Achieving well-designed places
[125] Plans should, at the most appropriate level, set out a clear design vision and expectations, so that applicants have as much certainty as possible about what is likely to be acceptable. Design policies should be developed with local communities and NHS Trusts so they reflect local aspirations, and are grounded in an understanding and evaluation of each area’s defining characteristics. Neighbourhood plans can play an important role in identifying the special qualities of each area and explaining how this should be reflected in development.
[127] Planning policies and decisions should ensure that developments:
(f) create places that are safe, inclusive and accessible and which promote health and well-being relevant to the local community, with a high standard of amenity for existing and future users factoring in likely climate change impacts; and where crime and disorder, and the fear of crime, do not undermine the quality of life or community cohesion and resilience.
Meeting the challenge of climate change, flooding and coastal change
Chapter Planning for climate change
[149] Plans should take a proactive approach to mitigating and adapting to climate change, taking into account the long-term implications for flood risk, coastal change, water supply, biodiversity and landscapes, and the risk of overheating from rising temperatures based on the current Community Health assessment and its trajectory as defined by an external professional. Policies should support appropriate measures to ensure the future resilience of communities and infrastructure to climate change impacts, such as providing space for physical protection measures, or making provision for the possible future relocation of vulnerable development and infrastructure.
[150] New development should be planned for in ways that:
(c) do not expose future citizens to risks from climate change as a result of new infrastructure.
+ Chapter 15. Conserving and enhancing the natural environment
Ground conditions and pollution
[178] Planning policies and decisions should ensure that:
(d) any remediation of land is considered within the susceptibility of the local population. The latest Community Health assessment would determine the suitability of land extraction and what mitigations would be needed to ensure there are no increase of stressors to local residents whatsoever.
[180] Planning policies and decisions should also ensure that new development is appropriate for its location taking into account the likely effects (including cumulative effects) of pollution on Community Health, living conditions and the natural environment, as well as the potential sensitivity of the site or the wider area to impacts that could arise from the development. In doing so they should:
[181] Planning policies and decisions should sustain and contribute towards compliance with relevant limit values or Community Health objectives for pollutants, taking into account the presence of Air Quality Management Areas and Clean Air Zones, and the cumulative impacts from individual sites in local areas on Community Health. Opportunities to improve air quality or mitigate impacts should be identified, such as through traffic and travel management, and green infrastructure provision and enhancement. So far as possible these opportunities should be considered at the plan-making stage, to ensure a strategic approach and limit the need for issues to be reconsidered when determining individual applications. Planning decisions should ensure that any new development in Air Quality Management Areas and Clean Air Zones is consistent with the local air quality action plan.
+ Chapter 17. Facilitating the sustainable use of minerals
[204] Planning policies should:
(i) ensure that precautions and mitigations are in place to ensure that through the process of any land remediation or mineral extraction that any dispersion by air of chemicals does not trespass into residential areas. This includes a comprehensive environmental impact assessment with wind modelling identifying any likely trespass and mitigations in place to ensure this does not take place.
[205] When determining planning applications, great weight should be given to the benefits of mineral extraction, including to the economy. In considering proposals for mineral extraction, minerals planning authorities should: (c) ensure that any unavoidable noise, dust and particle emissions and any blasting vibrations are controlled, mitigated or removed at source66, and establish appropriate Community Health noise limits for extraction in proximity to noise sensitive properties.
Conclusion
The National Planning Policy Framework (NPPF) of February 2019 (Chapter 8) has directed those working on the built environment to improve health. To accomplish this goal, we suggest urban planning programmes adopt the use of neuroscience, which can help understand the relationship between people, health and urban environments. This is especially relevant as the health issues which are becoming more acute in cities are related to mental and metabolic disorders which fall under the neuroscience line of study.
The challenge with introducing neuroscience to the urban realm is, however, the lack of a clear framework. To solve this challenge, we put forward a new neuroscience informed software and resilience framework, which can help urban built environment professionals, health organisations and citizens alike identify which areas are most vulnerable to health risks associated with urban environments.
In the UK, the Ministry of Homes, Communities and Local Government (MHCLG) recently updated the NPPF to reflect that when decisions are made on new development the local planning authorities' Local Plan is that which holds the most power. This element of planning devolution has the potential to radically help local communities define how their built environment is shaped. However, when it comes to health there is very little guidance and this presents a two-fold problem.
There is no active definition of health found in MHCLG documentation. This means that it is the responsibility of policy officers to define and draft accordingly. Whilst there is an abundance of literature available on health and place, this as much becomes the problem. Even with good intentions policy officers can draw from insights that exacerbate inequities and at worse can use definitions of health that are classist and structurally racist. We propose the following definitions:
Health: The equitable access to goods, services, and resources to allow our biological systems to reach homeostasis following a biological or psychological stressor; and
Urban Health: Relating to the intersectional lived experience of urban dwellers and the unique influence urbanisation has on biological systems through exposure to environmental and psychosocial stressors.
With no joined up thinking, definition and practice between planning authorities on health it is possible for greater disparities to occur as people do not live their lives defined by political boundaries.
This will be of even more importance as climate change creates further built environment decay, increasing the risk for serious and chronic health issues such as anxiety, obesity, neurodevelopmental problems and depression.
Recommendations
Government
To update the NPPF that includes definitions of health as prescribed in this document.
Update the Indicies of Multiple Deprivation to factor in environmental data.
The following is extracted from our 2020 paper, Neuroscience, Urban Regeneration & Urban Health:
A Pearson’s correlation was performed between the IMD and the SRS to mental health prevalence data from the NHS Digital Datastore. The SRS had a correlation value of r= 0.86 (p< 0.05), therefore showing strong positive correlation with mental health prevalence for an area. Instead, the IMD score for living environment (one of the IMD components) had a correlation value of r= 0.77 (p< 0.05) with the NHS mental health prevalence data, lower than the SRS score. Moreover, The SRS had a correlation of r= 0.91 (p< 0.05) with the IMD living environment values, indicating that the two measures are strongly related. These results indicate that the SRS score is a valid and accurate proxy for the impact of environmental stressors on human mental health. Since the correlation value of SRS to mental health was higher than that of living environment IMD (ie 0.86 > 0.77), it can therefore be argued that the SRS score is a better assessment system of environmental stressors linked to mental health than IMD. This is likely because the SRS is based on pollutant data that directly leads to the activation of the human stress-response system, rather than the analysis of levels of deprivation due to the built environment.
City/Local Government
To establish city wide sensors collecting data on air, noise, light and thermal data. The current data sets used by researchers are often modelled using algorithms. In order to make a genuine difference cities need to invest in the hardware as well as software.
To draft annually updated Local Design Codes based on construction and architecture materials that actively seek to lower stressors (based on the previous years recordings).
Private Sector
To perform Community Health Assessments regardless of any policy initiative.
Healthcare
GP’s to include UHI data in assessing health outcomes.