Exploring the nexus of urban form, transport, environment and health in large-scale urban studies: A state-of-the-art scoping review.

BACKGROUND: As the world becomes increasingly urbanised, there is recognition that public and planetary health relies upon a ubiquitous transition to sustainable cities. Disentanglement of the complex pathways of urban design, environmental exposures, and health, and the magnitude of these associations, remains a challenge. A state-of-the-art account of large-scale urban health studies is required to shape future research priorities and equity- and evidence-informed policies. OBJECTIVES: The purpose of this review was to synthesise evidence from large-scale urban studies focused on the interaction between urban form, transport, environmental exposures, and health. This review sought to determine common methodologies applied, limitations, and future opportunities for improved research practice. METHODS: Based on a literature search, 2958 articles were reviewed that covered three themes of: urban form; urban environmental health; and urban indicators. Studies were prioritised for inclusion that analysed at least 90 cities to ensure broad geographic representation and generalisability. Of the initially identified studies, following expert consultation and exclusion criteria, 66 were included. RESULTS: The complexity of the urban ecosystem on health was evidenced from the context dependent effects of urban form variables on environmental exposures and health. Compact city designs were generally advantageous for reducing harmful environmental exposure and promoting health, with some exceptions. Methodological heterogeneity was indicative of key urban research challenges; notable limitations included exposure and health data at varied spatial scales and resolutions, limited availability of local-level sociodemographic data, and the lack of consensus on robust methodologies that encompass best research practice. CONCLUSION: Future urban environmental health research for evidence-informed urban planning and policies requires a multi-faceted approach. Advances in geospatial and AI-driven techniques and urban indicators offer promising developments; however, there remains a wider call for increased data availability at local-levels, transparent and robust methodologies of large-scale urban studies, and greater exploration of urban health vulnerabilities and inequities.

Adaptation of the Recreovía During COVID-19 Lockdowns: Making Physical Activity Accessible to Older Adults in Bogotá, Colombia.

The community restrictions during the coronavirus disease 2019 pandemic adversely impacted older adults' physical activity levels. This convergent mixed-method study assessed the adaptation of the Recreovía, a community-based physical activity program in Bogotá, and characterized physical activity levels among older adult participants. Our results showed how the Recreovía adapted during the pandemic to continue promoting physical activity, through indoor and outdoor strategies, including virtual physical activity sessions and safety protocols. During this time, 72%-79% of the older adults attending the adapted program were physically active. A greater proportion of park users (84.2%) and more people involved in vigorous physical activity were observed during Recreovía days. Older adults had positive experiences and perceptions of the Recreovía program related to their health and social well-being. Even though the older adults prefer being outdoors, the adapted program allowed participants to continue with their physical activity routines as much as possible during the pandemic.

Need and Interest in Nature Prescriptions to Protect Cardiovascular and Mental Health: A Nationally-Representative Study With Insights for Future Randomised Trials.

OBJECTIVE: "Nature prescriptions" are increasingly being adopted by health sectors as an adjunct to standard care to attend to health and social needs. We investigated levels of need and interest in nature prescriptions in adults with cardiovascular diseases, psychological distress and concomitants (e.g. physical inactivity, sedentary behaviour, obesity, loneliness, burn-out). METHODS: A nationally-representative survey of 3,319 adults across all states and territories of Australia was completed in February 2021 (response 84.0%). Participants were classified across 15 target groups using validated health indicators and surveyed on (1) time and frequency of visits to green and blue spaces (nature spaces), (2) interest in a nature prescription, and (3) potential confounders (e.g. age, income). Analyses were done using weighted logistic regressions. RESULTS: The sample was 50.5% female, 52.0% were aged ≥45 years, 15.2% were living alone and 19.3% were born overseas in non-English-speaking countries. Two-thirds of the sample spent 2 hours or more a week in nature, but these levels were generally lower in target groups (e.g. 57.7% in adults with type 2 diabetes). Most participants (81.9%) were interested in a nature prescription, even among those spending fewer than 2 hours a week in nature (76.4%). For example, 2 hours a week or more in nature was lowest among sedentary adults (36.9%) yet interest in nature prescriptions in this group was still high (74.0%). Lower levels of nature contact in target groups was not explained by differences in access to or preference for local nature spaces. CONCLUSIONS: High levels of interest in nature prescriptions amid low levels of nature contact in many target health groups provides impetus for developing randomised trials of interventions that enable people to spend more time in nature. These findings can inform intervention co-design processes with a wide range of community stakeholders, end-users in target health groups, and the health professionals who support them.

When Moving Is the Only Option: The Role of Necessity Versus Choice for Understanding and Promoting Physical Activity in Low- and Middle-Income Countries.

Given its origins in high-income countries, the field of physical activity and public health research and promotion has broadly followed a choice-based model. However, a substantial amount of the physical activity occurring routinely in many settings, particularly in low- and middle-income countries (LMICs), is the result of economic necessity and is not due to true, free choices. We propose the "necessity- versus choice-based physical activity models" framework as a conceptual tool to ground physical activity and public health research and promotion efforts in LMICs, helping ensurethat these efforts are relevant, ethical, responsive, and respectful to local contexts. Identifying ways to ensure that LMIC populations can maintain high levels of active transport while increasing opportunities for active leisure must be prioritized. To promote equity, physical activity research, programs, and policies in LMICs must focus on improving the conditions under which necessity-driven physical activity occurs for a vast majority of the population.

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.

"Green Enough Ain't Good Enough:" Public Perceptions and Emotions Related to Green Infrastructure in Environmental Justice Communities.

The concept of biophilic urban planning has inspired neighborhood greening projects in many older urban communities in the USA and beyond. The strengths (e.g., environmental management, biodiversity, heat island mitigation) and challenges (e.g., greenwashing, green gentrification) of such projects are well-documented. Additional research on the relationship between these projects and various social factors (e.g., public perceptions, feelings, and mental health and well-being) is necessary to better understand how people adapt to said projects while struggling to navigate other more pressing socioeconomic issues, especially in communities facing environmental injustice and health inequity. In this article, we focus on one aspect of biophilic urban planning-green stormwater infrastructure (GSI) (e.g., rain gardens, bio-swales, pervious pavements, and wildflower meadows)-in Waterfront South, a post-industrial neighborhood in Camden, NJ, USA, where residents have faced environmental injustices for decades. Our qualitative analysis of in-depth semi-structured interviews of sixteen residents offered a thorough insight into their perceptions and emotions regarding different types of urban GSI projects. Residents acknowledge the many benefits that GSI offers to combat the neighborhood's social and environmental injustices, but they are cautious about the possibility of some projects prompting new issues and concerns within the community. Our findings reveal potential implications in GSI planning, research, and practice in this neighborhood and similar urban places elsewhere that have yet to undergo gentrification.

The effect of different COVID-19 public health restrictions on mobility: A systematic review.

BACKGROUND: In response to the COVID-19 pandemic, most countries have introduced non-pharmaceutical interventions, such as stay-at-home orders, to reduce person-to-person contact and break trains of transmission. The aim of this systematic review was to assess the effect of different public health restrictions on mobility across different countries and cultures. The University of Bern COVID-19 Living Evidence database of COVID-19 and SARS-COV-2 publications was searched for retrospective or prospective studies evaluating the impact of COVID-19 public health restrictions on Google Mobility. Titles and abstracts were independently screened by two authors. Information from included studies was extracted by one researcher and double checked by another. Risk of bias of included articles was assessed using the Newcastle Ottowa Scale. Given the heterogeneous nature of the designs used, a narrative synthesis was undertaken. From the search, 1672 references were identified, of which 14 were included in the narrative synthesis. All studies reported data from the first wave of the pandemic, with Google Mobility Scores included from January to August 2020, with most studies analysing data during the first two months of the pandemic. Seven studies were assessed as having a moderate risk of bias and seven as a low risk of bias. Countries that introduced more stringent public health restrictions experienced greater reductions in mobility, through increased time at home and reductions in visits to shops, workplaces and use of public transport. Stay-at-home orders were the most effective of the individual strategies, whereas mask mandates had little effect of mobility. CONCLUSIONS: Public health restrictions, particularly stay-at-home orders have significantly impacted on transmission prevention behaviours. Further research is required to understand how to effectively address pandemic fatigue and to support the safe return back to normal day-to-day behaviours.

Individual Characteristics Associated with Active Travel in Low and High Income Groups in the UK.

Active travel (AT) has gained increasing attention as a way of addressing low levels of physical activity. However, little is known regarding the relationship between income and AT. The aim of this study was to investigate characteristics associated with undertaking AT in an adult population and by low- and high-income groups. Data collected from the Physical Activity and the Rejuvenation of Connswater (PARC) study in 2017 were used. Participants were categorised into socio-economic groups according to their weekly household income, and were categorised as participating in 'no' AT or 'some' AT and 'sufficient' AT. Multivariable logistic regression explored characteristics associated with AT in the full cohort, and the low- and high-income groups separately. Variables associated with AT in the low-income group were body mass index (BMI), physical activity self-efficacy, marital status, long term illness, difficulty walking and housing tenure. For the high-income group, BMI, marital status, housing tenure and education were associated with AT. For both income groups, there were consistent positive associations with the action/maintenance phase of the stage of change model across all AT categories. The findings suggest that population sub-groups may benefit from targeted initiatives to support engagement in AT and prevent further widening of inequalities.

Investigating the physical activity, health, wellbeing, social and environmental effects of a new urban greenway: a natural experiment (the PARC study).

BACKGROUND: Evidence for the health benefits of urban green space tends to stem from small, short-term quasi-experimental or cross-sectional observational research, whilst evidence from intervention studies is sparse. The development of an urban greenway (9 km running along 3 rivers) in Northern Ireland provided the opportunity to conduct a natural experiment. This study investigated the public health impact of the urban greenway on a range of physical activity, health, wellbeing, social, and perceptions of the environment outcomes. METHODS: A repeated cross-sectional household survey of adult residents (aged ≥16 years) who lived ≤1-mile radius of the greenway (intervention sample) and > 1-mile radius of the greenway (control sample) was conducted pre (2010/2011) and 6-months post implementation (2016/2017). We assessed changes in outcomes pre- and post-intervention follow-up including physical activity behaviour (primary outcome measure: Global Physical Activity Questionnaire), quality of life, mental wellbeing, social capital and perceptions of the built environment. Linear regression was used to calculate the mean difference between post-intervention and baseline measures adjusting for age, season, education, car ownership and deprivation. Multi-level models were fitted using a random intercept at the super output area (smallest geographical unit) to account for clustering within areas. The analyses were stratified by distance from the greenway and deprivation. We assessed change in the social patterning of outcomes over time using an ordered logit to make model-based outcome predictions across strata. RESULTS: The mean ages of intervention samples were 50.3 (SD 18.9) years at baseline (n = 1037) and 51.7 (SD 19.1) years at follow-up (n = 968). Post-intervention, 65% (adjusted OR 0.60, 95% CI 0.35 to 1.00) of residents who lived closest to the greenway (i.e., ≤400 m) and 60% (adjusted OR, 0.64 95% CI 0.41 to 0.99) who lived furthest from the greenway (i.e.,≥1200 m) met the physical activity guidelines - 68% of the intervention sample met the physical activity guidelines before the intervention. Residents in the most deprived quintiles had a similar reduction in physical activity behaviour as residents in less deprived quintiles. Quality of life at follow-up compared to baseline declined and this decline was significantly less than in the control area (adjusted differences in mean EQ5D: -11.0 (95% CI - 14.5 to - 7.4); - 30.5 (95% CI - 37.9 to - 23.2). Significant change in mental wellbeing was not observed despite improvements in some indicators of social capital. Positive perceptions of the local environment in relation to its attractiveness, traffic and safety increased. CONCLUSIONS: Our findings illustrate the major challenge of evaluating complex urban interventions and the difficulty of capturing and measuring the network of potential variables that influence or hinder meaningful outcomes. The results indicate at this stage no intervention effect for improvements in population-level physical activity behaviour or mental wellbeing. However, they show some modest improvements for secondary outcomes including positive perceptions of the environment and social capital constructs. The public health impact of urban greenways may take a longer period of time to be realised and there is a need to improve evaluation methodology that captures the complex systems nature of urban regeneration.

Designing Age-Friendly Communities: Exploring Qualitative Perspectives on Urban Green Spaces and Ageing in Two Indian Megacities.

The World Health Organization and the United Nations have increasingly acknowledged the importance of urban green space (UGS) for healthy ageing. However, low- and middle-income countries (LMICs) like India with exponential ageing populations have inadequate UGS. This qualitative study examined the relationships between UGS and healthy ageing in two megacities in India. Participants were recruited using snowball sampling in New Delhi and Chennai and semi-structured interviews were conducted with consenting participants (N = 60, female = 51%; age > 60 years; fluent in English, Hindi, or Tamil). Interviews were recorded, transcribed, translated, and analysed using inductive and thematic analysis. Benefits of UGS included community building and social capital, improved health and social resilience, physical activity promotion, reduced exposure to noise, air pollution, and heat. Poorly maintained UGS and lack of safe, age-friendly pedestrian infrastructure were identified as barriers to health promotion in later life. Neighbourhood disorder and crime constrained older adults' use of UGS in low-income neighbourhoods. This study underscores the role of UGS in the design of age-friendly communities in India. The findings highlight the benefits of UGS for older adults, particularly those living in socially disadvantaged or underserved communities, which often have least access to high-quality parks and green areas.

Geographic Distribution of the Ciclovia and Recreovia Programs by Neighborhood SES in Bogotá: How Unequal is the Geographic Access Assessed Via Distance-based Measures?

Ciclovia, also known as Open Streets initiatives in other countries, are city streets that are closed to motorized traffic and opened during certain times to residents for engaging in physical activity (PA). These initiatives are viewed by policy makers and health and community advocates as being beneficial to social, environmental, and community health. This study explores the geographic distribution of Ciclovia and Recreovia and the differences in geographic access assessed via distance-based measures, based on the socioeconomic status (SES) of the area. Results from this study show that the median distance to the Ciclovia according to SES ranges from 2930 m for SES 1 (most disadvantaged) to 482 m for SES 6 (wealthiest). The median distance to the Recreovia sites ranges from 5173 m for SES 1 to 3869 m for SES 6. This study found revealing urban inequities in the distribution of Ciclovia, whereas there was less inequalities within the Recreovia sites. This study shows that urban interventions are needed to promote recreational activity and reduce health disparities in under resourced, low SES areas.

Defining pathways to healthy sustainable urban development.

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