The Role of the Built Environment on Health Across the Life Course: A Call for CollaborACTION

Introduction

Creating supportive environments is a bedrock of health promotion. ¹ We know and understand the dynamic interplay that exists between people and places, and the importance of context when it comes to efforts that promote the health and well-being of individuals. ² The built environment refers to physical environment surroundings and conditions that are constructed by human activity (eg, buildings, streets, and parks). ³ The distinction of environmental aspects that are man-made is important because it focuses attention toward what is modifiable. For example, aspects of the built environment can be shaped to support health and well-being, social interactions, and environmental sustainability. Built environments vary in scale; they can range from the design and layout of rooms and classrooms, which makeup the buildings in which we live and learn and work, which are located and connected to each other through sidewalks and roads in neighborhoods that collectively form our urban cities. We all engage with some aspect of the built environment every day. This means when it comes to the practice of health promotion, everyone can do something to move closer toward creating supportive and healthy built environments for all.

Over 30 years of built environment and health research underpinned by socioecological models of health behavior provides a strong, evidence-based foundation from which to act. Although much of the research focuses on physical activity as the outcome, the findings are applicable to health and well-being more broadly given that as a behavior, physical activity is a “best-buy” when it comes to public health. ⁴ This article summarizes the important influence of the built environment on health across the lifecourse (youth, adults, and older adults) and across different behavioral settings (home, neighborhood, and community; workplace; and schools). Based on decades of evidence, we call for collaboration and action (collaborACTION) from policy makers, health practitioners, nongovernment organizations (NGOs), employers, communities, and other health as well as nonhealth stakeholders to advance health for all.

Role of the Built Environment on Health: Youth

Key built environment features associated with children’s health and well-being include the availability and access to local destinations, including green space and nature and local infrastructure and services. ^{5 –7} Green spaces (eg, parks) and nature are important places for youth. Much of the evidence supporting relationships between the built environment and children’s health focuses on children’s physical activity behaviors (eg, active play and walking and cycling to and from school or around the neighborhood) ^{8 –10} and obesity. ^11,12

Although having local destinations such as schools, parks, shops, and recreation centres are important, ⁵ children (and parents) are more likely to use these destinations and services if they are located within walking distance of their home. ^{13 –16} Although younger children need others to accompany them to local destinations such as schools, ¹⁷ as children age and become more independent, parents have reported that a round trip of 1 mile (ie, 0.5 mile 1-way) is an acceptable walking distance for children aged 10 to 12 years. ¹⁸ Children living in more “walkable” neighborhoods (eg, well-connected streets with safe crossing points, sidewalks, local destinations present, and low traffic volumes and speeds) are more likely to be physically active when compared to those living in less walkable communities. ^{19 –21} However, having destinations nearby does not necessarily mean children walk there or use the destination. Parent perceptions of neighborhood safety (eg, perceived traffic exposure, stranger danger, crime, and neighborhood disorder) can potentially restrict children’s access to their neighborhood environment, whereas high levels of parent-perceived neighborhood safety have been found to positively affect young children’s general health and development. ^7,22

The quality of destinations is also important. More attractive and well-maintained parks with high-quality play equipment are more likely to be used. ²³ Children are more likely to perceive playgrounds offering a range of activities and some level of managed risk as exciting and challenging, ^24,25 which may increase use. ²⁶ Emerging evidence suggests natural play environments, with elements such as trees, wood, and flowers, benefit children’s mental health and behavioral, cognitive, and physical development, ²⁷ highlighting that spaces and places can be modified to promote use and better health outcomes for children.

Other behavior settings such as schools, recreation venues, and early childhood education and care services can also be designed as physical places for social interaction ²⁸ and physical activity. ^29,30 For example, modifying the school environment (eg, playground markings, provision of play equipment, and size and the amount of greenspace) has been shown to increase children’s play and physical activity levels, ^31,32 although the evidence is somewhat inconclusive due to the small number of intervention studies conducted to date. ³³

The “built food environment” (ie, the type, location, and number of food outlets) around homes and schools also has the potential to influence children’s health. Although the evidence in this rapidly growing area of research is mixed, several international studies suggest neighborhoods with more healthy food outlets (eg, supermarkets and fresh produce stores) and fewer unhealthy food outlets (eg, fast food outlets and convenience stores) around children’s homes is associated with healthier dietary outcomes and lower levels of overweight and obesity in children. ^34,35 Similarly, some studies have found increased exposure to unhealthy food outlets close to schools is associated with increased body weight and increased intake of high-caloric foods in schoolchildren. ^36,37 Other food-related built environment characteristics that have the potential to impact children’s nutritional health include food advertising, the provision of community amenities such as water fountains, breast-feeding facilities, and community gardens. ³⁸

Role of the Built Environment on Health: Adults

Adult health-related outcomes and risk factors associated with the built environment include physical activity–related behaviors, ^39,40 dietary intake, ^41,42 blood pressure, ⁴³ , obesity, ^{44 –47} cardiovascular disease, ⁴⁸ diabetes mellitus, ⁴⁹ cardiometabolic syndrome, ^{50 –52} and mental health (eg, depression, ⁵³ stress, ⁵⁴ and subjective well-being). ⁵⁵

Features of the built environment associated with adult health include street connectivity, land use mix and access to destinations, density, green public open spaces, the food environment, pedestrian infrastructure (eg, sidewalks, lighting), aesthetics, and safety. However, some researchers have found null or contrary to expected results for some of these built environment features. ⁴⁰ Land use mix and destinations are particularly important for physical activity. ^40,56 Proximity to destinations facilitates walking, cycling, active transport, and park use—all of which are associated with health benefits. ^{57 –61} Distances within 800 m are important for walking trips to food-related destinations (eg, supermarkets, cafes/restaurants, and small food stores) and 0.75 mile for community-orientated destinations (eg, post offices, community centres, child care centres, and libraries) and public transport stops. ^62,63 Parks are positively associated with levels of physical activity and negatively associated with mental health and stress-related problems, ^{56,64 –67} while social infrastructure destinations such as hospitals and health-related services, arts and cultural institutions, and community housing influence subjective well-being. ⁵⁵ Some researchers have investigated built environment typologies (eg, traditional vs neo-traditional neighborhoods) in an effort to understand the collective effect of the built environment on health. ^{62,68 –73} Although these analyses confirm previously mentioned findings, they move away from establishing what built environment features are associated with health to demonstrating how they combine in providing health supportive environments. ⁶² Demonstrating and providing case studies of what walkable and healthy built environments look like provides guidance to those in policy and practice seeking to design them. ⁷⁴

Differences in sex play a role in how the built environment influences health. For example, women who relocated to areas with a higher density of fee paying recreational facilities had a reduction in physical activity, ⁷⁵ while those relocating to higher residential density areas were more likely to increase their walking. ⁷⁶ In contrast to most literature, women relocating to areas with a higher commercial jobs to resident ratio took fewer steps, and walking was reduced for women moving to areas with less cul-de-sacs. ⁷⁶ Such findings have implications for socially inclusive built environment design.

Most built environment and health-related research has focused on the home neighborhood ⁵⁰ ; however, emergent evidence highlights the importance of workplaces, ^77,78 and activity or town centres, ^62,79 for adult health and well-being. Workplace built environments and their relationship with workplace and leisure time physical activity and health is recognized as an important research area with the potential to affect peoples’ health through location-specific behaviors and built environment interventions. ^77,78 In a US study, bike facilities and interesting things to look at were predictive of workplace physical activity, while healthy restaurants, recreational facilities, and seeing other people being active also predicted travel and leisure physical activity in and around the workplace. ⁷⁷ In another US study, Hoehner et al found people living and working in areas with high street connectivity, and more recreational facilities had improved cardiorespiratory fitness when compared to people living in areas in the lowest tertile for these factors. ⁷⁸ Findings from studies investigating the built environment around activity or town centers and workplaces have important implications for the types of facilities and interventions that could be provided to support adult health and the sustainability of urban environments. Indeed their colocation along with residential housing offers a promising way forward not only for equitable access to resources but also for delivering the “20-minute city” allowing people to live, work, and play locally and sustainably. ^80,81

Role of the Built Environment on Health: Older Adults

For older adults, defined here as people aged ≥65 years, neighborhood environments are an important health-promoting context. Declining physical functioning and mobility mean that older adults are more vulnerable to environmental challenges and barriers, and as life space shrinks, they spend more time in their neighborhoods. Yet far less built environment and health research focuses specifically on this population group compared to adults and youth. Most research on the role of built environments on older adults’ health has been on physical activity–related behaviors.

The strongest and most consistent evidence exists for the role of destinations within the neighborhood on the health of older adults. Having access to general destinations is a key facilitator of physical activity in older adults, especially active transport. ^82,83 Access to parks, public open space, and recreational facilities is positively associated with recreational physical activity, ⁸⁴ with qualitative research highlighting the need for affordable recreational facilities that offer supervised group activities for older adults specifically to facilitate physical activity. ⁸⁵ In addition, shops and commercial services, public transport stops, and food outlets (ie, grocery stores, restaurants/cafes) are also important for promoting physical activity in older adults. ^82,83,85 Having to travel further to supermarkets has been shown to relate to fewer daily servings consumed of fresh fruit and vegetables. ⁸⁶ Neighborhood destinations are not only important places for older adults to walk to or be physically active in, but they can also be salient for social interaction and connectedness, ⁸⁷ with further potential benefits for mitigating loneliness. There is modest evidence demonstrating that the availability of essential amenities such as sewer, waste management, and electricity are negatively related to depression outcomes. ⁸⁸ Greater availability and access to services in the local area also relates to less mobility limitation in older adults. ⁸⁷

Empirical evidence demonstrates the importance of having continuous pedestrian infrastructure within neighborhoods for active travel, ^83,85 walking, and overall physical activity ⁸⁴ among older adults. ⁸² Sidewalks should be of high quality (smooth, nonslippery surfaces), well maintained (no cracks, good upkeep, and lack of temporary obstacles), even gradient (appropriate curb cuts and railings where necessary), and be wide enough with adequate separation between pedestrians and other users. ⁸⁵ Other important street-based amenities include the presence of benches and seating facilities, ^83,85 good street lighting, ^82,83,85 shade or protection from inclement weather, ^82,85 and the presence of public toilets. ⁸⁵ The presence and quality of infrastructure also impacts on physical functioning and disability, with poor conditions related to increased risk of falls and fall-related injuries in older adults. ^87,89

Neighborhood safety from crime positively relates to older adults levels of physical activity. ^82,84,85 There is also strong evidence of a negative association for personal and crime-related safety on depression-related outcomes, suggesting interventions promoting high levels of perceived neighborhood safety may lower the risk of depression and depressive symptoms among older adults. ⁹⁰ Perceiving neighborhoods as unsafe compared to very safe relates to greater functional decline and increased risk of mobility disability among older adults, while living in higher crime areas is associated with self-reported chronic conditions, specifically greater chances of developing cancer over a 2-year onset period. ⁸⁸

Although most of the evidence of the impact of the built environment on older adults health relates to community-dwelling older adults, some research has also focused on institutionalized older adult samples specifically (ie, those living in aged-care facilities), showing how architecture and building design can impact health. For example, specific design interventions in long-term care environments (eg, lighting, acoustics, room temperature, and the use of colors, contrast, and patterns) can impact behavior, function, well-being, social abilities, orientation, and care outcomes in older adults living with dementia. ⁹¹

Discussion

The provision of health-supportive built environments has been recommended by researchers, public health advocates, health policy makers, and health promotion practitioners as a way to increase population physical activity levels, which is a critical strategy for reducing rates of noncommunicable and chronic diseases. ⁹² The built environment can also support healthy eating for all ages if the availability and accessibility of healthy food are incorporated as part of the planning and design of a community. ⁹³ This includes considering retail types, densities and locations, transport infrastructure to food retailers, food advertising, the potential for public open space to be used for food production and education, and the provision of community amenities, such as water fountains, community gardens, and breast-feeding facilities. ³⁸

Although retrofitting existing environments is challenging and costly, there are examples of more cost-effective, place-based interventions that involve temporary site changes (eg, ‘pop-up’ parks) and temporary road closures to limit traffic. ^21,94 More permanent changes include improvements to park infrastructure, ^94,95 traffic calming infrastructure (eg, crosswalks and street crossings), bike lanes and pedestrian paths, and enhancements to aesthetics (eg, landscaping and public art). However, some built environment features are more or less important for health according to the demographic group of interest. Below, we briefly outline additional considerations when trying to create more health-enhancing built environments for children, older adults, and workplaces.

Call to Action for Creating “Child-Friendly” Neighborhoods

There is mounting evidence to suggest that how we design neighborhoods are important for youth. Creating healthy built environments for youth should consider the community food environment, key local destinations needed for children, how children can get to these destinations (eg, walkability and public transport options), and child and parent perceptions and safety concerns about their neighborhood. It is crucial to have policies and legislation in place to design built environment infrastructure appropriate for children from the beginning; however, developing effective place-based interventions to target healthy behaviors in children is also required. Place-based initiatives that create better environments for children are not just the responsibility of urban designers and planners. Working toward better environments for children requires input from many stakeholders and the wider community and children themselves. Teachers, early years’ service providers (eg, paediatricians, early childhood education, and care), and parents can lobby for better and safer environments. Service providers may get involved through educating families and children about the benefits of playing and interacting with outdoor environments outweighing the “risks” (eg, injury and safety) and equipping children with the skills to navigate their environments safely. ⁹⁶

Call to Action for Built Environments Supportive of Older Adult Health

Overall, health-enhancing neighborhoods for older adults provide easy access to a rich mix of destinations needed for daily living as well as parks/open spaces and recreational facilities. Such neighborhoods also have high-quality and well-maintained pedestrian friendly infrastructure that is safe and well lit, with amenities such as benches and public toilets. There are also planning implications for the siting of senior-specific housing complexes and aged-care facilities, where residents are still living independently or with lower required levels of care. These should be located close to activity centers that have a mix of destinations and with safe, functional, and well-designed and maintained pedestrian infrastructure facilitating use. On its own, a supportive built environment may be insufficient; there is still a need to advocate and promote tailored interventions and programs to encourage and maximize use and involvement of older adults in their local neighborhood environments. To maximize the effectiveness of environmental interventions, these should also be accompanied by efforts to raise awareness of these features. Older adults themselves can be passionate and outspoken advocates for policy and environmental change, with local government authorities responsive to the needs and concerns of older people, particularly in maintaining the quality of the built environment. ⁹⁷ The “Our Voice” framework is an evidence-based tool for encouraging and empowering older adults to be “citizen scientists” by documenting environmental facilitators and barriers and using this knowledge to shape advocacy campaigns for changes that build healthier communities. Preliminary evidence demonstrates the framework’s adaptability across cultures and age-groups and potential for improving individual and community health. ⁹⁸

Call to Action for Healthy Workplace Built Environments

Employers can enhance the health and well-being of their employees through implementing built environment-based initiatives in the workplace. Supportive workplace built environments for a healthy workforce considers built environment design both within and around the workplace. Built environment elements surrounding the workplace such as sidewalks, walkable access to public transit, on-road bike lanes, well-connected streets, and interesting things to look at in the built environments surrounding workplaces can promote more active transport (walking, cycling, and public transit) to and from work by employees. ^77,99,100 Workplaces located near attractive, safe spaces with facilities (eg, recreation centers, gyms, and parks) enable employees to engage in recreational physical activity before, after, or during work time (eg, “walking” meetings with colleagues), which can improve staff health and productivity. ^77,78 In addition, employers can play their part to support active commuting to and from work through providing supportive infrastructure within workplaces (eg, end of trip facilities such as bicycle storage, bicycle service stations, showers, and change rooms). ^77,99 Workplaces with physical and visual access to greenery (eg, indoor plants and park views) are likely to reduce the stress levels of employees and promote well-being. ¹⁰¹ Organizational-led built environment levers can promote more active and healthy behaviors among employees. These levers may include initiatives such as managing parking through fees and charges, short- and long-term bays that limit the bays available for staff, and/or providing priority access to green commuters and shift workers. Such parking initiatives should be done in conjunction with strategies to increase employee active transport to and from work. Office relocations provide a significant opportunity to change the way employees get to and from and work, which can positively impact their health. ¹⁰² Additional levers include providing employer subsided public transit travel cards, having workplace bikes available to cycle to/from off-site meetings as well as promoting stair use within office buildings, holding “walk to work” days, subsidizing local gym memberships costs, and arranging visits by local active travel officers (eg, Travel Smart/Your Move) ¹⁰³ to discuss and provide employees with maps, routes, and distances outlining their options for taking active routes to and from work each day. ^{99,100,104,105}

It is also important for the food environment within and around the workplace to be supportive of healthy eating. Providing access to healthy food choices within workplace canteens, cafeterias, and vending machines as well as providing access to water fountains/coolers, providing fresh fruit and vegetables free of charge, and implementing healthy catering policies may increase healthy behaviors among employees. ^77,105 Providing a lunchroom or break room with heating (eg, microwave, toaster, and oven) and cooling capabilities (eg, refrigerator) also allows workers to bring in healthier, home-prepared foods. Food outlets around the workplace are likely to be accessed by workers during work and nonwork hours. Access to healthy food options near workplaces promotes healthy eating by facilitating the purchasing and consumption of healthier food while access to unhealthy food outlets such as convenience and fast-food stores leads to unhealthy eating behaviors (decreased fruit and vegateable intake and increased energy intake). ^106,107 Employers may consider working with local food retailers to promote and subsidize healthier food options for their staff.

Research With Direct Impact for Policymaking and Practice: A Call for Future Action

We call to action all public health researchers, health policy makers, health advocates, and health promotion practitioners to improve the current understanding of the impact of the built environment on health and direct more attention to working in collaboration with stakeholders beyond health to ensure we provide people with optimal built environments for health and well-being.

For built environment and health research to have the greatest impact, it must be designed and operate with knowledge of the public policy context. It must include policy makers and practitioners to identify questions of concern for those working in different policy and practice areas, ¹⁰⁸ ensure policy and practice relevant research questions, apply policy and practice relevant methods, include multidisciplinary team members to acknowledge the multidimensionality of urban policy and practice contexts, ¹⁰⁹ disseminate research using appropriate messages for different audiences, and engage in advocacy for policy and practice change. ^74,108 Academic interests don’t always align to policy or practice concerns, but to engage policy makers and practitioners it must connect to their current priorities and contexts and deliver a clear message, provide a story, have good face validity, and emphasize economic benefits. ¹¹⁰ Collaboration can be beneficial to both researchers and organizations implementing built environment interventions. Academic researchers can assist with designing robust before-and-after studies, data collection, and analysis which organizations may not have the budget or expertise for. ⁹⁹ In return, researchers can get better access to data of a higher quality and more suited to peer-reviewed publication.

Urban health problems are complex and involve a range of stakeholders including representatives and elected officials from multiple levels and portfolios of government, residents, employers, advocacy groups, media, justice, and the private sector. ¹⁰⁹ For built environment interventions to successfully provide a range of benefits, they require collaboration from multiple sectors of policy makers including housing, transport, land use, health, and urban planning. ^{88,99,111,112} Similarly, socioecological problems addressed in urban health research require complex interventions across multiple levels of influence. ¹¹³ Researchers also need to become more sophisticated in their understanding of the policy environment. ¹¹⁰ Policy is created and influenced within a policy network, not by single decision makers and includes interconnected events and networks of knowledge-based experts with shared beliefs and professional judgments. ¹¹⁴

One of the difficulties facing policy makers and practitioners is understanding how research findings can be implemented. For example, residential density, safety from traffic, recreational facilities, street connectivity, and walkability are all associated with physical activity, ⁴⁸ but which issue does the policy maker or town planner address first? Research needs to be better designed according to policy and practice needs with clearer implementation strategies. More intervention-based research is also needed with appropriate research design including economic evaluation of costs, maintenance, and long-term sustainability. ^113,115 Very few papers argue for more economic evaluation in future research. ²¹ Moreover, policy-focused intervention research is less common than other research designs ¹¹⁶ impacting on the confidence of the cost-effectiveness of economic evaluations of the built environment. Less research of this type and a lack of clarity in the reporting of economic modeling decision-making can also result in wide variation in costs between studies. This also raises the importance of using research methods of most relevance to the policy and practice audience. ¹⁰⁸ Feasibility decisions about policy change are well communicated to government when they can be reliably costed for their economic impact and case studies can be more compelling than rigorous research or systematic literature reviews. ⁷⁴

Making research accessible and useful for policy makers, practitioners, NGOs, community groups, and employers can also be achieved through the development of indicators. These abbreviated statistics for geographic areas enable reporting and monitoring over time provide a tool for community engagement, and inform healthy urban planning policies and practices. ¹¹⁷ Use of indicators can assist with the identification of intervention research needs when described according to a hierarchy of monitoring and reporting, understanding why results have occurred, and how they can be addressed in the future. Indicators also provide a useful means to translate academic research and can be well used in policy and practice contexts if made accessible and are directly linked to the needs of policy makers and practitioners. ¹¹⁸

Conclusion

We can all advocate for healthier built environments, and it is our collective responsibility to create better built environments for all people today and our future generations. Targeting the community, policy, and systems levels is needed to provide healthier built environments for children, adults, and older adults, and working together to do this requires active collaboration and action between researchers, communities, policy makers, and health promotion practitioners.