Healthy City Assessments: Reviewing assessment tools for healthy cities

Type of the Paper: Peer-reviewed Conference Paper / Full Paper

Track title: Integration of needs – inclusive, integrated design enabling health, care and well-being

Healthy City Assessments:
Reviewing assessment tools for healthy cities

Sofia Sudermann ^1*, Elke Miedema PhD ^2*, Christa Reicher professor ³, Marcel Schweiker professor ⁴ and Anna-Johanna Klasander artistic professor ⁵

^1* Chair of Urban Design and Institute for Urban Design and European Urbanism, Faculty of Architecture, RWTH Aachen University, Aachen, Germany; sofia.sudermann@rwth-aachen.de;

^2* Division Architectural Theory and Method, Department of Architecture and Civil Engineering, Chalmers University of Technology, Gothenburg, Sweden; miedema@chalmers.se; 0000-0002-8440-4859

³ Chair of Urban Design and Institute for Urban Design and European Urbanism, Faculty of Architecture, RWTH Aachen University, Aachen, Germany; reicher@staedtebau.rwth-aachen.de;

⁴ Institute for Occupational, Social and Environmental Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany; mschweiker@ukaachen.de; 0000-0003-3906-4688

⁵ Division Urban Design and Planning, Department of Architecture and Civil Engineering, Chalmers University of Technology, Gothenburg, Sweden; anna-johanna.klasander@chalmers.se;

Abstract: The built environment influences health. The Healthy Cities Movement focuses on creating healthier and more sustainable cities, including healthy urban design. This focus on health is essential in an age of climate change, urban density, and inequality where planners, developers, and communities have the responsibility to design healthy places for all. There are multiple assessment tools for healthy and sustainable cities and buildings design. However, it is unclear which health perspectives are incorporated or overlooked in these tools. This paper aims to (1) map existing assessment tools relating to urban design and health, (2) examine which health-related outcomes are incorporated, to (3) propose criteria for an assessment tool for healthy cities. The methods include a questionnaire, three semi-structured interviews with experts on healthy urban design, and analysis of recent assessment tools. The results include conceptualization of healthy design criteria. The identified criteria additionally show issues for action in urban development regarding sustainable, healthy cities. The outcome can be considered an approach to develop tools for healthier cities. Assessment tools that include holistic perspectives on health may be able to reflect upon urban health and contribute to healthy communities.

Keywords: healthy city; health-driven design; assessment tool; resilience; urban planning

1. Introduction

Predictions suggest that in 2050 70% of the world's population will live in cities (United Nations, 2019). Such global urbanization is associated with a range of health risks that affect the environment and people, both in terms of disease outbreaks and lifestyle- related issues (WHO, 2022a). The challenge is to create healthy cities that improve everyday living conditions and focus on both human health and planetary health. Urban health research examines the impact of the urban environment on human health (Corburn, 2009) and it indicates that urban planning and design can help promote both public health (WHO, 2022a) and planetary health (Corburn, 2009). Consequently, both planetary and human health and well-being are increasingly in the focus of public decision-making processes in urban planning and design (Grant et al., 2017). To stimulate the design of healthy, sustainable communities and cities and to understand the relation between urban design, human and planetary health, several assessment tools have been developed (Grant et al., 2022; SALUS, 2021). However, these tools have different programmatic foci, and it is unclear which health objectives are considered or overlooked by each tool. This study, therefore (1) maps existing assessment tools relating to urban design and health and (2) examines which health-related outcomes are incorporated to (3) propose criteria for an assessment tool for healthy cities. The paper intends to provide inspiration and orientation for health-driven urban design and development.

2. Theories and Methods
2.1. Theories

This paper relies on several core concepts and theories, including interpretations of health, urban health challenges, determinants of health and the World Health Organization (WHO) Healthy Cities Network.

While there are multiple definitions of health there are three models according to Rohde et al. (2020), (1) medicinal, (2) holistic and (3) wellness. The medicinal model states that good health prevails in the absence of disease (Rohde et al., 2020). This medicinal focus on (causes of) disease is also referred to as the pathogenic approach (Sieber, 2017). The holistic model defines ‘health’ as proposed by the WHO in 1946 as: ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ (WHO, 2020, p. 1). The holistic model thus considers health as more than biophysical health but the inter-relation between emotions, mental, spiritual, and biophysical aspects. The wellness model is based on the salutogenic approach, including health promotion and well-being (Rohde et al., 2020; Sieber, 2017). Health can thus be considered either in terms of disease (pathogenic) or in terms of health and quality of life (salutogenic) (Antonovsky, 1979; Naidoo & Wills, 2019). These health concepts are dynamic and influenced by individual preferences and objectives and thereby often personal perspectives (Schweiker et al., 2021). Moreover, they are often used as interchangeable and without definition (Hanc, McAndrew & Ucci, 2019). According to Huber et al. (2011, p. 1), a new formulation of the definition of health is needed to address current challenges in society, namely ‘health’ as ‘the ability to adapt and self-manage in the face of social, physical, and emotional challenges’. Furthermore, the diverse interpretations of health can lead to contradictions in (building) design (Miedema, 2020), which raises questions about the interpretations of health in relation to healthy cities and urban design.

Cities must tackle critical global challenges in a collaborative manner, including the protection and promotion of public health (WHO & UN-Habitat, 2016). The WHO and UN-Habitat emphasize infectious (communicable) diseases (e.g. Covid-19, HIV/AIDS, tuberculosis), non-communicable diseases (NCDs, e.g. cardiovascular diseases, cancer, chronic respiratory diseases, diabetes) and injuries and violence as ‘triple threats’ to urban health (WHO & UN-Habitat, 2016, p. 21; UN-Habitat, 2021). Additionally, the burden of disease is greater in poor countries than in wealthy countries (WHO, 2010).

Individual or population health is influenced by the social, economic, and physical environment together with personal characteristics and behaviors, known as determinants of health (WHO, 2017). The social determinants of health (SDH) can be modified and are thus starting points for health promotion (WHO, 2010). The ‘HealthMap’ (Figure 1) shows the ‘urban components’ of the health determinants and sets goals for human and planetary health in a global context (Grant, 2019). Grant claims that: ‘The HealthMap is a systemic tool [and application stakeholders should t]reat any definitions of components as loose and all implied relationships as fluid; in each application stakeholders need to reassess the relevance of the map to their local situation’ (ibid.).

Figure 1. The HealthMap. The determinants of health and wellbeing in our cities

(Barton & Grant, 2006 developed from the model by Dahlgren & Whitehead, 1991).

The WHO European Healthy Cities Network (WHO, 2022b), defines a ‘healthy city’ as follows:

A healthy city is one that continually creates and improves its physical and social environments and expands the community resources that enable people to mutually support each other in performing all the functions of life and developing to their maximum potential.

The healthy city is thus a continuous process, not an achievement of which a final health status can be sufficient (ibid.). According to WHO every city can become a healthy city (ibid.). First, city leaders must understand the current health conditions and be willing to continuously improve them through policies and planning. Then, to succeed, they need healthy city approach, that includes both the practices and the planning and design of urban environment (ibid.).

A rich number of assessment ‘tools’, or ‘systems’, ‘certification systems’, ‘rating systems’ (Poveda & Lipsett, 2014) for ‘sustainable’, or ‘environmental’ building, ‘community’ or ‘neighborhood’ and ‘urban’ or ‘city’ development have been developed to support and assess the implementation of sustainability in local and multi-level projects of buildings, communities and cities (Wallhagen, 2016; Lind, 2020). The first assessment tools for sustainable buildings exist on the global market since the 1990s (e.g. BREEAM, LEED) and have been complemented by assessment tools for communities and cities in the twenty-first century (ibid.). Fenner and Ryce (2008, p. 55 f.) divide assessment tools into three categories: knowledge-based tools (‘manuals and information sources’), performance-based tools (‘life cycle assessment and simulation tools’) and building rating tools (‘design checklists and credit rating calculators’). Several assessment tools provide a ‘certificate’ or ‘label’ with different quality levels (e.g. platinum, gold or silver) for a fee, assigning a quality standard to building and urban development projects, such as ‘green’, ‘sustainable’ or ‘environmental’ (Fuerst & McAllister, 2011; Miller et al., 2010). By specifying a set of criteria or indicators, the tools can support project and process participants in achieving sustainability goals for the construction of a building, community, or urban area. Additionally, these tools have the potential to serve as a market driver to establish sustainability in the construction industry and in environmental design (Wallhagen, 2016; Lind, 2020). For this study, the tools are collectively termed ‘assessment tools’. They include certification/rating systems, guides and tools that focus on the urban scale and assess environmental, social, and economic sustainability aspects for communities or cities.

2.2. Methods

To identify criteria to be included in an assessment tool for healthy cities, the methods used for this study include (1) a questionnaire to three experts on healthy urban design, (2) semi-structured interviews with the same experts and (3) an analysis of recent assessment tools. The research design comprises of four stages: questionnaire, interviews, tool assessment and development of assessment criteria.

1. The questionnaire mixed qualitative open-ended questions (1,2,4,5,6,7) with one quantitative question (3). Participant were with three experts on healthy urban design (Table 1). The questionnaire focused on assessment tools/certification systems for healthy cities and communities, the perception of a healthy city and suggestions for assessment criteria for healthier cities.

2. Qualitative semi-structured expert interviews with the same experts (n=3) focused also on the certification of healthy cities, the perception of a healthy city and suggestions for assessment criteria for healthier cities. The interview participants were experts in healthy urban design (editor of journal) or developers of assessment tools. The selection of the experts aimed to achieve the most comprehensive picture possible on the topics of ‘healthier cities’ and the ‘certification/assessment of healthy cities’. These experts can be characterized as specialists in their respective fields of research and practice. That is, they were expected to offer an informative contribution to the topic with their detailed, specific wealth of knowledge and experience (Schütz, 1972; Bogner, Littig & Menz, 2014).

3. Thematic analysis of assessment tools relating to urban and building design to health (n=16) focused on their definitions and dimensions relating to health (Table 3). The selection was based on a literature search with snowballing and the use of search terms such as ‘health’, ‘urban design’, ‘urban planning’ and ‘assessment tool’ or ‘certification system’ (or synonyms) and expert recommendations. The final selection of resources to be included in the analysis was based on the level of awareness, reputations of the publishers and authors and relevance across different country-specific situations. Eventually, only assessment tools that address the urban scale (e.g. ‘neighborhood’, ‘community’ or ‘city’) were included. The final 16 selected items represent a broad range of stakeholders, settlement types and cities.

   Based upon the results from stage 1-3 several assessment criteria for healthy cities were developed and implemented in a reference guide. The triangulation of the results facilitated the recognition of larger structures (Groat & Wang, 2013).

3. Results

3.1. Results from questionnaire and expert interviews

The questionnaire and the expert interviews related to two main themes: certification of healthy cities and interpretations and suggestions for assessment criteria.

Table 1. Questions of the questionnaire.

3.1.1. Certification of ‘healthy cities’

One expert showed that obtaining a certified healthy label enhances a location’s attractiveness to investors and can increase market value. Another pointed out that the requirements for a healthy city are defined using the criteria catalogue of a certification system and can help cities to achieve a healthy status. Certificates, labels, and guidelines can with their systems, program and recommendations serve as orientation for the assessment and development of healthy cities. According to two experts, these include, for instance, BREEAM Communities, Fitwel Community, LEED Cities and Communities, STAR Communities, the Blue Zones Project Community, and the WELL Community Standard. Additionally, two interviewees mentioned practical implementation for healthy cities design, including the NY City’s DDC Active Design Guidelines: Promoting Physical Activity and Health in Design (2010), Inclusive Healthy Places. A Guide to Inclusion & Health in Public Space (2018) by the Gehl Institute and Integrating Health in Urban and Territorial Planning: A Sourcebook (2020) by the UN-Habitat and World Health Organization. One expert emphasized that besides technical guides, the process to achieve the goals of a healthy city must be considered, including (1) implementation of health in all policies (HiAP), (2) health impact appraisal for urban plans and policies and (3) leadership and governance for health in cities. When applying a certification system for healthy cities, one must ensure that this system is not generic and considers regional context (ibid.).

3.1.2. Interpretations and suggestions for assessment criteria

All experts mentioned that a ‘healthy city’ strives to improve and promote the physical, social, and mental health of all residents and the environment. One mentioned ‘air quality, access to recreational public space, access to healthy food, provision of adequate health care, opportunities for social interaction’ influence public health. The same expert also refers to physical, social, and mental health as hard factors and adds sociocultural aspects for healthy cities. Another mentioned that emphasis is placed on ‘all’: ‘across all silos and from the top municipal leadership through to local civic leaders and communities, [...] for all, and in all policies’. The joint effort of ‘all’ involved is necessary for creating a healthy city (ibid.). Another mentioned that ‘all’ implies that minorities are considered and included in the planning process. The experts as combined discussed that assessing a healthy city requires criteria that:

• encompass the synthetic construct of (1) human health and (2) planetary health;

• consider the local, regional, and cultural contexts of the city; and

• include transitions between the local and global levels.

These requirements for the criteria show that each city must be considered individually according to its specific characteristics. According to one expert, a methodical approach for practice is ‘to map data on health outcomes with other urban factors. Often poor health outcomes map clearly with the lack of basic amenities such as public open space, poor air quality and access to healthy food’. The Urban Land Institute's Building Healthy Places Toolkit: Strategies for Enhancing Health in the Built Environment (2015) is an expert-recommended entry point for further information on healthy cities and its components (ibid.). One mentioned that ‘[i]nformed local decisions – and responsibilities’ constitute the basis for implementing the criteria for a healthy city.

3.2. Assessment tools relating to health – An analysis

Table 3 shows an overview of the 16 selected resources, i.e. existing assessment tools, and how those relate to health. Each of these resources has been assigned a resource reference number (Ref. No.) and one of three categories (rating system (Ref. No. 1-7), design guide (Ref. No. 8-13), and toolkit (Ref. No. 14-16)) to show its application (Table 2). These categories arose from an analysis of the nature of the resources themselves to organize them in a meaningful way. To enable transparency of the search method, this study includes a search Id (snowball (n=12; Ref. No. 1, 4, 6-10, and 12-16) and expert (n=4; Ref. No. 2, 3, 5, and 11)) for each resource.

Table 2. Categories of resource developed for the assessment tools’ analysis.

Table 3. Assessment tools’ analysis.

3.3. Conceptualizing assessment criteria for healthy cities

Based on the analysis of the 16 resources relating to health (see Section 3.2.), 20 assessment criteria for healthy cities were extracted (Table 4). The 20 individual criteria were found in the 16 resources. Each identified criterion is assigned to a category and indicates the resources on which the assumption is based. The categories include transport (1), program (2), access (3), and human and planetary health (4). Additionally, exemplary implementations from assessment tools’ analysis for urban design are provided. A cross (x) indicates which target group (individual, local community and/or city) is affected by the assessment criterion. The assessment criteria are intended to promote physical activity, health equity, diversity and resiliency and need to be accessible and inclusive for all.

Listed in order of frequency of mention in the resources, the identified assessment criteria are: Access to nature (12); Public open space (11); Walkability (11); Bikeability (10); Public participation (10); Access to healthy food (10); Access to public transport (9); Noise mitigation (9); Health services and safety (8); Outdoor air quality (8); Access to drinking water (7); Housing provision (5); Maintenance (5); Light pollution (5); Natural resources (5); Thermal comfort (5); Arts and culture (4); Parking (4); Smoke-free environment (4); Land use mix (3).

Table 4. Assessment criteria for healthy cities.

4. Discussion

The following section evaluates the main results and findings from the expert interviews and the analysis of the assessment tools and highlights three key learnings.

Outcome 1: Different interpretations of health and a lack of transparency

A variety of assessment tools relate to public health on an urban scale. These tools are based on various interpretations of health (see also Section 2) and sustainability, which must be discussed and evaluated in an application case (certification process). For instance, the BREEAM Communities’ criteria catalogue favors assigning aspects of health protection (pathogenic approach), whereas the Life Radius of the Blue Zones Project addresses health promotion (salutogenic approach). Following Section 2 and the 1946 WHO definition of health, 9 out of 16 assessment tools analyzed (see Section 3.2., Ref. No. 1, 3, 5, 6, 9, 11, 13, 14 and 15) contain criteria displaying a holistic approach to physical, social and mental health. Therefore, these tools can support a positive, salutogenic approach to health.

Furthermore, it is not clear to what extent these different assessment tools are built on evidence-based medical and scientific research. In the same vein, one may wish to know what sources, information and studies are used for developing the assessment tools and whether these tools are (freely) accessible and comprehensible. One example of user-friendliness and a transparent approach to the strength of evidence is the NY City’s DDC Active Design Guidelines: Promoting Physical Activity and Health in Design (2010). For each design strategy, the Guidelines indicate whether it is based on strong evidence, emerging evidence or best practice, including source references (ibid).

Outcome 2: Certification systems – the purpose can differ

The results from the expert interviews provide an opportunity to discuss the role of certification systems in urban development and the related development of ‘healthy cities’. The quality of these certification systems varies due to the definition and interpretation of the concept of health and the comprehension of sustainability, which is reflected in different criteria catalogues. Therefore, individual programmatic focal points should be critically reviewed. Additionally, it is questionable which intentions and goals the certificate developers and a city must pursue to obtain a healthy city certificate and whether these meet the local requirements regarding the well-being of the city’s residents and global sustainability. One expert explained that a certification process facilitates ‘political gaming’ and ‘with a poor scheme the criteria are met merely as numeric targets, and not in spirit’. Moreover, there is a danger that the weighted scoring of the criteria in the certification process can be manipulated for the better and that alternatives to the weighting are required as a result (ibid.; Grant & Barton, 2013).

One expert mentioned that critical engagement leads to the core idea that the center of decision-making should ideally be the health and common good of residents and the environment rather than the profitability of cities. However, according to another expert, as with realism, capitalism favors market-oriented decisions. Thus, what matters is effectiveness. That is, if a healthy cities certification system ultimately contributes to the health promotion of residents and sustainability for the benefit of the environment, the certification process has served its purpose. Thus, such a system can contribute to the solution on the path to creating healthy cities.

Outcome 3: Salutogenic approach for healthy or health-promoting cities

The difference between a pathogenic and salutogenic approach to public health are theoretically clear, while practically more inter twined (Bauer, Davies & Pelikan, 2006). Still, both approaches are needed and should be incorporated in city design. Healthy cities movement needs to support and encourage individuals and communities to develop healthy behaviors through both extrinsic and intrinsic motivations. This study corresponds to the WHO’s (2022b; see Section 2) definition of a healthy city, which does include both of those perspectives.

5. Conclusions

This study highlighted possibilities to facilitate health promotion in cities through urban spatial design and planning, and assessment tools for urban development. The work included an overview of urban health issues and relevant considerations for using assessment tools. Findings on the thematic field of healthy city provide insight into the current state of research and offer incentives for further research and discussions. Thus, this section comprises a summary and considerations for future work.

The study at hand analyzed which assessment criteria must be considered in healthy cities’ objective and development planning and identified the obstacles and benefits that assessment tools offer to create healthy cities. The study highlighted the current state of science and discussions about healthy cities and raised awareness and clarified the importance of health promotion through urban spatial planning and development. These findings additionally highlight that engagement in the design of the built environment can contribute to healthier, more equitable societies.

The criteria identified here indicate a need for action in urban development to create sustainable, healthy cities. This outcome can be considered an approach to develop tools for healthier cities. For this study, a limited number of assessment tools (n=16) and the number of interviews (n=3) were used to determine the assessment criteria, influencing the results, and enabling the supplementation of further criteria. Moreover, the study promoted a better understanding of current application-related assessment tools for urban development and their health requirements to explore the framework in which they can contribute to healthier cities. Various perspectives were gathered to provide solutions for the development of healthy cities. Building structures and establishing processes that prioritize health in all policies (HiAP) is key to creating healthy cities. Thus, health promotion through urban planning should be a political process, involving a multitude of decision-makers responsible for developing sustainable, healthy cities.

Contributor statement

Conceptualization: SS and EM with feedback from the others

Methodology: SS and EM

Visualization: SS

Writing – Original Draft: SS with support of EM

Writing – Editing: SS and EM with support of CR, MS and AK.

Acknowledgments

The authors express their gratitude to the experts for participating in interviews, answering the questions, and providing supplementary research materials. SS, EM and AK were supported by an IDEA League research grant between RWTH Aachen University in Aachen, Germany and Chalmers University of Technology in Gothenburg, Sweden. MS contribution was supported by a research grant (21055) by VILLUM FONDEN.

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    Figure

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   Tables

All tables are created by the author (SS).