This article was published in the June issue of InMotion.
While preventing chronic disease through more active lifestyles is nothing new to health professionals, their cause may have found new allies, thanks to climate change. Sedentary lifestyles are not only a risk factor for many diseases, they are also symptomatic of the energy inefficient transport that many climate change activists want to do away with. Designing communities that encourage physical activities in all its forms is now seen as a fundamental part of the solution to both problems. The question now is can the realms of health, environment and urban planning join forces to achieve it?
In industrialised countries, chronic diseases make up the majority of deaths, disability and illness, with seemingly no abatement. In Australia the figure is 90 per cent according to the Australian Institute of Health and Welfare, with one in five Australians affected by two or more chronic diseases, including arthritis, cardiovascular disease, cancer, musculoskeletal problems and chronic obstructive pulmonary disease. The need to get people moving has acquired an urgency.
Physical activity doesn’t just prevent many of these diseases but can also ease symptoms and reduce the need for more extreme interventions like surgery. The Lancet had this in mind when the prestigious journal declared in 2015 that climate change is the greatest opportunity for global health to address chronic diseases that are lifestyle-driven. Many of the actions required to mitigate environmental damage are identical to those needed to create better health.
The second Lancet Commission on Health and Climate Change provided nine recommendations for governments. One recommendation was to ‘encourag[e] a transition to cities that support and promote healthy lifestyles for the individual and the planet’.
The idea of healthy, active communities through smarter urban design is not new. This year marks 30 years since the World Health Organization established its Healthy Cities program, which enshrined urban planning in the public health toolkit. However, the need for enduring and uniform approaches that address the root causes of chronic diseases is now critical.
Professor Billie Giles-Corti, a public health researcher who directs the McCaughey VicHealth Community Health Unit at University of Melbourne, has worked for many years to uncover the hidden aspects of our built environment that influence behaviour and health. Despite interacting with our physical environments every day, many of us would not consider how our brain responds to that environment and makes decisions about how to use it.
‘Most people may not even realise why they don’t want to walk in their neighbourhoods. They can’t really articulate it, but it might explain to a health professional why patients do or don’t act on good advice,’ Professor Giles-Corti says.
It’s rare that health professionals will factor in their patients’ surroundings when they’re encouraging regular exercise. However, this is exactly what physiotherapists need to be doing when they prescribe exercises and more active lifestyles, according to Professor Giles-Corti.
She recalls a paediatrician who used Google Maps’ street view function to explore the neighbourhood in which her patients lived and better understand what physical activity would suit them. Street view enables anyone to explore a suburb at human scale, looking at things like busy roads, quality of the footpaths, distance to the nearest open space and any safety issues. Working through potential barriers to exercise ensured that the paediatrician’s patients and their families were more likely to adhere to their program.
‘It’s quite useful as a professional to look at what’s realistic. If they live in a hostile environment then you’d be better advising them to go to a recreation centre or somewhere a bit more formal,’ she says.
Large-scale solutions involve going deeper than simply removing the disincentives to individual people getting outdoors. This is where smarter urban design comes in. Many government initiatives have attempted to ‘design in’ particular outcomes, whether that’s safer cycling routes or better pedestrian walkways, using tools and guidelines. The Healthy Urban Development Checklist developed by New South Wales Health uses 10 ‘health items’ to create a checklist against which planners can measure the health of new developments. To encourage people to use public transport, current Victorian guidelines recommend measures like ‘comfortable, weather-protected stops’ in safe areas with lots of activity.
However, many policy initiatives have mixed success. Billie and her team are trying to measure this, identifying whether people’s behaviour is positively influenced by planning decisions. These decisions create a patchwork of conditions around which people structure their days and lives.
The research team examined an open space guideline in Victoria that was developed by the local division of Parks and Leisure Australia in June 2013. The guideline suggested that 95 per cent of homes in each neighbourhood should have some type of park, one hectare in size, located no more than 400 metres away.
However, Billie and her team found that the policy had no effect on people’s likelihood to walk more and no effect on their mental health. She thinks the reason for this is improper implementation.
‘Seventy-five per cent of the parks were less than a hectare—and often much smaller than that, perhaps a small pocket of grass at the end of the street,’ she says. A hectare is roughly the size of a 400m running track.
Their research went on to show that planners had to delve deeper to identify the tipping point at which people would actually use the park for physical activity.
‘It’s to do with size. If the parks are over 1.5 hectares, then people are more likely to walk,’ Billie explains.
Her current research is attempting to locate whether the failure of initiatives intended to promote health is due to the policy itself or the way it was delivered.
‘We’re trying to understand those unintended consequences and keep a forensic evidence base on what’s working and not working,’ she explains.
The resulting data are known as ‘policy-relevant measures’ and will help to answer the question asked by every public health practitioner: does the policy predict behaviour?
Planning is a complex process, with many parties involved who represent sometimes-competing interests. These can range from neighbourhood character to waste management, according to Nicholas Touzeau, a planner at a large consulting firm in Melbourne.
‘There’s so much discretion involved in planning decisions and interpreting policy. With something as potentially nebulous as developing new planning policy with the goal to improve public health outcomes, I suspect that eventual policy outcomes can risk becoming quite high level and simply another factor decision-makers need to take into account,’ he says.
Yet a lack of outcomes-focused decision-making can lead to oversights of how individuals will interact with the physical environment, evident in public spaces that no one uses. The use of cul-de-sacs in suburbs built in Australia from the 1960s to the 1980s has come under criticism for discouraging walking. The lack of any direct thoroughfare between streets made navigating the neighbourhood inconvenient for pedestrians, leading to car dependency.
To achieve changes in behaviour and long-term health, the work of researchers on identifying good planning practice is equally important. Through the Australian Prevention Partnership Centre, Billie’s team is currently developing a national liveability index, measuring communities against the risk and preventive factors for chronic disease. These include access to open space, access to food and alcohol, transportation options and how walkable the area is. This work will show whether policies have been delivered that promote health across the country, and will allow comparisons within and between cities.
‘We’re mapping across different cities so we can see where the pockets of liveability are, what the health impact of that is and how this affects the people who actually live there. And, if you live in an area that’s not liveable, identifying where exactly they are and seeing what can be done to improve the liveability of those areas,’ Billie said in an interview with Radio National in April 2016.
Blunter instruments like the Economist Intelligence Unit’s Global Liveability Index don’t offer citizens or decision-makers a micro-level view of how liveable smaller pockets within a city are. This liveability index will fill that knowledge gap, with a specific focus on chronic disease.
‘This is an aspiration, but we’re not delivering the infrastructure on the fringe to be able to achieve that aspiration,’ she says.
Nicholas Touzeau echoes this, pointing out that growth presents additional challenges for maintaining liveable cities.
‘Melbourne faces becoming a victim of its own success, with 100 000 people showing up to live each year to share in its fabled “liveability”. These expectations can go a long way to hampering good planning and development outcomes by pushing growth out to the fringe,’ he says.
In the context of population growth, ageing populations and stretched healthcare resources, prevention through good planning in our cities takes on greater importance. Fortunately, the concurrent problem of climate change means that environmentalists and health professionals are part of the same chorus of people calling for an end to current patterns of activity and consumption that are high energy, high-calorie and high-risk. For disease prevention, the stars have seemingly aligned under a cloud of CO2.
‘I think there’s a great opportunity for physios to add their voice to a growing movement. Doctors for the Environment are getting involved now and I think there’s a great place for physiotherapists to be doing that as well,’ Billie says.