Lecture 7: Neighbourhood, Place, and Health

Built Environment: Definition, scope, and health implications

• The built environment touches all aspects of daily life: the buildings we live in, the water and electricity distribution systems, and the roads, bridges, and transportation systems we use to move around. It is deliberately planned and executed by vested authorities.
• Definition: The term 'built environment' refers to surroundings created for humans, by humans, and to be used for human activity. Examples include cities, buildings, urban spaces, walkways, roads, parks, etc.
• Key idea: The built environment is human-made and designed; it shapes daily living and has social consequences.
• Health relevance: The built environment highlights the connection between physical space and social outcomes, and it includes how communities respond to environmental changes arising from human modification of the natural environment.
• Overall framing: The built environment acts as a social determinant of health (SDOH) because its design and organization can promote health for some populations while acting as a barrier for others.

Socioeconomic position (SEP) and health: Recap and core ideas

• SEP is often referred to as social class, social stratum, or socioeconomic status; it implies social stratification based on attributes like income, education, and employment.
• Health gradients: People in higher-status jobs and with higher educational attainment tend to have better health outcomes.
• Three routes linking SEP to health outcomes:
  • Health knowledge and health literacy
  • Better work conditions and employment benefits
  • Social standing and networks (social capital)
• Emphasis on causation uncertainty: While patterns are robust, direct causal pathways from work, employment, and education to health outcomes (e.g., hypertension) are not fully established.

SEP and neighborhood choice: How socioeconomic status influences where people live

• Individuals’ SEP influences the neighborhoods they can access and afford.
• This leads to differential exposure to neighborhood environments with varying health determinants (e.g., safety, services, green space, noise, crowding).
• The result is a potential mechanism for health inequalities across neighborhoods that track SES.

Neighborhood health assessment: Criteria for a healthy community

• Rating scale adapted from McMurray & Clendon (2011): 10 = excellent for health; 1 = poor for health.
• Criteria:
  • Clean and safe physical environment
  • Peace, equity, and social justice
  • Adequate access to food, water, shelter, income, safety, work, and recreation for all
  • Adequate access to health care services
  • Opportunities for learning and skill development
  • Strong, mutually supportive relationships and networks
  • Workplaces that are supportive of individual and family well-being
  • Wide participation of residents in decision-making
  • Strong local cultural and spiritual heritage
  • Diverse and vital economy
  • Protection of the natural environment
  • Responsible use of resources to ensure long-term sustainability

The built environment: Key concepts and focus areas

• The built environment comprises human-made spaces where people live, work, and play; it is the product of deliberate planning by authorities.
• Core focus: It shapes how people experience daily life, health risks, and opportunities for healthy behaviors.
• Key components include housing, transport systems, public spaces, and access to services.

The neighborhood environment and health: Mediators and pathways

• Neighborhood physical environments affect health through exposures (pollution, safety, access to resources).
• Mediators include: environmental exposures, food and recreational resources, aesthetic quality and natural spaces, services, and behavioral factors.
• Intermediary processes include socioeconomic position, housing quality, neighborhood safety, social networks, local institutions, norms, stress, and individual biological and psychosocial characteristics.
• Conceptual model (Figure 1): Neighborhood environments contribute to health inequalities via a complex system of physical, social, and economic pathways, where structural factors (like residential segregation) shape resource distribution and access.

Built environment: Key topics that predict health outcomes

• Public transportation: Accessibility, affordability, reliability, and coverage influence physical activity and exposure to healthy options.
• Building design: Indoor environmental quality, safety, and accessibility affect health outcomes.
• Parks and green space: Availability and quality support physical activity, mental health, and overall well-being.
• Housing and segregation: Housing conditions and racial/ethnic segregation shape exposure to hazards and access to resources.
• Public health: Public health infrastructure and policies intersect with the built environment to shape health outcomes.
• Physical activity: The built environment can promote or hinder physical activity through infrastructure and land-use patterns.
• Food access: Local food environments influence dietary behaviors and nutrition.

Toronto case example: Neighborhood income, greenspace, and equity indicators

• Income mapping (2016 Census data, Toronto CMA context):
  • Very High income: 140% to 831% of CMA average ($50,479)
  • High income: 120% to 140%
  • Middle income: 80% to 120%
  • Low income: 60% to 80%
  • Very Low income: 37% to 60%
  • Average is referenced relative to the CMA average; Census tracts are used for delineation.
• Greenspace distribution: Percent greenspace categories range across 0.0–77.4% in different tracts (color-coded map scale such as 0.0–15.0%, 15.1–25.0%, etc.).
• Urban forest and BIPOC populations: Spatial distribution maps show tree canopy (%), and percent BIPOC population by census tract, illustrating disparities in environmental assets and population demographics within the city.
• Purpose: These maps illustrate how SES, environment, and race/ethnicity intersect geographically to shape health determinants.

Neighborhood physical environments and health outcomes: Key associations

• Physical activity:
  • Population density, land-use mix, and proximity to non-residential destinations are linked to more walking for transportation.
  • Walking for recreation is associated with pedestrian infrastructure, aesthetics, safety, and land-use mix.
  • Proximity to parks and recreation facilities increases physical activity; greater proximity predicts higher odds of activity.
  • Evidence supports implementing design and land-use policies to promote physical activity in urban areas.
• Diet:
  • Local food environments influence dietary behaviors; supermarkets with a variety of healthy foods at lower cost promote healthier choices.
  • Availability of healthy foods in stores correlates with higher intake and home availability of those foods.
  • Proximity to fast-food outlets is associated with poorer diets.
• Depression and mental health:
  • Perceptions of neighborhood disorder link to higher depressive symptoms.
  • Poor neighborhood and home-built environment quality associate with depression.
  • Neighborhood problems (including public transport, green space, and services) are linked to depression; walkability is linked to lower depressive symptoms.
• Obesity, diabetes, and hypertension:
  • Physical environment aspects linked to BMI include recreational resources and walkability.
  • Poor access to supermarkets associates with higher BMI.
  • Neighborhood green space correlates with lower BMI in children.
  • Better physical activity and food environments relate to lower incidence of type 2 diabetes.

Obesity, diabetes, hypertension: The obesogenic built environment

• The built environment can be obesogenic: it increases obesity risk independent of individual behavior.
• Urban sprawl is associated with higher obesity and BMI; longer minutes walked are linked to hypertension (i.e., more active commuting relates differently to hypertension risk).
• Longer commuting times predict unhealthy behaviors in general.
• The community context links urban sprawl to obesity; use of public transport tends to be negatively associated with obesity.

Systemic elements that facilitate obesity: interconnected influences

• A diagrammatic representation (not shown here) depicts a network of interacting factors:
  • Individual level: Stress, self-esteem, body image, medications, psychological and biological attributes, genetics.
  • Behavioral: Diet, activity, and other health behaviors.
  • Socioeconomic: SEP, access to resources, time constraints, and work demands.
  • Environmental and market: High-calorie food marketing, prices of fresh versus processed foods, density of food outlets, urban design, and access to transport.
  • Structural: Advertising of high-calorie foods, cultural norms, and regulatory/economic contexts.
  • Outcomes: Obesity prevalence and associated health problems.
• Key takeaway: The obesity burden emerges from a complex, multi-layered system linking individual choices with environmental and structural forces.

Table of built-environment elements associated with weight gain

• Sector of built environment and weight-gain factors:
  • Urban sprawl: more time commuting -> greater car use; less active commuting.
  • Public transport adequacy: more trains/buses, affordability, proximity to stations, destination accessibility, cycling facilities.
  • Town planning: amount of green space, footpaths, street connectivity.
  • Land use and work/education places: cycling infrastructure, safe crossings.
  • Land-use mix: variety of education, shops, employment, and residence encourages walking.
  • Density of outlets: high density of convenience stores and fast-food outlets; affordable fresh-food outlets.
  • Features that encourage walking: proximity to public transport and presence of stairs.
  • Food environment and dedicated exercise spaces (e.g., gymnasiums).
• Overall message: Specific built-environment features can promote or hinder weight management through opportunities for activity, access to healthy foods, and daily transportation choices.

COVID-19 and built-environment risk and equity considerations

• Features that increase disease risk include:
  • Crowding/density: Close proximity to others without masks (e.g., talking, shouting, singing) in crowded indoor spaces (e.g., prisons, churches, dormitories, meatpacking plants).
  • Poverty and racism: Poor and minority communities are often concentrated in neighborhoods with worse health outcomes; higher COVID-19 incidence and mortality in racialized neighborhoods; frontline workers disproportionately represented in deprived areas.
  • Poor indoor air circulation: Crowded indoor spaces worsen aerosol transmission; recommendations include increasing outdoor air, limiting recirculation, improving filtration, and maintaining ventilation in the kitchen and other areas; open windows and fans can help but HVAC upgrades are costly and not designed for pandemics.
  • Air pollution: Higher ambient PM and NOx levels correlate with higher COVID-19 incidence, severity, and mortality; proximity to roadways and waste facilities associated with higher COVID-19 burden in poorer, racialized areas; reducing ambient pollution improves outcomes.
• Practical implications: Environmental justice considerations are central; improving housing quality, reducing crowding, and lowering exposure to pollutants can mitigate risk and improve outcomes in future public health emergencies.

Features of the built environment that promote health

• Active transportation: Well-maintained paths, bike lanes, destinations, and low-speed roads encourage incidental physical activity.
• Public transportation: Affordable, reliable, and efficient transit increases physical activity and can reduce type 2 diabetes risk through greater activity.
• Walkable neighborhoods: Strong street connectivity, mixed land use, higher population and residential density, aesthetically pleasing surroundings, and accessible green space promote daily activity.
• Health-promoting food environments: Access to affordable, nutritious foods improves dietary outcomes and overall health.

Long-term implications of COVID-19 for the built environment

• Infection-safe buildings: Reconfiguring buildings to reduce transmission risk.
• Increased homeworking: More people working from home reduces commuter-related exposures and alters demand for office space and transport.
• Re-envisioned streets: Urban redesigns to support safe walking/biking, more outdoor spaces, and reduced crowding.
• Re-emphasis on greenspace and nature: Greater recognition of the health benefits of outdoor spaces.
• Changes in modes of travel: Potential shifts toward active transport and public transit with improved safety and resilience.
• Urban-to-exurban shift: Possible population movement from dense cities to exurbs and rural areas.

Synthesis: Policy implications and intervention opportunities

• The built environment is a modifiable determinant of health, not a fixed given.
• Policy interventions can target:
  • Housing quality and affordability to reduce crowding and improve environmental conditions.
  • Transportation planning to promote active transport and accessible public transit.
  • Land-use planning to increase green space, walkability, and access to healthy foods.
  • Environmental justice efforts to reduce disparities in pollution, resource access, and health outcomes.
• The COVID-19 experience underscores the need to plan resilient, equitable environments that support health in both ordinary times and public health emergencies.

Key takeaways and overarching themes

• The built environment is a deliberate, human-made space that shapes health outcomes through physical design, accessibility, and social organization.
• Socioeconomic position interacts with neighborhood characteristics to produce health inequalities; lower SEP often correlates with environments that pose higher health risks and fewer health-promoting resources.
• Neighborhoods influence health via multiple, interacting pathways: physical exposures, access to food and physical activity resources, safety, social networks, and institutional supports.
• Health outcomes such as obesity, diabetes, cardiovascular risk, mental health, and infectious disease vulnerability are linked to the design and resources of neighborhoods.
• Equality-focused policy and planning can mitigate health disparities by improving housing, transportation, green space, food access, and environmental quality; the COVID-19 era highlights the urgency of such interventions.