Making Healthy Places, Second Edition, Discussion Questions

Discussion Questions Making Healthy Places, Second Edition Designing and Building for Well-Being, Equity, and Sustainability Edited by Nisha D. Botchwey, Andrew Dannenberg, and Howard Frumkin

Chapter 1: An Introduction to Healthy, Equitable, and Sustainable Places

By Howard Frumkin, Andrew L. Dannenberg, Nisha D. Botchwey 1. Give three examples of the tensions between public goods (such as parks and roads) and private entitlements (such as freedom to use one’s land for any desired purpose) that may arise in public health and urban planning decisions.

2. What types of information might a community collect when conducting surveillance related to the health effects of the built environment and community design? From what sources could such information be obtained?

3. Because financial profitability plays a major role in most private-sector decisions, how might health concerns be made a part of the bottom line for private developers and for lenders that finance developments?

4. Consider a study that evaluates the health of people in two communities, one with sidewalks and one without. The study authors find that the rate of lung cancer is higher in the community without side- walks and conclude that sidewalks protect against lung cancer. What concerns would you have about accepting this conclusion?

What alternative explanations might you propose for this study finding?

5. What information about the health implications of their work should land use and transportation planners be taught during their initial or subsequent training?

6. Give two examples of sustainability initiatives that also deliver improved health and two examples of sustainability initiatives that might undermine health.

7. Suppose that in each of two cities—one in western Europe and one in sub-Saharan Africa—urban planners and public health officials decide to work together to advance health through the built environment. What priorities do you think might emerge for the

groups in each city, how would they differ, and what would be the implications for their work?

8. “Urban planners and public health officials should routinely engage with the communities they serve before and while implementing any programs.” Please agree or disagree and explain your reasoning.

PART I. Health Impacts of the Built Environment Chapter 2: Physical Activity and the Built Environment

By Nisha D. Botchwey, M. Renée Umstattd Meyer, Meaghan McSorley 1. Describe the differences between physical activity for transportation and physical activity for recreation. How do features of the built environment affect these types of physical activity differently?

2. Identify five key findings from research on the relationship between the built environment and physical activity. How could you use these key findings to design active communities in rural, in suburban, and in urban settings?

3. What programs can you implement or changes could you make to the built environment to increase physical activity in urban, suburban, and rural communities? Which attributes of the built environment could you target to support long-term increases in physical activity?

4. What changes to the built environment could you make to promote physical activity in low- to middle-income countries? What outcome would you expect from such changes, and how might your strategies in these areas need to be different from high-income countries?

5. Using table 2.1, for each of the environ- mental attributes at the macroscale, microscale, and social environment documented to be related to physical activity, identify the decision-maker groups with authority to make changes. For each type of decisionmaker, identify some of the scientific, community, advocacy, and business groups that could be involved in educating and influencing these decision- makers.

Chapter 3: Food, Nutrition, and Community Design

By Roxanne Dupuis, Karen Glanz, Carolyn Cannuscio 1. How does the food environment either support health or contribute to adverse health consequences and health disparities?

2. How can the production, distribution, and marketing of food contribute to risk of obesity and other chronic diseases?

3. What considerations related to social justice and racial equity affect food environments?

4. What strategies have been tried and found promising for improving the food environment to support the health of communities?

5. How do health emergencies and natural disasters affect food insecurity?

Chapter 4: The Built Environment and Air Quality

By Patrick Lott Kinney, Priyanka Nadia deSouza 1. What are the primary sources of air pollution in your community?

2. What are the links between air pollution and climate change?

3. Motor vehicles are a major source of air pollution in many cities. Identify three transportation strategies for reducing air pollution and explain how they would function.

4. Access air pollution monitoring data for your city (usually available from the health department or the environment department—or at https://www.iqair .com/us/). Can you find any inequitable patterns? Are poorer neighborhoods disproportionately located near emissions sources such as major roadways or incinerators?

5. “Tight buildings” save energy by reducing air exchange between the inside and the outside, but doing so can result in a buildup of indoor pollutants. How might this problem be addressed to optimize both the building’s energy performance and the quality of indoor air?

6. Climate change is increasing the risk of wildfires, which generate large quantities of smoke. Investigate a recent wildfire season, describe its impacts on air quality in affected areas, and discuss built environment strategies to reduce harm.

7. Read up on recent efforts to introduce clean cookstoves in a particular region in the Global South, discuss the challenges that arose, and discuss how these might be overcome in future efforts.

Chapter 5: Injury, Violence, and the Built Environment

By Corinne Peek-Asa, Christopher N. Morrison 1. Select an injury type and fill in the cells for the Haddon matrix to identify built environment approaches to prevent that type of injury.

2. Research provides critical evidence to support built environmental approaches to prevent injuries. In most cases, it is not feasible or ethical to test the impact of built environment interventions using an experimental study design in which the researchers select research participants, groups, or places to receive the intervention; select others to receive a control condition; and then compare injuries for the intervention versus control groups. What alternatives approaches are available? What are the strengths and weaknesses of these approaches?

3. A strong conceptual framework and clear empirical evidence are necessary but insufficient conditions to implement a built environment approach to prevent injury.

What obstacles might public health practitioners face when attempting to implement a preventive intervention to reduce injury? How could they overcome these obstacles?

4. Based on your results for question 1, select one cell from the Haddon matrix and investigate the theory and empirical evidence supporting the intervention you

proposed. How strong is the theoretical foundation? How robust is the scientific evidence? How successful have public health practitioners been at implementing this approach?

Chapter 6: Water, Health, and the Built Environment

By Charisma S. Acey, Emmanuel Frimpong Boamah 1. Thinking about where you live, how might greater community involvement in water decision-making help address the challenges of water, wastewater, and stormwater management?

2. How can nature-based approaches help address the problems of too much and too little water in cities? What can make these approaches more effective?

3. What regulations protect water quality in the United States? How effective are they?

What are their limitations, and why?

4. What are the similarities and differences facing countries with differing levels of economic development in the Global North and Global South when it comes to water, wastewater, and stormwater?

5. Describe the challenges of water afford- ability. In your community, are there specific households that disproportionately face some of these affordability challenges? If so, why? What factors make potable water unaffordable to house- holds? What kinds of interventions could help make water more affordable?

6. Do onsite sewerage systems offer a solution to the large percentage of the world’s population lacking safely managed sanitation services? What are the benefits? What are the challenges?

7. List the challenges communities face in meeting the human right to water expressed in Goal 6 of the UN Sustainable Development Goals. What are the barriers in realizing the human right to water? What would you advise decision-makers to prioritize in meeting this challenge?

Chapter 7: Built Environments, Mental Health and Well-being

By Xiangrong Jiang, Chia-Ching Wu, Chun-Yen Chang, William C. Sullivan 1. Can you identify a place or places that make you feel more comfortable, peaceful, happy, or calm? What features do you think most contribute to those feelings?

2. If there is a place that makes you feel happy, is that a short-lived, momentary response?

Or does that place contribute to your long-term sense of well-being?

3. Social isolation and loneliness are bad for mental health, and crowding is bad for mental health. What features of the built environment do you think promote a “just right” amount of social interaction?

4. Why do you think road rage is so well recognized relative to “sidewalk rage”? What policy implications would you draw from a comparison of the two?

5. A key public health strategy during the COVID-19 pandemic was “social distancing.”

What do you think were the mental health consequences? Can you think of built environment strategies that would have minimized any adverse consequences while minimizing the risk of infection?

6. Displacement—say, by being evicted from a home or being priced out of a neighborhood—is a frightening and anxiety-provoking experience. What strategies can you think of to minimize these adverse outcomes?

Chapter 8: Social Capital and Community Design

By Kasley Killam, Ichiro Kawachi 1. What lessons can be learned from the design of previous planned communities to influence social capital?

2. What cost-effective strategies might enhance social interactions in an urban area? What about in a rural area?

3. Reflect on the shared spaces in your community. What elements contribute to social capital, and what elements inhibit it?

4. Imagine that you are responsible for overseeing new development in your city. What efforts would you take to incorporate insights about social capital into your plan? What stakeholders would you engage?

5. How do you think cultural influences, such as individualism and collectivism, might affect the connections between the built environment, social capital, and health in different countries?

6. What design strategies can you envision to promote social capital while reducing the risk of infection during a pandemic?

Chapter 9: Inequity, Gentrification, and Urban Health

By Helen V. S. Cole, Isabelle Anguelovski 1. How does environmental racism take place in cities, and what are its drivers and manifestations?

2. What role does urban greening play in producing environmental inequalities and health injustices?

3. How do the different types of environ- mental justice manifest in urban examples you are familiar with?

4. What urban policies and interventions can mitigate the impacts of gentrification on socially marginalized residents’ lives, and how?

5. What land use planning tools and changes allow just and equitable urban greening?

Chapter 10: Healthy Places Across the Lifespan

By Nisha Botchwey, Nsedu Obot Witherspoon, Jordana L. Maisel, Howard Frumkin 1. Name three vulnerable populations. For each group, explain why it is vulnerable and describe the specific health implications that people in that group face as a result of community design choices.

2. What issues would you need to consider before approaching individuals in a vulnerable population about design features in a new project that might have positive or negative impacts on them?

3. What are examples of (a) vulnerabilities that can be avoided through community design and (b) strategies that mitigate unavoidable vulnerabilities?

4. Identify universal design strategies that have improved health outcomes for children, older adults, or people with disabilities in low- and middle-income countries or have the potential to do so. Describe the social and policy environments in which these strategies were integrated into the design process or as a retrofit.

5. What applications of the 8-80 Cities concept could provide solutions to healthy places for vulnerable populations in your community?

PART II. Designing Places for Well-being, Equity, and Sustainability Chapter 11: Transportation, Land Use, and Health

By Susan Handy 1. What features of the built environment encourage and discourage physical activity and active transportation?

2. How do transportation systems and land use patterns impact environmental quality and climate change?

3. What policies facilitate development that promotes health and is equitable and sustainable? Of these, which are most feasible for your city or region, and why?

4. Why might some land use and transportation planners be reluctant to incorporate health considerations into their decisions?

5. How can more interactions between public health departments and planning departments be encouraged?

Chapter 12: Healthy Homes

By David E. Jacobs, Amanda Reddy 1. What are the ways in which housing conditions affect health? What health out- comes are most closely linked to housing conditions?

2. What policies are effective for expanding the availability of affordable housing?

3. What interventions are effective for addressing substandard housing conditions?

4. Give an example of a housing program that promotes health and describe how it works.

5. How can investments in healthy housing be financed?

Chapter 13: Healthy Workplaces

By Jonathan A. Bach, Paul Schulte, L. Casey Chosewood, Gregory R. Wagner 1. What work place design elements might be most effective in protecting workers from injury? Which elements might be most effective in assuring and promoting the overall health of workers? Which elements might affect both worker safety and worker health?

2. What policies and programs can be used in workplaces to maximize worker inter- action with the built environment to promote health?

3. What are the limitations of the built environment in protecting and promoting the health and safety of workers?

4. Workers have fewer work-related injuries today as a result of laws, regulations, and enforcement policies than they have in the past. What are the benefits, risks, and barriers to using mandatory interventions to promote the overall health of workers both on and off the job?

Chapter 14: Healthy Healthcare Settings

By Craig Zimring, Jennifer R. DuBose, Bea Sennewald 1. In what ways can the design of a health care facility affect the health and experience of patients, of staff, and of patients’ family members?

2. Why should hospitals be concerned with sustainability?

3. How can evidence-based design be used in built environment settings other than health care facilities, such as schools, office buildings, and community design on a larger scale?

4. What opportunities exist for professionals and staff in health care settings to try to influence the design of the communities in which they work and live?

Chapter 15: Healthy Schools

By Claire L. Barnett, Erika Sita Eitland 1. When was the last time you visited or attended a public school?

2. What do you think are the greatest barriers to fast, responsive investment and policies for healthy school buildings?

3. School budgets are often limited. For existing K–12 facilities, it may be difficult to achieve a holistically healthy school building. If you could invest in one feature of a healthy building, what would it be?

4. Brainstorm and list all the vulnerable populations that should be considered when designing, maintaining, and operating healthy K–12 facilities. Consider children and adults.

5. What public health systems are in place or should be in place to prevent or to investigate and track children’s exposures to health hazards in schools?

6. If you were to promote the healthy schools movement, what issue would you advocate for? What would be your strategy for gaining support? Who are your allies in this effort?

7. How would you prepare your local school to stay open during the next pandemic?

Chapter 16: Contact with Nature

By Howard Frumkin 1. Can you identify five mechanisms through which nature contact might benefit health?

2. Do you think public health advice ought to include a “recommended daily dose” of nature? What kind of evidence would you want to support such a recommendation?

3. Imagine you are the health advisor to your city’s parks commissioner. What advice would you offer to optimize the health benefits of parks?

4. Visit a park close to your home. Systematically describe the park’s features, identifying those that promote health and those that do not.

Chapter 17: Climate Change, Cities, and Health

By José G. Siri, Katherine Britt Indvik 1. What are the most important ways in which cities contribute to climate change?

2. What are some of the direct and indirect impacts of climate change (for example, heat, hurricanes, and drought) on urban health?

3. What health equity issue related to urban climate impacts resonates most with you, and why?

4. Give several examples of adaptation and mitigation actions you might take in your city.

5. Describe a health co-benefit climate mitigation or adaptation actions not mentioned in this chapter.

Chapter 18: Community Resilience and Healthy Places

By José G. Siri, Katherine Britt Indvik, Kimberley O’Sullivan 1. Can a system or structure be sustainable but not resilient? Resilient but not sustainable?

Why or why not?

2. Describe one significant failure of resilience in the built environment and one significant success.

3. How did the COVID-19 crisis highlight resilience or a lack of resilience relevant to making healthy places?

4. What are some concrete actions your city or community could take to improve healthy resilience?

5. What are some ways that the built environment itself can promote community resilience?

PART III. Strategies for Healthy Places: A Toolkit Chapter 19: Healthy Behavioral Choices and the Built Environment

By Christopher Coutts, Patrice C. Williams 1. Name three behaviors in which individuals may engage that are beneficial both to the individual and to the community. How might these beneficial behaviors be encouraged through modifications to the built environment? How might an individual’s characteristics facilitate or impede these behaviors?

2. Explain whether obesity is a communicable disease or a chronic disease based on the social ecological model, the theory of planner behavior, the integrated behavioral model, social cognitive theory, the health belief model, or behavioral economics.

3. Outline strategies that, when implemented at each level of the health impact pyramid, can support sustained health improvements in urban, suburban, and rural communities.

4. Identify a specific current community issue in a low- to moderate-income country and explain how social marketing could be used to address that issue and achieve change.

5. How is structural racism related to health behaviors and health outcomes? What strategies are most opportune to reduce racial and ethnic disparities and address structural racism?

Chapter 20: Legislation, Policy, and Governance for Healthy Places

By Eugenie L. Birch 1.

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3.

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What are the ways in which policy and legislation are different?

How might approaches to affecting change differ at the different levels of government?

What are complete streets, and why should communities have policies that favor them?

What are some actions local governments can take to promote health through the built environment?

5. In what ways could the New Urban Agenda be used to promote health in low- tomiddle-income countries?

Chapter 21: Community Engagement for Health, Equity, and Sustainability

By Manal J. Aboelata, Jasneet K. Bains 1. What are the challenges to successful community engagement in creating healthy, equitable, and sustainable neighborhoods? How can these be overcome?

2. In what way are the challenges and strategies different in disenfranchised communities? Do you think it is important to engage residents from disenfranchised, marginalized, or underrepresented groups? Why? 3. What lessons do the examples demonstrate about the factors that contribute to successful community engagement projects? To ineffective processes?

4. What policies, tools, or strategies can be used to counteract potentially inequitable and negative impacts of changes to the built environment?

5. How do power dynamics in communities impact participation?

Chapter 22: Measuring, Assessing, and Certifying Healthy Places

By Carolyn A. Fan, Andrew L. Dannenberg 1. What are some types of measures of health-related components of the built environment in a community? Why is it difficult to obtain ideal measures?

2. How do certification standards such as LEED, Fitwel, and WELL promote healthy community design and healthy buildings?

3. Identify five different walkability or park audit tools available at https://active livingresearch.org/tools and resources/all. How do the tools differ in content and emphasis?

4. In what kinds of settings are health impact assessments (HIAs) particularly useful for assessing the likely effects of proposed projects and policies on people’s health?

5. What barriers may prevent an HIA from influencing a decision about a proposed project or policy?

PART IV. Looking Forward, Taking Action Chapter 23: Training the Next Generation of Healthy Placemakers

By Nisha D. Botchwey, Olivia E. Chatman, Matthew Trowbridge, Yakut Gazi 1. What are some examples of vocabulary and communication constructs (for example, acronyms) that are used in urban planning or in public health that frequently need “translation” in the course of interdisciplinary collaboration to promote healthy places?

2. What are the tangible benefits of multidisciplinary research and practice collaboration?

What are some strategies for organizing and supporting collaborative projects in academic or practice environments?

3. What are the core competencies that should be acquired by university students and professionals engaged in promoting healthy places? What critical interdisciplinary healthy places skills are most challenging to learn and develop in online learning environments?

4. What are some examples of successful collaborations to promote healthy places in your community? What populations, professionals, and collaborative processes made these projects successful?

5. How are the goals for planners and public health officials similar, and how are they different? What are some examples of jobs or projects that would benefit from crosstrained staff?

Chapter 24: Innovative Technologies for Healthy Places

By J. Aaron Hipp, Mariela Alfonzo, Sonia Sequeira 1. Make a compelling argument for the use of the term Smart Place over Smart City.

2. Identify at least one example of a Smart Place technology near your school, home, or work. How does this technology sup- port health, and who within the space is supported?

3. Provide an additional example of urban health big data with examples of each of the five V’s: volume, velocity, veracity, variety, and value.

4. New urban health technologies that support Smart Places are developed each day.

Describe one new technology and how it improves health, efficiencies, and inequities.

Chapter 25: Healthy Places Research: Emerging Opportunities

By Andrew L. Dannenberg, Nisha D. Botchwey, Howard Frumkin 1.

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Why is conclusive proof of a link between a particular built environment design and a specific health impact seldom available?

What are the advantages and disadvantages of using natural experiments to document links between health and the built environment?

How can case studies be used to guide future community design decisions?

What are some examples of data collected for purposes other than healthy community design that might be useful for con- ducting research on links between health and the built environment?

Given resources to conduct a research project on one of the emerging opportunities described in this chapter, which topic would you select, and how would you design a research study to provide new information on the subject?

Chapter 26: COVID and the Built Environment: Lessons Learned

By Howard Frumkin 1. How would you distinguish urban density from crowding? How would you explain this distinction to a mayor? A health com- missioner? A business owner? A worried parent?

2. Research at the neighborhood level showed a link between a history of redlining and being hard hit by COVID-19. Give at least three reasons that could explain this association.

3. What transportation policies might you recommend that could draw on the COVID-19 experience to promote health, clean air, and other benefits?

4. How did the pandemic affect commercial real estate demand and prices in your city?

What follow-on impacts did this have?

5. What are the advantages and disadvantages of working from home? What design strategies, in both offices and homes, can accommodate greater teleworking and optimize the well-being of workers?

6. During a pandemic such as COVID-19, how would you advise the parks commissioner in your city to balance the need for infection control with the demand to be in parks?