Creating healthy and sustainable cities: what gets measured, gets done

Since the first Lancet Series on urban design, transport, and health (Series 1) was published in 2016, the urgency to make the transition to healthy and sustainable cities worldwide has intensified. That year, the UN's Sustainable Development Goals1UN General AssemblyResolution adopted by the General Assembly: transforming our world: the 2030 agenda for sustainable development. United Nations, New YorkOct, 2015Google Scholar for promoting prosperity while protecting the planet and ensuring equity came into force. WHO also released its Shanghai Declaration on promoting health in the 2030 Agenda for Sustainable Development. At WHO Global Conference on non-communicable diseases (NCDs) in 2017, heads of states reiterated their commitment to reduce premature mortality from NCDs by a third by 2030. In 2018, WHO published the Global Action Plan for Physical Activity, which featured recommendations to create active environments. Cobenefits of integrated city planning policies for individual and planetary health are now recognised globally, and scientific evidence about rapidly changing earth systems and increasingly extreme weather has reinforced the urgency to transition to net-zero-emission cities.2IPCC. Summary for policymakers. In: Masson-Delmotte V, Zhai P, Pirani A, et al, eds. Climate change 2021: the physical science basis. Contribution of working group I to the sixth assessment report of the Intergovernmental Panel on Climate Change. Cambridge, UK: Cambridge University Press (in press).Google Scholar Series 13Giles-Corti B Vernez-Moudon A Reis R et al.City planning and population health: a global challenge.Lancet. 2016; 388: 2912-2924Summary Full Text Full Text PDF PubMed Scopus (532) Google Scholar highlighted evidence supporting pedestrian-friendly and cycling-friendly, higher-density compact cities with proximate shops, services, and transit. In that Series, we identified eight integrated urban systems policies that work together to create eight intervention foci—the 8D's—to develop more compact cities that enable sustainable mobility, reduce NCDs and road trauma, and manage urbanisation.3Giles-Corti B Vernez-Moudon A Reis R et al.City planning and population health: a global challenge.Lancet. 2016; 388: 2912-2924Summary Full Text Full Text PDF PubMed Scopus (532) Google Scholar Three of these interventions relate to regional planning (destination accessibility; distribution of employment; and demand management to reduce driving) and five relate to local urban design (design of pedestrian-friendly and cycling-friendly movement networks; optimising residential density; reducing distance to public transport; increasing diversity of housing and mixed land uses; and enhancing desirability of active transport modes). The 8D's work together to create built environments that influence transport mode choices, which in turn affect individual, social, and environmental risk factors associated with health and wellbeing. Series 1 proposed city planning policy and spatial indicators (table) to benchmark and monitor progress towards achieving healthy and sustainable cities.TableCity planning policy and spatial indicators proposed in the first urban design, transport, and health SeriesIndicators from Series 1Indicators assessed in Series 2Policy indicators (ie, policies and legislation)Integrated transport and urban planningNational and state transport and urban planning legislation requires integrated transport and urban planning actions to create healthy and sustainable cities and regular review of progressPaper 14Lowe M Giles-Corti B Boeing G et al.Assessing urban design and transport planning policy to create healthy and sustainable cities: indicators for 25 cities worldwide.Lancet Global Health. 2022; 10: e882-e894Summary Full Text Full Text PDF PubMed Scopus (6) Google ScholarAir pollutionNational and state air pollution legislation seeks to protect and improve air quality to promote the health of urban populationsPaper 14Lowe M Giles-Corti B Boeing G et al.Assessing urban design and transport planning policy to create healthy and sustainable cities: indicators for 25 cities worldwide.Lancet Global Health. 2022; 10: e882-e894Summary Full Text Full Text PDF PubMed Scopus (6) Google ScholarDestination accessibilityNational and state transport and urban planning legislation requires coordinated planning of transport, employment, land use, and infrastructure that ensures access by public transportPaper 14Lowe M Giles-Corti B Boeing G et al.Assessing urban design and transport planning policy to create healthy and sustainable cities: indicators for 25 cities worldwide.Lancet Global Health. 2022; 10: e882-e894Summary Full Text Full Text PDF PubMed Scopus (6) Google ScholarDistribution of employmentUrban planning and design codes require a balanced ratio of jobs to housing (eg, from 1:0·8 to 1:1·2)Paper 14Lowe M Giles-Corti B Boeing G et al.Assessing urban design and transport planning policy to create healthy and sustainable cities: indicators for 25 cities worldwide.Lancet Global Health. 2022; 10: e882-e894Summary Full Text Full Text PDF PubMed Scopus (6) Google ScholarDemand managementUrban planning, building codes, and local government policies limit car parking and price parking appropriately for contextPaper 14Lowe M Giles-Corti B Boeing G et al.Assessing urban design and transport planning policy to create healthy and sustainable cities: indicators for 25 cities worldwide.Lancet Global Health. 2022; 10: e882-e894Summary Full Text Full Text PDF PubMed Scopus (6) Google ScholarDesignUrban design codes create pedestrian-friendly and cycling-friendly neighbourhoods, requiring highly connected street networks, pedestrian and cycling infrastructure, and public open space; lot layouts maximise natural surveillancePaper 14Lowe M Giles-Corti B Boeing G et al.Assessing urban design and transport planning policy to create healthy and sustainable cities: indicators for 25 cities worldwide.Lancet Global Health. 2022; 10: e882-e894Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar (lot layouts were not assessed, due to data unavailability across cities)DensityUrban design codes require minimum and maximum context-specific housing densities, including higher-density development around activity centres and transport hubsPaper 14Lowe M Giles-Corti B Boeing G et al.Assessing urban design and transport planning policy to create healthy and sustainable cities: indicators for 25 cities worldwide.Lancet Global Health. 2022; 10: e882-e894Summary Full Text Full Text PDF PubMed Scopus (6) Google ScholarDistance to public transportUrban design codes require frequent service public transport to be within 400–800 m of residential walkable catchmentsPaper 14Lowe M Giles-Corti B Boeing G et al.Assessing urban design and transport planning policy to create healthy and sustainable cities: indicators for 25 cities worldwide.Lancet Global Health. 2022; 10: e882-e894Summary Full Text Full Text PDF PubMed Scopus (6) Google ScholarDiversityUrban design codes require a diverse mix of housing types and local destinations needed for daily livingNot measured separately; partly covered by other policy indicators (eg, destination accessibility and design)5Boeing G Lowe M Giles-Corti B et al.Using open data and open-source software to measure and map spatial indicators of urban design and transport features for healthy and sustainable cities in 25 cities worldwide.Lancet Global Health. 2022; 10: e907-e918Summary Full Text Full Text PDF PubMed Scopus (5) Google ScholarDesirabilityUrban design codes incorporate crime prevention through urban design principles, manage traffic exposure, and establish urban greening provisionsNot measured separately; partly covered by other policy indicators (eg, design, demand management, air pollution)5Boeing G Lowe M Giles-Corti B et al.Using open data and open-source software to measure and map spatial indicators of urban design and transport features for healthy and sustainable cities in 25 cities worldwide.Lancet Global Health. 2022; 10: e907-e918Summary Full Text Full Text PDF PubMed Scopus (5) Google ScholarWalking and cycling participation and public transport use targetsNot proposed in Series OnePaper 14Lowe M Giles-Corti B Boeing G et al.Assessing urban design and transport planning policy to create healthy and sustainable cities: indicators for 25 cities worldwide.Lancet Global Health. 2022; 10: e882-e894Summary Full Text Full Text PDF PubMed Scopus (6) Google ScholarGovernment transport investmentTransport infrastructure investment by modePercentage of total government transport expenditure in a given financial year spent on pedestrian infrastructure, cycling infrastructure, public transport, and road infrastructurePaper 14Lowe M Giles-Corti B Boeing G et al.Assessing urban design and transport planning policy to create healthy and sustainable cities: indicators for 25 cities worldwide.Lancet Global Health. 2022; 10: e882-e894Summary Full Text Full Text PDF PubMed Scopus (6) Google ScholarSpatial indicators?†Choice of final indicators and distance thresholds for Series 2 were informed by available data and the indicator frameworks for UN Sustainable Development Goals1 or UN Habitat's New Urban Agenda.Urban design and transport featuresPublic transport accessPercentage of population living within 400–800 m of high-frequency public transportPaper 3;5Boeing G Lowe M Giles-Corti B et al.Using open data and open-source software to measure and map spatial indicators of urban design and transport features for healthy and sustainable cities in 25 cities worldwide.Lancet Global Health. 2022; 10: e907-e918Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar percentage of population living within 500 m of a frequently serviced public transport stop†Choice of final indicators and distance thresholds for Series 2 were informed by available data and the indicator frameworks for UN Sustainable Development Goals1 or UN Habitat's New Urban Agenda.EmploymentPercentage of population with employment within 30 min of their home by walking, cycling, or public transportNot measured, as comparable data available not for all citiesDistribution of employmentUrban planning and design codes require a balanced ratio of jobs to housing (eg, from 1:0·8 to 1:1·2)Not measured, as comparable data not available for all citiesTransport infrastructureRatio of roads (km) to footpaths (km) and designated cycle lanes (km)Not measured, as comparable reliable data not available for all citiesDesignStreet connectivity (eg, ped sheds‡Ratio of straight line distance buffer to street network distance buffer ≥0·6 within 0·8–1·2 km) of desintations eg, shops, schools, services, and transport hubsPaper 3;5Boeing G Lowe M Giles-Corti B et al.Using open data and open-source software to measure and map spatial indicators of urban design and transport features for healthy and sustainable cities in 25 cities worldwide.Lancet Global Health. 2022; 10: e907-e918Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar street intersection density in the local walkable neighbourhood of residence*Local walkable neighbourhood defined as the intersection between urban neighbourhood grid and 1 km extent of pedestrian street network from sample address points.DensityDwellings per area: within 1·2 km of activity centres and public transport hubs, and in urban fringe developmentsPaper 3;5Boeing G Lowe M Giles-Corti B et al.Using open data and open-source software to measure and map spatial indicators of urban design and transport features for healthy and sustainable cities in 25 cities worldwide.Lancet Global Health. 2022; 10: e907-e918Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar population density in the local walkable neighbourhood of residence*Local walkable neighbourhood defined as the intersection between urban neighbourhood grid and 1 km extent of pedestrian street network from sample address points.Distance to transitPercentage of population living within 400 m of a bus stop and 800 m of a rail stopPaper 3;5Boeing G Lowe M Giles-Corti B et al.Using open data and open-source software to measure and map spatial indicators of urban design and transport features for healthy and sustainable cities in 25 cities worldwide.Lancet Global Health. 2022; 10: e907-e918Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar percentage of population living within 500 m of any public transport stop†Choice of final indicators and distance thresholds for Series 2 were informed by available data and the indicator frameworks for UN Sustainable Development Goals1 or UN Habitat's New Urban Agenda.DestinationsPercentage of (urban) land area allocated to destinations required for daily livingPaper 3;5Boeing G Lowe M Giles-Corti B et al.Using open data and open-source software to measure and map spatial indicators of urban design and transport features for healthy and sustainable cities in 25 cities worldwide.Lancet Global Health. 2022; 10: e907-e918Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar percentage of population living within 500 m of a fresh food market, a convenience store, and public transport (ie, any stop and a stop with a high-frequency service)Open or green spacePercentage of (urban) land area allocated to open or green spacePaper 3;5Boeing G Lowe M Giles-Corti B et al.Using open data and open-source software to measure and map spatial indicators of urban design and transport features for healthy and sustainable cities in 25 cities worldwide.Lancet Global Health. 2022; 10: e907-e918Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar Percentage of population living within 500 m of a public open space (ie, any public open space and any public open space than 1·5 hectares)WalkabilityNot proposed in Series 1Paper 3;5Boeing G Lowe M Giles-Corti B et al.Using open data and open-source software to measure and map spatial indicators of urban design and transport features for healthy and sustainable cities in 25 cities worldwide.Lancet Global Health. 2022; 10: e907-e918Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar combined population density, street intersection density, and daily living destinations in local neighbourhoodTransport outcomesTrip mode shareProportion of total and commuting trips made by walking, cycling, public transport, and private motor vehicleNot measured as indicators; however, paper 14Lowe M Giles-Corti B Boeing G et al.Assessing urban design and transport planning policy to create healthy and sustainable cities: indicators for 25 cities worldwide.Lancet Global Health. 2022; 10: e882-e894Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar measured policy targets for walking, cycling, and public transport use; and paper 26Cerin E Giles-Corti B Lowe M et al.Determining optimal thresholds for spatial indicators of healthy and sustainable cities: findings from the IPEN Adult study.Lancet Global Health. 2022; 10: e895-e906Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar estimated prevalence of any walking for transport in 14 cities in 10 countries* Local walkable neighbourhood defined as the intersection between urban neighbourhood grid and 1 km extent of pedestrian street network from sample address points.† Choice of final indicators and distance thresholds for Series 2 were informed by available data and the indicator frameworks for UN Sustainable Development Goals1UN General AssemblyResolution adopted by the General Assembly: transforming our world: the 2030 agenda for sustainable development. United Nations, New YorkOct, 2015Google Scholar or UN Habitat's New Urban Agenda.‡ Ratio of straight line distance buffer to street network distance buffer Open table in a new tab This second Series on urban design, transport, and health (Series 2) moves beyond describing why societies need to make the transition to healthier, more sustainable cities, to focus on how and what must change. A glossary of terms is available in the appendix. Series 2 shows the feasibility of assessing health-supportive city planning policies and creating spatial indicators of urban design and transport features, by use of standardised methods across cities worldwide. To do this, we formed the multidisciplinary Global Healthy and Sustainable City-Indicators Collaboration, with expertise in public health, urban and transport planning, urban design, architecture, computer and geospatial science, behavioural science, statistics, epidemiology, complex systems science, and public policy. The goal of Series 2 is to facilitate the development of a global system of policy and spatial indicators for healthy and sustainable cities. Building on methodologies developed in Australia,7Arundel J Lowe M Hooper P et al.Creating liveable cities in Australia: mapping urban policy implementations and evidence-based national liveability indicators. Centre for Urban Research, RMIT University, Melbourne2017Google Scholar, 8Alderton A Higgs C Davern M et al.Measuring and monitoring liveability in a low-to-middle income country: a proof-of-concept for Bangkok, Thailand and lessons from an international partnership.Cities Health. 2021; 5: 320-328Crossref Scopus (4) Google Scholar we measured a modified list of the indicators recommended in Series 1 for 25 cities in 19 middle-income and high-income countries. We sought to answer multiple questions: (1) Is it feasible to measure policies in cities worldwide? (2) If so, do cities have city planning policies that will lead to healthy and sustainable cities?4Lowe M Giles-Corti B Boeing G et al.Assessing urban design and transport planning policy to create healthy and sustainable cities: indicators for 25 cities worldwide.Lancet Global Health. 2022; 10: e882-e894Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar (3) What are the thresholds for urban design and transport features to achieve active and sustainable lifestyles?6Cerin E Giles-Corti B Lowe M et al.Determining optimal thresholds for spatial indicators of healthy and sustainable cities: findings from the IPEN Adult study.Lancet Global Health. 2022; 10: e895-e906Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar (4) Is it feasible to consistently measure spatial indicators of urban design and transport features that enable active and sustainable lifestyles in cities worldwide? (5) If so, are there inequities in access to supportive environments between and within cities?5Boeing G Lowe M Giles-Corti B et al.Using open data and open-source software to measure and map spatial indicators of urban design and transport features for healthy and sustainable cities in 25 cities worldwide.Lancet Global Health. 2022; 10: e907-e918Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar Given the rapidly evolving global challenges that have arisen since our original framework and indicators were published in 2016, the final paper in Series 29Giles-Corti B Moudon AV Lowe M et al.What next? An expanded view of city planning and global health, and the need for evidence-informed policy to be implemented and monitored.Lancet Global Health. 2022; 10: e919-e926Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar considers "where to next?" It updates and expands our 2016 framework of the pathways through which city planning affects ecosystem, human, and planetary health and recommends additional city planning indicators to benchmark and monitor cities. It then outlines global, national, regional, and local actions urgently needed to move from evidence to implementation. Series 2 underscores that integrated city planning has never been more important and identifies actions that must be taken. It is well known that what gets measured, gets done. We therefore provide open-source tools to facilitate measurement of city planning policies and interventions and to enable immediate action.5Boeing G Lowe M Giles-Corti B et al.Using open data and open-source software to measure and map spatial indicators of urban design and transport features for healthy and sustainable cities in 25 cities worldwide.Lancet Global Health. 2022; 10: e907-e918Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 10Liu S Higgs C Arundel J et al.A generalized framework for measuring pedestrian accessibility around the world using open data.Geographical Analysis. 2021; (published online May 19.)https://doi.org/10.1111/gean.12290Crossref Scopus (5) Google Scholar Our vision is that evidence-informed indicators measuring city planning policies and outcomes will be used worldwide to benchmark and monitor progress to hasten the transition to a healthy, sustainable future. BG-C and MS were supported by National Health and Medical Research Council (NHMRC) Senior Principal Research Fellowship funding (grant numbers: 1107672 and 1136250); BG-C and HB were also supported by RMIT Vice-Chancellor's Fellowships; CH was supported through an NHMRC Centre for Research Excellence in Healthy Liveable Communities (grant number: 1061404) and The Australian Prevention Partnership Centre (grant number: 9100003); DA was supported by an Impact Acceleration Award from the Economic and Social Research Council and funding from the Global Challenges Research Fund administered by the Department for the Economy, Northern Ireland, UK. EC's research was supported by the Australian Catholic University. APR was supported by the Centre for Health and Social Care Research of the University of Vic, Central University of Catalonia. The Barcelona Provincial Council and City Council of Vic provided funding for the Barcelona and Vic data collection. AAF was supported by a research fellowship from the Brazilian National Council for Scientific and Technological Development (grant number: 309301/2020-3). GB was supported by a grant from The Public Goods Projects. SL was supported by the experiential fellowships from College of Social Science and Humanities, Northeastern University. JFS was supported by Australian Catholic University. DS was supported by the Center for Diabetes Translation Research, Washington University in St Louis, MO, (grant number: P30DK092950 from National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK] at the National Institutes of Health [NIH]) and by the Centers for Disease Control and Prevention (CDC) (grant number: U48DP006395). MAA was supported by the National Cancer Institute at the NIH (grant number: R01CA198915). GV was supported by Ayudas para contratos Juan de la Cierva-formación 2019 (grant number: FJC2019-041233-I), and the Centro de Excelencia Severo Ochoa 2019–23 Program (grant number: CEX2018-000806-S) from the Spanish Government. RFH was supported by the UK Research and Innovation—National Health and Medical Research Council (grant number: MR/T038934/1). All other authors declare no competing interests. The content of this article is solely the responsibility of the authors and does not represent the official views of any of the NIDDK/NIH, CDC, or of any of the funding agencies supporting this work. We thank Karel Frömel, Faculty of Physical Culture, Palacký University Olomouc, Olomouc, Czech Republic; David Vale, Lisbon School of Architecture, University of Lisbon, Lisbon, Portugal; Andreia Pizarro, Research Center in Physical Activity, Health and Leisure (CIAFEL), Faculty of Sports, and Laboratory for Integrative and Translational Research in Population Health (ITR), University of Porto, Porto, Portugal; Javier Molina-García, Department of Teaching of Musical, Visual and Corporal Expression, University of Valencia, Valencia, Spain; Hannah Hook, College of Health Solutions, Arizona State University, Phoenix, AZ, USA; Adetoyeje Y Oyeyemi, Department of Physiotherapy, University of Maiduguri, Maiduguri, Nigeria; Belinda Nemec, Melbourne; Judy Boyce, Healthy Liveable Cities Lab, Centre for Urban Research, RMIT University, Melbourne, VIC, Australia Download .pdf (.18 MB) Help with pdf files Supplementary appendix City planning policies to support health and sustainability: an international comparison of policy indicators for 25 citiesCity planning policies influence urban lifestyles, health, and sustainability. We assessed policy frameworks for city planning for 25 cities across 19 lower-middle-income countries, upper-middle-income countries, and high-income countries to identify whether these policies supported the creation of healthy and sustainable cities. We systematically collected policy data for evidence-informed indicators related to integrated city planning, air pollution, destination accessibility, distribution of employment, demand management, design, density, distance to public transport, and transport infrastructure investment. Full-Text PDF Open AccessUsing open data and open-source software to develop spatial indicators of urban design and transport features for achieving healthy and sustainable citiesBenchmarking and monitoring of urban design and transport features is crucial to achieving local and international health and sustainability goals. However, most urban indicator frameworks use coarse spatial scales that either only allow between-city comparisons, or require expensive, technical, local spatial analyses for within-city comparisons. This study developed a reusable, open-source urban indicator computational framework using open data to enable consistent local and global comparative analyses. Full-Text PDF Open AccessWhat next? Expanding our view of city planning and global health, and implementing and monitoring evidence-informed policyThis Series on urban design, transport, and health aimed to facilitate development of a global system of health-related policy and spatial indicators to assess achievements and deficiencies in urban and transport policies and features. This final paper in the Series summarises key findings, considers what to do next, and outlines urgent key actions. Our study of 25 cities in 19 countries found that, despite many well intentioned policies, few cities had measurable standards and policy targets to achieve healthy and sustainable cities. Full-Text PDF Open AccessDetermining thresholds for spatial urban design and transport features that support walking to create healthy and sustainable cities: findings from the IPEN Adult studyAn essential characteristic of a healthy and sustainable city is a physically active population. Effective policies for healthy and sustainable cities require evidence-informed quantitative targets. We aimed to identify the minimum thresholds for urban design and transport features associated with two physical activity criteria: at least 80% probability of engaging in any walking for transport and WHO's target of at least 15% relative reduction in insufficient physical activity through walking. The International Physical Activity and the Environment Network Adult (known as IPEN) study (N=11 615; 14 cities across ten countries) provided data on local urban design and transport features linked to walking. Full-Text PDF Open AccessWhat gets measured does not always get done – Authors' replyIn their Correspondence, Jennifer Kent and colleagues have concerns about the sentiment "what gets measured, gets done" expressed through the title of the lead Comment in the Lancet Global Health Series on urban design, transport, and health1 "promotes measurement alone as a legitimate pathway to decision making". Full-Text PDF Open AccessWhat gets measured does not always get doneWe commend the authors of the Lancet Global Health Series on urban design, transport, and health on the delivery of a comprehensive set of recommendations, which are relevant and useful. We have the greatest respect for their work in measuring the health impacts of urban form in various international contexts. Full-Text PDF Open Access