1.  REVIEWING THE EVIDENCE 
Creating Healthy Communities, Healthy Homes,
Healthy People: Initiating a Research Agenda
on the Built Environment and Public Health
Mounting evidence suggests | Shobha Srinivasan, PhD, Liam R. O’Fallon, MA, and Allen Dearry, PhD
physical and mental health prob-
lems relate to the built environ-
ment, including human-modified THE BUILT ENVIRONMENT— cular disease, cancer) require Environmental Health
places such as homes, schools, human-modified places such as such research efforts. These com- The scientific community’s
workplaces, parks, industrial
homes, schools, workplaces, parks, plex diseases are attributable to definition of “environmental
areas, farms, roads and high-
industrial areas, farms, roads and an interaction of genetic and en- health” also has changed in re-
ways. The public health rele-
highways—is our most important vironmental influences, and many cent years. Two decades ago, the
vance of the built environment
requires examination. habitat, since 80% of North of the latter can be directly con- study of environmental health fo-
Preliminary research dem- Americans live in towns and cities nected to the built environment. cused almost exclusively on
onstrates the health benefits of and spend 90% of their time in- While research has focused on chemical toxicants and their rela-
sustainable communities. How- doors.1 To date, much discussion the negative public health conse- tionship to cancer and other ill-
ever, the impact of mediating of the built environment has fo- quences of the built environment, nesses. Now the definition of en-
and moderating factors within cused on the challenges of provid- there has been very limited focus vironmental health is much
the built environment on health ing adequate transportation on the benefits of living in sus- broader, and researchers are
must be explored further. Given (roads, highways, infrastructure, tainable communities. A research studying the effects on human
the complexity of the built en-
public transportation), urban agenda on the public health and health of the physical and social
vironment, understanding its
sprawl, air pollution due to in- quality-of-life benefits of sustain- environment, which includes is-
influence on human health
creased traffic, the lack of side- able communities is necessary. sues related to urban and rural
requires a community-based,
multilevel, interdisciplinary re- walks, and the diminishing natural development, appropriate uses of
search approach. environment. New evidence, how- DEFINITIONS land, pesticide use, public trans-
The authors offer recom- ever, increasingly recognizes that portation systems, and industrial
mendations, based upon a re- even the places we live and work Built Environment development.11 This change is re-
cent conference sponsored by clearly affect our health.2 Never- Scientists’ understanding of flected in the U.S. Department of
the National Institute of Envi- theless, causal relationships be- the “built environment” has un- Health and Human Service’s
ronmental Health Sciences tween the built environment and dergone several changes. Health (DHHS) Healthy People 201012
(NIEHS), for research and pol- specific human illnesses are often Canada’s10 definition of the built current definition of environmen-
icy approaches, and suggest in-
difficult to ascertain.3 environment has been modified tal health:
teragency research alliances for
Recent research explores the as follows and provides a frame- In its broadest sense, environ-
greater public health impact.
effect of improved built environ- work for this discussion: mental health comprises those
(Am J Public Health. 2003;93:
ments on physical activity,4 The built environment includes aspects of human health, dis-
1446–1450) ease, and injury that are deter-
asthma,5 obesity,6 cardiovascular our homes, schools, workplaces,
parks/recreation areas, business mined or influenced by factors
disease, lung cancer mortality,7 areas and roads. It extends over- in the environment. This in-
and mental health.8,9 However, a head in the form of electric cludes not only the study of the
transmission lines, underground direct pathological effects of
pressing need remains for more various chemical, physical, and
in the form of waste disposal
concerted research to identify sites and subway trains, and biological agents, but also the
mechanisms by which the built across the country in the form of effects on health of the broad
highways. The built environment physical and social environ-
environment adversely and posi- ment, which includes housing,
encompasses all buildings, spaces
tively impacts health and to de- and products that are created or urban development, land-use
velop appropriate interventions to modified by people. It impacts and transportation, industry,
indoor and outdoor physical en- and agriculture.
reduce or eliminate harmful
vironments (e.g., climatic condi-
health effects. The growing tions and indoor/outdoor air Thus, the broader definition of
health burden and attendant eco- quality), as well as social environ- “environmental health” encom-
nomic costs associated with ments (e.g., civic participation, passes the “built environment”
community capacity and invest-
higher chronic disease incidence ment) and subsequently our within its scope and provides the
(e.g., obesity, asthma, cardiovas- health and quality of life. context for future research.
1446 | Reviewing the Evidence | Peer Reviewed | Srinivasan et al. American Journal of Public Health | September 2003, Vol 93, No. 9

2.  REVIEWING THE EVIDENCE 
THE BUILT ENVIRONMENT Transportation increased computer usage, con- and higher rates of crime, making
AND HEALTH In recent decades, US residents cern about crime, little contact neighborhoods less safe for walk-
have had a greater reliance on with neighbors and geographic ing and in some cases resulting in
Research on the connections cars and trucks, which burn fossil isolation have created communi- greater social isolation.37,38 Un-
between the built environment fuels, for transportation needs. In- ties that are not interconnected.29 derstanding linkages between so-
and health has largely focused creased vehicle use and the meth- This isolation may result in a lack cioeconomic inequity and health
on housing, transportation, and ods employed in energy genera- of social networks and diminished is essential to reducing exposures
neighborhood characteristics. tion contribute to air pollution social capital,31 which can con- to environmental hazards as well
These research endeavors have that negatively impacts health.21 tribute to obesity, cardiovascular as disparities in health.
also pointed out that the burden In sprawling communities, cars disease, mental health problems,
of illness in the built environ- and trucks pollute the atmos- and increased rates of mortal- SUSTAINABLE
ment has been greater on lower phere with ground-level ozone ity.17,32–34 People who live in such COMMUNITIES
socioeconomic strata and minor- and particulate matter, contribut- isolated communities are often
ity populations. This section re- ing to human health problems unable to effect changes or deal While some research indicates
views some of the literature in such as lung disease.22,27 People with crises or public health chal- the negative health impact of the
these areas. most affected by air pollution in- lenges. Studies suggest that a re- built environment, there is very
clude older adults with pre- duction in childhood and adoles- limited research on the health
Housing existing respiratory disease,23 cent obesity, for example, through benefits of promoting sustainable
The association between sub- children, especially those with various intervention and preven- communities. The President’s
standard housing and health has asthma,24 persons with inade- tion programs, would yield long- Council in 1993 offered a work-
long been recognized.13,14 How- quate health care, and even term economic benefits.29,30 ing definition for sustainable com-
ever, only recently has a growing healthy individuals who work munities as “healthy communities
body of evidence emerged sug- and exercise outdoors.24,25 Health Disparities where natural and historic re-
gesting that physical and mental Higher dependence on motor In exploring the impact of the sources are preserved, jobs are
health problems—anxiety, depres- vehicles also has resulted in built environment on public available, sprawl is contained,
sion, attention deficit disorder, higher levels of congestion26 and health, research indicates that neighborhoods are secure, educa-
substance abuse, aggressive be- increased motor and pedestrian the burden of illness is greater tion is lifelong, transportation and
havior, asthma, heart disease, injuries and deaths.27 Lack of safe among minorities and low- health care are accessible, and all
and obesity—relate to the built sidewalks in growing urban areas income communities.17,29,32–33 citizens have opportunities to im-
environment, particularly to poor has resulted in a reduction in the Lower–socioeconomic status prove the quality of their lives.”39
urban planning and inadequate number of children walking or communities usually have limited The sparse research on sustain-
housing.15,16 Inadequate housing, biking to schools.12 Today, only access to quality housing stock able communities suggests that
for example, may indicate that in- 10% of children walk or bicycle and live in neighborhoods that diligent planning is needed to
habitants are under significant to school—a 40% reduction over do not facilitate outdoor activities create an environment that is con-
physical and mental stress.13, 17 the last 20 years.28 Research indi- or provide many healthy food ducive to the mental and physical
Dilapidated housing—leaking cates that inadequate urban plan- options.35 Inequities in construc- well-being of humans as well as
pipes, peeling paint, or cracks ning, including a dearth of bike tion and maintenance of low- the natural environment.40,41
and holes in ceilings—may be a paths and sidewalks, has con- income housing, especially for These studies contend that health
stressor that affects the human tributed to an increasingly seden- Blacks, older persons, persons benefits exist when people come
immune system.5,18 tary lifestyle for children, possibly with disabilities, and immigrants, into contact with the natural envi-
Housing disrepair among the factoring into the growing rates of have resulted in insufficient ronment. The studies recommend
poor exposes them dispropor- childhood obesity.29 housing, poor quality housing, both the creation of green spaces
tionately to lead, pests, air pollu- overcrowding, and higher levels and the use of environmentally
tants, contaminants, and greater Isolated Communities and of population density and health conscious construction.42
social risks.5,13 Pest sightings in- Sedentary Lifestyles problems.16,36 Consequently, Some argue that urban sprawl
crease when buildings are dilapi- Mounting evidence suggests these communities may experi- has created more highways, thus
dated, and no amount of clean- that there are social, health, and ence greater rates of respiratory causing greater air pollution.
ing can remove the pest problem economic consequences to iso- disease, developmental disorders, With the expansion of urban
when such structural disrepair lated and sedentary lifestyles.30 obesity, chronic illnesses, and areas and the resultant sprawl,
remains uncorrected. Further, Unfortunately, the physical and mental illness. agriculture has become more de-
pesticide use in dilapidated struc- social construct of the urban envi- Also, studies have consistently pendent on the use of pesticides
tures may jeopardize the health ronment promotes isolation.17 shown an association between a and mechanisms that can pro-
of inhabitants.19,20 Higher rates of television viewing, deteriorated physical environment duce larger quantities of food in
September 2003, Vol 93, No. 9 | American Journal of Public Health Srinivasan et al. | Peer Reviewed | Reviewing the Evidence | 1447

3.  REVIEWING THE EVIDENCE 
smaller areas. All this has had a tems.45 To address some of ties. To encourage research in STRATEGIES FOR
debilitating impact on human these gaps, the National Insti- this area, major recommenda- IMPLEMENTATION
health, resulting in greater rates tute of Environmental Health tions from the meeting included
of asthma and other respiratory Sciences (NIEHS) convened a the following: The built environment poses
problems. conference called the “Built En- many complex challenges that
Accordingly, there have been vironment—Healthy Communi- • Develop effective measures involve physical and social envi-
recommendations to develop ties, Healthy Homes, Healthy and indicators for sustainable ronments. In spite of research
green infrastructures to address People: Multilevel, Interdiscipli- communities. indicating that chronic diseases
the ecological and social impacts nary Research Approaches,” in • Conduct multidisciplinary re- of the 20th century, such as
of sprawl and their impact on July 2002 in Research Triangle search on the positive health im- heart disease, obesity, asthma,
health.43 Examples of the princi- Park, North Carolina. The Na- pacts of sustainable and planned and others, are affected by how
ples behind incorporating green tional Institutes of Health’s Of- communities. we design, build, and sustain
spaces and environmentally con- fice of Rare Diseases and Office • Assess the environmental our environment, many com-
scious construction in the built of Behavioral and Social Sci- health benefits of efficient or al- munities and planners still do
environment include using natu- ence Research cosponsored the ternate energy (for transporta- not fully understand the health
ral daylight, solar collectors, pas- conference. tion, agriculture, architecture, consequences of environmental
sive cooling, and nontoxic mate- As its objective, the confer- community design, and so on). factors. This stems partly from
rials; harvesting rainwater; ence sought to delineate areas • Develop models to incorporate the sparse research concerning
installing operable (openable) of research to better understand cost-effectiveness when adopting the health benefits of sustain-
windows; creating pedestrian and the connection between specific environmentally sustainable able communities. Creating
bike greenways; and filling build- illnesses and health challenges technologies. communities that are conscious
ing structures with plants, water, in the built environment. A • Create coordinated programs of environmental health con-
art, light, and natural air. Studies broad spectrum of participants among federal and nonfederal cerns may require partnerships
indicate health and occupational representing community organi- agencies that address research on and collaborations among poli-
benefits from using some or all zations, state and local depart- the built environment. cymakers, governments, re-
of these design principles ments of health, academic re- • Encourage multidisciplinary searchers, communities, and
through lowering workplace searchers, and federal agencies programs for training and re- health specialists with interdis-
stress and employee absenteeism, participated. They discussed the search within governmental and ciplinary perspectives.
enhancing and preserving land, state of the science and explored nongovernmental agencies. Awareness of environmental
reducing energy waste, and re- future directions in conducting • Improve communication and health consequences requires
ducing expenditures by having research on the built environ- partnership strategies among var- not only collaborative partner-
lower energy and maintenance ment and health. Speakers de- ious entities; especially encour- ships but also the adoption of
costs.44 These studies have ar- scribed current research and ex- age community participation in multidisciplinary research ap-
gued that these kinds of sustain- amined connections between research endeavors. proaches to environmental
able communities may in the the built environment and • Develop multilevel techniques health, such as studies that in-
long run translate into a healthier human health and discussed of measurement and longitudinal clude public health researchers,
economy. challenges in developing sustain- models of analysis for assessing health professionals, architects,
able communities that seek to the impact of the built environ- builders, planners, and trans-
ADDRESSING THE balance the social, economic, ment on sustainable communi- portation officials. Such multi-
CHALLENGES cultural, and ecological infra- ties. These measures and models disciplinary coalitions would be
structure with human health should account for individual, better equipped to develop indi-
Current research on the rela- and development. community, and systemic vari- cators and measures of sustain-
tionship between urban design The conference participants ables including biological factors, able communities and to eluci-
and human illness is inconclu- derived their major recommen- socioeconomic factors, and date their association with
sive and requires further explo- dations from current literature; neighborhood and physical envi- environmental health.39,46
ration. There is limited research they found gaps in the literature ronment variables. These coalitions may be better
on measures and methods to and research on sustainable • Identify factors and variables equipped to: (1) determine
quantify the health benefits of communities, and they found that mediate and moderate built what constitutes safe neighbor-
improved urban planning, in- that it focuses predominantly on environment health effects. hoods, (2) determine what con-
cluding an examination of land- the adverse health effects of the • Study methods and channels to stitutes safe and affordable
use policies that could support built environment, with very lit- translate research findings into housing, (3) provide green
sustainable and nonpolluting tle focus on the positive health policy and to the community-at- space for people to enjoy where
agricultural and industrial sys- impacts of sustainable communi- large that improve public health. they live and work, and (4) re-
1448 | Reviewing the Evidence | Peer Reviewed | Srinivasan et al. American Journal of Public Health | September 2003, Vol 93, No. 9

4.  REVIEWING THE EVIDENCE 
think the modes of transporta- An example is the “Southern Extramural Research, National Institute of 9. Weich S, Blanchard M, Prince M,
tion and travel from one place California Environmental Health Environmental Health Sciences, Research Burton E, Erens B, Sproston K. Mental
Triangle Park, NC. health and the built environment: cross-
to another. Project,”48 a collaborative effort Requests for reprints should be sent to sectional survey of individual and con-
Since 1993, the NIEHS has between Communities for a Bet- Shobha Srinivasan, PhD, Scientific Pro- textual risk factors for depression. Br J
supported a series of transla- ter Environment and the Univer- gram Administrator, National Institute of Psychiatry. 2002;180:428–433.
Environmental Health Sciences, 111 TW
tional research programs de- sity of Southern California Envi- 10. Health Canada, Division of Child-
Alexander Drive, P.O. Box 12233 (MD
hood and Adolescence. Natural and
signed to establish sustainable ronmental Health Center.49 Their EC-21), Research Triangle Park, NC
Built Environments. Ottawa: Health Can-
mechanisms for educating the partnership successfully provided 27709 (e-mail: sriniva2@niehs.nih.gov).
ada; 2002. Available at: http://www.
This article was accepted April 30,
public about environmental evidence to Los Angeles city hc-sc.gc.ca/dca-dea/publications/
2003.
healthy_dev_partb_5_e.html. Accessed
health issues and for supporting planners concerning adverse
August 8, 2003.
individual and community in- health effects of air pollution on Contributors 11. Olden K. The complex interaction
volvement in the identification children in low-income, largely All authors contributed equally in con-
of poverty, pollution, and health status.
ceptualizing this paper. S. Srinivasan was
and investigation of environmen- minority areas where oil refiner- primarily responsible for writing the ar-
The Scientist, February 16, 1998.
tal health concerns. The NIEHS ies were located. In so doing, the ticle. A. Dearry and L. R. O’Fallon 12. Healthy People 2010: Understanding
developed the translational re- partnership helped keep the oil helped with writing and reviewing the and Improving Health. Washington, DC:
article. US Dept of Health and Human Services;
search programs to foster part- refineries from reopening. 2001. Also available at: http://health.
nerships and alliances among The Northern Manhattan En- gov/healthypeople/document. Accessed
Acknowledgments
various relevant parties keen on vironmental Justice Partner- July 24, 2003.
The recommendations contained in this
understanding the effects and ship49 in New York is another article were the result of a meeting 13. Sharfstein J, Sandel M, Kahn R,
sponsored by National Institute of Envi- Bauchner H. Is child health at risk
risks to human health from ex- such project; it involves partner-
ronmental Health Sciences, Office of while families wait for housing vouch-
posure to physical and social en- ships between the West Harlem Rare Diseases and the Office of Behav- ers? Am J Public Health. 2001;91:
vironmental agents. Environmental Action and Co- ioral and Social Science Research, Na- 1191–1192.
tional Institutes of Health.
The NIEHS has defined lumbia University. The partner- 14. Thomson H, Petticrew M, Morrison
translational research as the ships have succeeded not only D. Health effects of housing improve-
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