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Last month saw the publication of Dr Theresa Tam’s first report as Canada’s Chief Public Health Officer. Here UD/MH Associate Sarah Willson discusses the report’s key messages on mental health and cities. Approaching public health through the lens of environmental design is not a novel concept, with the two fields holding a long and intertwined history. In 1854, British physician John Snow investigated the spread of cholera in Soho, London, and observed the connection between facets of urban design – residential density, the location of water pumps and sewage systems – and the incidence of ill-health among the local population. Since that landmark study and throughout the enmeshed history of urban planning and public health, mental health has been included on the agenda of public health. However, mental health has typically been addressed primarily through the promotion of public parks as sites of social interaction and escape. As understanding about the interactions between mental health and urban form deepens, this has begun to seep into government thinking. The ‘Designing Healthy Living’ report from Canada demonstrates this, illuminating the ways in which the built environment acts as a foundation for physical health and mental wellbeing. The report gathers together a wealth of research from the medical sciences and urban design disciplines. Within it, the built environment is defined as all the infrastructure we experience, both seen and unseen, in daily life – our homes, streets, workplaces, parks, public spaces and transport systems. Healthy living is addressed in three parts – physical activity, food choices and mental wellbeing, yet crucially the report acknowledges the interconnection of these three. Moreover, recognition is given to the fact that there are other factors which influence physical and mental health – economic inequality, political contexts, social & cultural factors, which lie outside the purview of urban design to address. The Canadian context Today, approximately 80% of Canadians reside in urban or suburban areas. Like many North American cities, Canadian urban spaces throughout the 20th century mostly expanded through the process of urban sprawl. This development of cities outwards to create low density residential housing, and single use zoning has resulted in migration to the suburbs and daily flocking to city centres in private automobiles. A strong message against continued urban sprawl is felt throughout the report. The expanding spatial footprint of cities has been linked to increased dependence on private car ownership, sedentary lifestyles and rising levels of obesity. Sedentary lifestyles are of concern to Canadian officials due to the link with chronic diseases such as diabetes and cardiovascular disease. Dr Tam calls for long-term planning that promotes daily incidental physical activity to change sedentary habits. In addition, Canada is experiencing an ageing population, with the number of Canadians over the age of 85 years growing at four times the rate of the Canadian population (Statistics Canada 2017). Mental health is also on the agenda for Canadian public officials, with an increase to 8% percentage of the population diagnosed with a mood disorder in 2014. Key messages on mental health from the Designing Healthy Living report This report views public health as a confluence of three factors: enough physical activity, maintaining healthy diets and living in supportive, sociable environments. It is this last factor in which this report primarily addresses mental health. The report explicitly outlines the ways in which neighbourhoods can be designed with mental health in mind:  The three ways in which urban design contributes to public health. Image source: Designing Healthy Living report. Social isolation and loneliness can result in stress, poor sleep, cognitive decline, impaired decision making and increased risk of depression among other effects (Cacioppo 2015). Neighbourhoods can be better designed to increase the likelihood of meeting other people and to provide places to gather. Designing green spaces, of whatever size, into our urban environments are discussed as a key tool for this. Green spaces offer opportunities for local people to walk for leisure and see others around, take part in outdoor sports, often in groups, and meet others through local conservation or gardening projects. Community belonging is important for mental wellbeing, with Canadians who feel strong ties to their local community more likely to report excellent or very good physical and mental health (Shields 2008). Regarding encouraging a sense of belonging through design, aesthetic places and sites of social interaction are sought after. Creating attractive urban spaces not only raises the aesthetic profile of an area, but has been shown to have a calming effect, reflect local culture and can build social connections. Community gardens, allotments, public art, and platforms for political engagement can encourage and enable people to become involved in their local communities and enhance ties to local areas (Cameron et al. 2013).  How urban design influences experiences of social support, stress and community belonging. Image source: Designing Healthy Living report. Urban spaces and transport systems offer up a lot of sensory stimuli with noise from cars and public transport, construction work, crowded pavements and metro systems, streetlights and noise from neighbours. For some, the excitement of the urban environment can be outweighed by the stress experienced managing sensory stimulation, inducing and heightening stress levels. Chronic stress has an extensive array of health impacts, from heart disease to anxiety and depression (Broschot et al. 2006). Therefore, the report proposes that designing quieter places that manage unwanted stimuli is an important goal for urban designers to counter chronic stress. Commuting to and from work, school and social engagements is part of daily life for many Canadians, and another potential source for chronic stress. Over the long term, lengthy or stressful commutes are linked to poor health. Therefore, improving commuter experience, through for example improving the efficiency of public transport systems and encouraging more people to use them or walk and cycle, can be another long-term plan to manage chronic stress for urban populations. Feeling safe where you live, work and visit within a city is important aspect of mental health, as fear and direct experience of crime can negatively affect mental wellbeing and behaviour. Urban dwellers, particularly those who perceive themselves as at greater risk of crime, such as women and ethnic minority groups, have been found to actively change their behaviour within urban space as a result, such as avoiding certain places, or restricting movement to certain times of day. Crime Prevention through Environmental Design, a UN-supported program, is promoted in the report as a method to broach this issue. It promotes clear demarcation of private and public space, improved surveillance, good street lighting and reducing underused spaces. (Cozens and Love 2015). Many of the design suggestions in the report are geared towards multiple mental wellbeing goals. The promotion of community gardens illustrates this well, offering quiet urban green space, places to socialise, and encouraging community belonging. Such an intervention also supports wider public health goals of increasing physical activity and access to healthy foods.  Davie Street Community Garden, Vancouver BC. Photograph by Geoff Peters Designing for specific populations Much of current research is based on adult populations, but the report takes steps to address how specific population groups experience the built environment, and how this in turn can be linked to mental health. For children, playing outdoors and safety fears of parents are important issues for good public health. Living near green spaces can instill regular physical activity in children from a young age. Green spaces are also found to positively affect behavioural development in children: Canadian children who spend more time outdoors have been found to have better mental wellness and fewer friendship issues. Highlighted in the report is the need for challenging play for children’s mental development, where children are encouraged to assess their environment and make decisions, enabling them to develop their abilities in managing risk and judgment (Brussoni et al. 2012). Given Canada’s aging population, issues around social isolation and loneliness are going to become increasingly important in decades to come. Those most at risk are identified as residents who are unmarried, have physical health problems, and are in lower-income groups. Designing for social environments and community belonging in younger years may be a way to buffer against older age social isolation. Ensuring neighbourhoods are walkable and well connected is another important design intervention, with safe, even pavements found to encourage walking and being more social into older age (Richard et al. 2013). Conclusion- connection to Mind the GAPS Overall, this is an encouraging report which places mental health firmly on the Canadian city design agenda. Connections can be made to the New Urban Agenda with the promotion of public green space, safe public spaces and community engagement. Although a Canada specific report, the design suggestions featured will strike a chord with many urban design and public health workers who find themselves working to stem the tide of urban sprawl and its effects. Many of the design features as are also seen in our Mind the GAPS Framework:
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