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Summary Transdisciplinary research approaches are being applied to today’s complex health problems, including the climate crisis and widening inequalities. Diverse forms of disciplinary and experiential knowledge are required to understand these challenges and develop workable solutions. We aimed to create an updated model reflective of the strengths and challenges of current transdisciplinary health research that can be a guide for future studies. We searched Medline using terms related to transdisciplinary, health and research. We coded data deductively and inductively using thematic analysis to develop a preliminary model of transdisciplinary research. The model was tested and improved through: (i) a workshop with 27 participants at an international conference in Xiamen, China and (ii) online questionnaire feedback from included study authors. Our revised model recommends the following approach: (i) co-learning, an ongoing phase that recognizes the distributed nature of knowledge generation and learning across partners; (ii) (pre-)development, activities that occur before and during project initiation to establish a shared mission and ways of working; (iii) reflection and refinement to evaluate and improve processes and results, responding to emergent information and priorities as an ongoing phase; (iv) conceptualization to develop goals and the study approach by combining diverse knowledge; (v) investigation to conduct the research; (vi) implementation to use new knowledge to solve societal problems. The model includes linear and cyclical processes that may cycle back to project development. Our new model will support transdisciplinary research teams and their partners by detailing the necessary ingredients to conduct such research and achieve health impact.

There are increasing arguments for bridging diverse knowledges and co-producing new knowledge between researchers, professional communities and citizens to create health-promoting built environment...

Sustainable development is best supported by intersectoral policies informed by a range of evidence and knowledge types (e.g. scientific and lay). Given China’s rapid urbanisation, scale and global importance in climate mitigation, this study investigates how evidence is perceived and used to inform urban health and sustainability policies at central and local levels. Well-informed senior professionals in government/scientific agencies (12 in Beijing and 11 in Ningbo) were interviewed. A thematic analysis is presented using deductive and inductive coding. Government agency participants described formal remits and processes determining the scope and use of evidence by different tiers of government. Academic evidence was influential when commissioned by government departments. Public opinion and economic priorities were two factors that also influenced the use or weight of evidence in policymaking. This study shows that scientific evidence produced or commissioned by government was routinely used to inform urban health and sustainability policy. Extensive and routine data collection is regularly used to inform cyclical policy processes, which improves adaptive capacity. This study contributes to knowledge on the ‘cultures of evidence use’. Environmental governance can be further improved through increased data-sharing and use of diverse knowledge types. Policy relevance • Insights are provided into the ‘cultures of evidence use’ in urban sustainability and health governance in two Chinese cities, noting the complex interconnections between national policy agendas, the public and evidence. Policies are centrally led and informed by officially commissioned scientific evidence. • Environmental health data were used for monitoring policy implementation, and they were interpreted with careful consideration of public opinion and economic priorities. • There were opportunities for local priorities to shift the policy agenda, particularly when the public became aware of a specific environmental health threat. • Environmental governance could be strengthened in these settings through increased cross-sector data-sharing and integration of diverse knowledge types. • A strength of China’s approach is routine data collection that feeds a monitoring and policy cycle rarely achieved elsewhere. This cycle provides feedback to government departments, allows policy adjustment over time and can inform decisions during crises.

Background: Household overcrowding is associated with increased risk of infectious diseases across contexts and countries. Limited data exist linking household overcrowding and risk of COVID-19. We used data collected from the Virus Watch cohort to examine the association between overcrowded households and SARS-CoV-2. Methods: The Virus Watch study is a household community cohort of acute respiratory infections in England & Wales that began recruitment in June 2020. We calculated the persons per room for each household and classified accommodation as overcrowded when the number of rooms was fewer than the number of people. We considered two primary outcomes - PCR-confirmed positive SARS-CoV-2 antigen tests and laboratory confirmed SARS-CoV-2 antibodies (Roche Elecsys anti-N total immunoglobulin assay). We used mixed effects logistic regression models that accounted for household structure to estimate the association between household overcrowding and SARS-CoV-2 infection. Results: The proportion of participants with a positive SARS-CoV-2 PCR result was highest in the overcrowded group (6.6%; 73/1,102) and lowest in the under-occupied group (2.9%; 682/23,219). In a mixed effects logistic regression model that included age, sex, ethnicity, household income and geographical region, we found strong evidence of an increased odds of having a positive PCR SARS-CoV-2 antigen result (Odds Ratio 3.72; 95% CI: 1.92, 7.13; p-value < 0.001) and increased odds of having a positive SARS-CoV-2 antibody result in individuals living in overcrowded houses (2.96; 95% CI: 1.13, 7.74; p-value =0.027) compared to people living in under-occupied houses. The proportion of variation at the household level was 75.1% and 74.0% in the PCR and antibody models respectively. Discussion: Public health interventions to prevent and stop the spread of SARS-CoV-2 should consider the much greater risk of infection for people living in overcrowded households and pay greater attention to reducing household transmission. There is an urgent need to better recognise housing as a leading determinant of health in the context of a pandemic and beyond.

This article is included in Complex Urban Systems for Sustainability and Health: CUSSH collection. Data availability: No data are associated with this article. Copyright: © 2021 Davies M et al. This paper describes a global research programme on the complex systemic connections between urban development and health. Through transdisciplinary methods the Complex Urban Systems for Sustainability and Health (CUSSH) project will develop critical evidence on how to achieve the far-reaching transformation of cities needed to address vital environmental imperatives for planetary health in the 21st Century. CUSSH’s core components include: (i) a review of evidence on the effects of climate actions (both mitigation and adaptation) and factors influencing their implementation in urban settings; (ii) the development and application of methods for tracking the progress of cities towards sustainability and health goals; (iii) the development and application of models to assess the impact on population health, health inequalities, socio-economic development and environmental parameters of urban development strategies, in order to support policy decisions; (iv) iterative in-depth engagements with stakeholders in partner cities in low-, middle- and high-income settings, using systems-based participatory methods, to test and support the implementation of the transformative changes needed to meet local and global health and sustainability objectives; (v) a programme of public engagement and capacity building. Through these steps, the programme will provide transferable evidence on how to accelerate actions essential to achieving population-level health and global climate goals through, amongst others, changing cities’ energy provision, transport infrastructure, green infrastructure, air quality, waste management and housing.

The Complex Urban Systems for Sustainability and Health (CUSSH) project is a global research programme on the complex systemic connections between urban development and health. Through transdisciplinary methods it will develop critical evidence on how to achieve the far-reaching transformation of cities needed to address vital environmental imperatives for planetary health in the 21st century. CUSSH’s core components include: (i) a review of evidence on the effects of climate actions (both mitigation and adaptation) and factors influencing their implementation in urban settings; (ii) the development and application of methods for tracking the progress of cities towards sustainability and health goals; (iii) the development and application of models to assess the impact on population health, health inequalities, socio-economic development and environmental parameters of urban development strategies, in order to support policy decisions; (iv) iterative in-depth engagements with stakeholders in partner cities in low-, middle- and high-income settings, using systems-based participatory methods, to test and support the implementation of the transformative changes needed to meet local and global health and sustainability objectives; (v) a programme of public engagement and capacity building. Through these steps, the programme will provide transferable evidence on how to accelerate actions essential to achieving population-level health and global climate goals through, amongst others, changing cities’ energy provision, transport infrastructure, green infrastructure, air quality, waste management and housing.

Anthropogenic environmental change will heavily impact cities, yet associated health risks will depend significantly on decisions made by urban leaders across a wide range of non-health sectors, including transport, energy, housing, basic urban services, and others. A subset of planetary health researchers focus on understanding the urban health impacts of global environmental change, and how these vary globally and within cities. Such researchers increasingly adopt collaborative transdisciplinary approaches to engage policy-makers, private citizens, and other actors in identifying and evaluating potential policy solutions that will reduce environmental impacts in ways that simultaneously promote health, equity, and/or local economies-in other words, maximising 'co-benefits'. This report presents observations from a participatory workshop focused on challenges and opportunities for urban planetary health research. The workshop, held at the 16th International Conference on Urban Health (ICUH) in Xiamen, China, in November 2019, brought together 49 participants and covered topics related to collaboration, data, and research impact. It featured research projects funded by the Wellcome Trust's Our Planet Our Health (OPOH) programme. This report aims to concisely summarise and disseminate participants' collective contributions to current methodological practice in urban planetary health research.

Public health practitioners produce urban health indicator (UHI) tools to inform built environment policy and decision-making, among other objectives. Indicator producers perceive UHI tools as an easily understandable form of evidence about the urban environment impact on health for policy-makers’ consumption. However, indicator producers often conceptualise policy-making as a rational and linear process, therefore underestimating the complex and contested nature of developing and implementing policy. This study investigates the health-promotion value of UHI tools in the complex urban planning policy and decision-making context. A thematic analysis was conducted following semi-structured interviews with 22 indicator producers and users in San Francisco, Melbourne and Sydney. The analysis was informed by collaborative rationality and systems theories and the results were used to develop causal loop diagrams (CLDs) of producers and users’ mental models. The preliminary CLDs were tested and improved through a participatory modelling workshop (six participants). A high-level CLD depicts users and producers’ shared mental model in which indicator development and use are embedded in policy development and application processes. In the cases analysed, creating and using UHI tools increased inter-sectoral relationships, which supported actors to better understand each other’s opportunities and constraints. These relationships spurred new advocates for health in diverse organisations, supporting health-in-all-policies and whole-of-society approaches. Constraints to health-promoting policy and implementation (such as those which are legal, political and economic in nature), were overcome through community involvement in UHI tools and advocacy effectiveness. A number of factors reduced the perceived relevance and authority of UHI tools, including: a high number of available indicators, lack of neighbourhood scale data and poor-quality data. In summary, UHI tools were a form of evidence that influenced local urban planning policy and decision-making when they were embedded in policy processes, networks and institutions. In contrast to the dominant policy impact model in the indicator literature, such evidence did not typically influence policy as an exogenous entity. Indicators had impact when they were embedded in local institutions and well-resourced over time, resulting in trusted relationships and collaborations among indicator producers and users. Further research is needed to explore other governance contexts and how UHI tools affect the power of different actors, particularly for under-represented communities.

Urban health indicator (UHI) tools provide evidence about the health impacts of the physical urban environment which can be used in built environment policy and decision-making. Where UHI tools provide data at the neighborhood (and lower) scale they can provide valuable information about health inequalities and environmental deprivation. This review performs a census of UHI tools and explores their nature and characteristics (including how they represent, simplify or address complex systems) to increase understanding of their potential use by municipal built environment policy and decision-makers. We searched seven bibliographic databases, four key journals and six practitioner websites and conducted Google searches between January 27, 2016 and February 24, 2016 for UHI tools. We extracted data from primary studies and online indicator systems. We included 198 documents which identified 145 UHI tools comprising 8006 indicators, from which we developed a taxonomy. Our taxonomy classifies the significant diversity of UHI tools with respect to topic, spatial scale, format, scope and purpose. The proportions of UHI tools which measure data at the neighborhood and lower scale, and present data via interactive maps, have both increased over time. This is particularly relevant to built environment policy and decision-makers, reflects growing analytical capability and offers the potential for improved understanding of the complexity of influences on urban health (an aspect noted as a particular challenge by some indicator producers). The relation between urban health indicators and health impacts attributable to modifiable environmental characteristics is often indirect. Furthermore, the use of UHI tools in policy and decision-making appears to be limited, thus raising questions about the continued development of such tools by multiple organisations duplicating scarce resources. Further research is needed to understand the requirements of built environment policy and decision-makers, public health professionals and local communities regarding the form and presentation of indicators which support their varied objectives. Electronic supplementary material The online version of this article (10.1007/s11524-018-0228-8) contains supplementary material, which is available to authorized users.

Global initiatives have raised awareness of the need for cross-departmental and cross-sectoral activities to support urban health, sustainability, and equity, with respective indicators routinely used as a way to catalyze and monitor action toward pre-defined goals. Despite the existence of at least 145 urban health indicator (UHI) tools globally, there has been very little research on the use of indicators by policy- and decision-makers; more attention has been devoted to their development and validation. This paper describes the second part of a two-part systematic review of the characteristics (part A) and use (part B, this part) of UHI tools by municipal built environment policy- and decision-makers. Part B is a narrative synthesis of studies on the use of UHI tools. This PRISMA-P compliant review follows a mixed methods sequential explanatory design. The search was conducted using seven bibliographic databases, grey literature searches, and key journal hand searches. Ten studies describing the use of ten UHI tools in seven countries were included in the narrative synthesis, resulting in development of a theory of change (ToC). We found that both expert-led and participatory indicator projects can be underpinned by research evidence and residents’ knowledge. Our findings contradict the dominant view of indicator use in policy-making as a linear process, highlighting a number of technical, organizational, political, knowledge, and contextual factors that affect their use. Participatory UHI tools with community involvement were generally more effective at supporting “health in all policies” and “whole-of-society” approaches to governing healthy cities than expert-led processes. UHI tool producers proposed a range of techniques to address urban health complexity characteristics. Finally, in combining data from both parts of the review, we found that potentially important UHI tool features, such as neighbourhood-scale data, were influential in the use of indicators by built environment policy- and decision-makers. Electronic supplementary material The online version of this article (10.1007/s11524-019-00378-w) contains supplementary material, which is available to authorized users.

A growing number of international standards promote Healthy Built Environment (HBE) principles which aim to enhance occupant and user health and wellbeing. Few studies examine the implementation of these standards; whether and how they affect health through changes to built-environment design, construction, and operations. This study reviews a set of sustainability and HBE standards, based on a qualitative analysis of standard documents, standard and socio-technical literature on normalization and negotiation, and interviews with 31 practitioners from four geographical regions. The analysis indicates that standards can impact individual, organizational, and market-scale definitions of an HBE. Some changes to practice are identified, such as procurement and internal layout decisions. There is more limited evidence of changes to dominant, short-term decision-making practices related to cost control and user engagement in operational decisions. HBE standards risk establishing narrow definitions of health and wellbeing focused on building occupants rather than promoting broader, contextually situated, principles of equity, inclusion, and ecosystem functioning crucial for health. There is a need to improve sustainability and HBE standards to take better account of local contexts and promote systems thinking. Further examination of dominant collective negotiation processes is required to identify opportunities to better embed standards within organizational practice.

Gemma McKinnon and colleagues argue that multidisciplinary action in planning and health will contribute to more equitable communities and improved health and wellbeing

Background At least 145 urban health indicator (UHI) tools exist internationally. Previous studies have shown that public health researchers and practitioners produce them to inform built environment policy and decision making. Little research exists on their use and how it affects policy. This study used qualitative system dynamics to investigate the benefit and use of UHI tools to promote health in the complex context of urban planning policy and decision making. Methods This qualitative system dynamics study involved semistructured interviews with indicator producers (typically public health professionals) and indicator users (typically urban planners) in case study settings of San Francisco (CA, USA), Melbourne (VIC, Australia), and Sydney (NSW, Australia) to ascertain experts’ understandings (or mental models) of the use (ie, direct reporting of) and value (ie, knowledge gained leading to policy changes) of UHI tools in urban planning policy and decision making. Exemplifying cases of UHI tools (ie, those designed with characteristics to support policy makers) were selected from the literature and we used purposive sampling to approach potential interview participants through departmental websites and the professional network of HP. We did a thematic analysis using collaborative rationality and systems theories. We constructed causal loop diagrams (CLDs) using system dynamics methods (CLDs represented participants’ mental models). We tested whether our preliminary CLDs corresponded to experts’ views through a participatory workshop. Findings Interviews took place on April 5–7, 2016, with six participants in the USA, and March 13–22, 2018, with 16 participants in Australia, and the workshop was on Jan 16, 2019, with six participants in the USA. Indicator users and producers had overlapping mental models of the value and use of UHI tools, and workshop participants broadly agreed with the CLDs. The thematic analysis produced five themes that were represented in CLDs, summarised as follows. Developing and applying UHI tools increases knowledge of the social determinants of health and intersectoral relationships. This supports actors to better understand each other's perspectives and helps create new advocates for health in diverse organisations, supporting health-in-all-policies or whole-of-society approaches. Community involvement in UHI tools and having effective advocates for health reduces obstacles to health-promoting policy. However, the high number of available indicators can create confusion and reduce indicator use. Interpretation UHI tools influence local urban planning when they are embedded in policy processes, networks, and institutions, which often requires long-term funding. Indicator producers should consider such resource requirements and the potential for co-producing indicators to create intersectoral relationships and better respond to users’ information needs. Further research is needed to explore how UHI tools affect the power of different actors in governance processes, particularly of under-represented communities. Funding The Building Research Establishment (BRE) and BRE Trust.

Background Urban health indicator (UHI) tools offer one form of evidence about the urban environment's impact on health to inform built environment policy and decision making, particularly in relation to health and spatial inequalities. Many UHI tools have been developed, potentially duplicating scarce resources, with little knowledge of their subsequent impact on policy. This study aimed to examine the nature and characteristics of UHI tools to increase understanding of their potential use by municipal built environment policy and decision-makers. Methods The methods of this systematic review are detailed in our published protocol, including a PRISMA-P checklist. We defined UHI tools as compilations of UHIs that needed to measure at least two physical urban environment characteristics. We searched seven bibliographic databases, four key journals, and six practitioner websites, and conducted Google searches between Jan 27, 2016, and Feb 24, 2016, for UHI tools. We extracted data from primary studies and online indicator systems. Findings We included 198 documents, which identified 145 UHI tools comprising 8006 indicators, from which we developed a taxonomy of indicators (using a hybrid inductive and deductive approach). The diversity in UHI tools was extensive with respect to topic, spatial scale, format, scope, and purpose, which we identified as key taxonomic classifiers. Over time, the proportion of UHI tools that measured data at the neighbourhood and lower scale increased, as did the proportion of tools that presented data via interactive maps. This increase reflected growing analytical capability, and offered the potential for improved understanding of the complexity of influences on urban health (an aspect noted as being especially challenging by some indicator producers). Interpretation UHI tools of increasing sophistication provide insights into multiple dimensions of the urban environment and their impacts on health, but they are not always used in the policy and decision-making process. In addition, many indicators have only an indirect association with health impacts attributable to modifiable urban environment characteristics. Further research is needed to understand the form and presentation of indicators that are of greatest utility to built environment policy development, and that reflect community input and health and development priorities. Funding HP is fully funded by the Building Research Establishment Ltd. HR was supported by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care North Thames at Barts Health NHS Trust.