Integrating health into the complex urban planning policy and decision-making context: a systems thinking analysis.

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. [ABSTRACT FROM AUTHOR]