著：（美）安·福賽斯 譯：劉康 劉欣宜 校：陳崇賢

1 健康場所：回顧與展望

如何營造一個健康場所？大多數(shù)城市規(guī)劃設(shè)計，從自行車友好城市到綠地空間可達(dá)性，都關(guān)注建成環(huán)境如何影響健康。但是，長期致力于從事該研究領(lǐng)域的人意識到，僅靠建造一個物理空間是無法營造真正的健康場所的；事實(shí)上，規(guī)劃師和設(shè)計師在城鄉(xiāng)地區(qū)還需要解決評估、設(shè)計、建造、使用、運(yùn)營、管控、策劃以及更新等一系列問題[1-2]（圖1～4）。這種綜合的工作方式把營造的過程與場所融合，不僅是建造一個包含促進(jìn)健康作用要素的場所，而且更全面地回應(yīng)了“應(yīng)該建造什么”“如何建造”，以及“為誰建造”的問題。在這種方式下，場所不再是一個靜態(tài)的環(huán)境，而是一種隨著時間的推移、根據(jù)不同的用途和使用者而發(fā)展的存在[3]。

圖1 公園為人們提供了可以進(jìn)行體育活動的場所，而其綠色空間可以提升人們的心理健康（中國北京）Parks provide settings where people can choose to undertake physical activity and as green areas can enhance mental well-being (Beijing, China)

圖2 健康場所提供了各種實(shí)現(xiàn)健康生活的基礎(chǔ)，但有時也會帶來安全與污染問題（中國北海）Healthy places provide options for gaining access to the resources needed for a healthy life but some options can also can pose problems in terms of safety and pollution(Beihai, China)

圖3 健康場所既關(guān)于如何使用空間，也關(guān)于如何設(shè)計空間。圖中，人們在人行道上跳舞（墨西哥瓦哈卡）Healthy places are as much about how spaces are used as how they are designed.In this image people dance in a pedestrianized street (Oaxaca, Mexico)

圖4 營造健康場所的相關(guān)策略，與實(shí)現(xiàn)可持續(xù)發(fā)展和提高生活質(zhì)量目標(biāo)所需要的策略類似。斯德哥爾摩的哈馬碧濱水新城是一個城市更新項(xiàng)目，旨在減少其生態(tài)足跡，但同時它有許多促進(jìn)健康的要素，如網(wǎng)絡(luò)化的道路系統(tǒng)以及方便到達(dá)的藍(lán)綠空間（瑞士哈馬碧濱水新城）Many strategies for creating healthy places are similar to those achieving other aims such as sustainability or quality of life.Hammarby Sj?stad in Stokholm is an urban redevelopment designed to minimize its ecological footprint but it has many health promoting features such as networked path systems and access to water and green space (Hammarby Sj?stad, Sweden)

在2017年出版的《營造健康社區(qū)：基于循證的規(guī)劃設(shè)計策略》（Creating Healthy Neighborhoods: Evidence-Based Planning and Design Strategies，簡稱《營造健康社區(qū)》）中，探討了關(guān)注場所的物理環(huán)境的同時也應(yīng)重視營造更健康場所的過程性。該書是由我與埃米莉·薩洛蒙（Emily Salomon）、勞拉·斯米德（Laura Smead）二位合著的，綜合了各個領(lǐng)域的研究，是一本城市規(guī)劃與設(shè)計領(lǐng)域的實(shí)踐手冊[4]。該書主要針對中高收入國家的居住區(qū)環(huán)境，也受到了當(dāng)下為老齡化社會創(chuàng)造更健康環(huán)境的挑戰(zhàn)的啟發(fā)，旨在彌補(bǔ)研究與實(shí)踐之間的鴻溝。書中提出8項(xiàng)普遍性原則與20項(xiàng)針對性建議，并列舉了83項(xiàng)具體措施。其中5項(xiàng)原則關(guān)注環(huán)境：有利健康的空間布局、可達(dá)性方式的選擇、支持積極的社會關(guān)系、防止危害與污染物的措施、滿足最弱勢群體基本需求的規(guī)劃（包括住房條件、食物來源與交通等）。另外3項(xiàng)原則考慮了營造場所的過程及居住與使用的人群，包括在特定情景下評估健康的重要性：關(guān)鍵的健康問題與相關(guān)利益者、物理干預(yù)與其他健康促進(jìn)措施之間的權(quán)衡、持續(xù)動態(tài)化的措施。

在《營造健康社區(qū)》出版幾年后，經(jīng)歷了新冠肺炎疫情，我又重新回顧了這項(xiàng)工作，以此思考基于循證方法營造健康場所的潛在可能性與局限性。這篇文章是實(shí)踐反思的一個例子，審視先前的工作以理解循證實(shí)踐是如何產(chǎn)生的，是否經(jīng)得起自我檢驗(yàn)，以及它對未來營造更健康的社區(qū)意味著什么。完善的循證實(shí)踐可以產(chǎn)生諸多效益，但由于它需要建立長時間的多方協(xié)作，所以難以實(shí)現(xiàn)。

2 如何產(chǎn)生：《營造健康社區(qū)》的形成過程

《營造健康社區(qū)》不是一蹴而就的，它整合了幾十年來有關(guān)健康與場所的研究工作，試圖讓它變得更具實(shí)用性。其中包括先前的研究簡報與健康影響評估工具的開發(fā)，開展健康和創(chuàng)新社區(qū)的原創(chuàng)性研究，以及對循證實(shí)踐優(yōu)勢與局限的探究。我與合著者曾作為規(guī)劃師的實(shí)踐經(jīng)驗(yàn)也為這項(xiàng)工作提供了重要的基礎(chǔ)。

2.1 證據(jù)權(quán)衡的整合

該書直接借鑒了已有的健康研究結(jié)果，基于實(shí)用性視角進(jìn)行了2次整合梳理。在這些研究報道中篩選了許多獨(dú)立研究與綜述的文章，確定了證據(jù)權(quán)衡支持的關(guān)鍵發(fā)現(xiàn)以及有待探究的問題，同時，還考慮了與弱勢群體相關(guān)的內(nèi)容，以便為設(shè)計實(shí)踐提供參考[5]。受到其他領(lǐng)域類似項(xiàng)目的啟發(fā)，我們做了大量整合多項(xiàng)研究的工作。這項(xiàng)工作意味著規(guī)劃師與設(shè)計師可以利用一個研究領(lǐng)域中所有證據(jù)發(fā)現(xiàn)綜合的結(jié)果，而不是依賴于一兩個高度公開但無法反映更大范圍結(jié)果發(fā)現(xiàn)的研究。該整合工作的第一階段成果——健康設(shè)計（design for health, DFH）規(guī)劃信息表，是來自我在2005年左右在明尼蘇達(dá)大學(xué)負(fù)責(zé)的第一個項(xiàng)目；而第二階段成果——“怡城”（Health and Places Initiative, HAPI）項(xiàng)目研究簡報，是2015年左右在哈佛大學(xué)負(fù)責(zé)項(xiàng)目的一部分成果，該項(xiàng)目主要關(guān)注中國地區(qū)人口老齡化問題[5]。

盡管每個研究領(lǐng)域探究的具體問題有所不同，但我們的整合研究工作基本聚焦在幾個方面：即使人們暴露在有噪聲或低空氣質(zhì)量等有害因素中，也能免受其害的環(huán)境；讓人們能夠獲得社區(qū)服務(wù)或社會互動等健康生活基本需求的環(huán)境；支持健康飲食和體力活動等健康行為的環(huán)境。由于研究結(jié)果參差不齊，一些問題的相關(guān)研究較為豐富，而另一些則相對缺乏，這增加了整合研究結(jié)果的復(fù)雜性。但最終這些對多項(xiàng)研究結(jié)果的總結(jié)構(gòu)成了《營造健康社區(qū)》的主體內(nèi)容。

人們也許會問既然已有許多作者在盡心撰寫文獻(xiàn)綜述，為什么還需要這些總結(jié)？盡管類似的綜述十分有必要，但它們涉及的內(nèi)容范圍較為局限。在實(shí)踐中，設(shè)計師需要站在更高的角度以應(yīng)對更廣泛的問題，同時還需要考慮哪些是真正適合規(guī)劃和設(shè)計的干預(yù)措施。

《營造健康社區(qū)》中提及的策略也體現(xiàn)了我們在相同的項(xiàng)目中進(jìn)行2次健康影響評估工作的經(jīng)驗(yàn)總結(jié)，相關(guān)工作包括了制定清單、舉辦研討會以及基于地理信息系統(tǒng)（geographic information system, GIS）的 大尺度場地處理[6-8]。這些工作強(qiáng)調(diào)了找出健康相關(guān)問題的過程，讓當(dāng)?shù)鼐用駞⑴c并理解具體問題，評估方案、策劃和現(xiàn)有場所的健康效益。雖然這些工作內(nèi)容的設(shè)定是為了評估設(shè)計與開發(fā)提案，但也能用于評估現(xiàn)有的場所，這種回顧性健康影響評估（health impact assessment, HIA）的形式，也可稱為健康評估（health assessment）。

在開發(fā)這些評估工具的10多年時間里，我擔(dān)心這種措施清單的模式在某種程度上過度簡化了研究內(nèi)容。然而，從業(yè)者十分感謝能通過一種簡單的方法評估他們所做的工作，尤其是針對城市規(guī)劃和設(shè)計領(lǐng)域。在歷代工具中，我更傾向于快速健康影響評估（the rapid HIA）。通過精心設(shè)計的研討會形式，讓來自不同領(lǐng)域及不同知識背景的參與者都可以對提案和現(xiàn)有的證據(jù)（如研究、項(xiàng)目調(diào)查及地方知識等）提出反饋。《營造健康社區(qū)》既借鑒了以清單為導(dǎo)向的評估要素，也參考了研討會形式背后的想法，即把不同的群體和不同形式的知識聚集在一起。

2.2 關(guān)于健康場所和社區(qū)規(guī)劃的研究

我開始創(chuàng)建這類研究整合和健康評估工具的部分原因是希望健康與場所的研究更容易在實(shí)踐中應(yīng)用，但這是一項(xiàng)棘手的工作。在健康研究領(lǐng)域，規(guī)模龐大的團(tuán)隊(duì)通常將一個問題拆分為許多相互聯(lián)系且小而細(xì)的問題進(jìn)行研究。這就意味著每個研究人員都只了解一個相對細(xì)小的問題，但在實(shí)踐中，各類問題和不同的環(huán)境因素都有可能是重要的。此外，需要篩選大量研究來找出細(xì)微但重要的差異，關(guān)于“密度”（density）的討論就是其中一個例子。密度差異會帶來不同的效應(yīng)，取決于具體的健康問題、場地及人群，這在關(guān)于緊湊型和分散型城市的爭論中有所體現(xiàn)[9]。同樣地，混合用地并不是對所有人群與健康問題都有益，一個高密度混合使用區(qū)，對身體健康的成年人來說有助于他們進(jìn)行體力活動與獲取相關(guān)資源，但對于患有哮喘的老年人卻是具有挑戰(zhàn)性的。

關(guān)于體力活動和飲食環(huán)境的研究，讓我站在了專業(yè)的角度看待健康研究的動機(jī)和實(shí)踐。過往的工作使我明白外部環(huán)境、體力活動以及健康飲食之間的聯(lián)系比最初預(yù)想的要復(fù)雜，這種復(fù)雜聯(lián)系的呈現(xiàn)通?？梢娪谘芯课恼轮?，而非媒體報道中。我意識到當(dāng)證據(jù)的權(quán)衡起到關(guān)鍵作用的時候，去推廣一項(xiàng)研究的內(nèi)容在某些方面會有很大壓力。

我的第二個研究領(lǐng)域是包括新城鎮(zhèn)在內(nèi)的創(chuàng)新型社區(qū)規(guī)劃，這也是該書框架的核心。我對健康的興趣源自可持續(xù)性設(shè)計，為此寫了一系列有關(guān)全球各地社區(qū)規(guī)劃調(diào)查的書和文章[10-12]，這些基于案例研究的項(xiàng)目讓我深刻認(rèn)識到采取創(chuàng)新方法來營造城市空間的必要性[13]。我對如何營造更好的場所以及創(chuàng)造什么樣的空間的興趣，促成了《營造健康社區(qū)》這本書。

2.3 循證實(shí)踐

最后探討的是循證實(shí)踐（evidence-based practice, EBP）最大的問題——即它如何以及是否能真正改善規(guī)劃和設(shè)計的結(jié)果[14]，這是一個長期存在的問題。目前循證實(shí)踐的實(shí)施也面臨諸多挑戰(zhàn)，包括：從業(yè)者通常依靠自己所受的設(shè)計訓(xùn)練和實(shí)踐經(jīng)驗(yàn)做出決定，而不依賴于研究性知識，因而循證實(shí)踐對他們來說沒有吸引力；一個具有穩(wěn)定扎實(shí)的研究領(lǐng)域可能與規(guī)劃設(shè)計關(guān)聯(lián)較少，這使得循證實(shí)踐缺少實(shí)用性；針對一類地區(qū)或一個時間段的研究結(jié)果難以具有普適性；另外，一些研究由于缺少研究結(jié)果而無法發(fā)表，從而導(dǎo)致研究的不均衡[15]等。

但是，我在《營造健康社區(qū)》中闡述了我的觀點(diǎn)，即循證實(shí)踐是具有可操作性的，該書的確解決了它的局限性。該書以過程為導(dǎo)向，讓使用者能夠根據(jù)不同的情況來運(yùn)用健康知識。同時，我們也闡明了現(xiàn)有證據(jù)的優(yōu)勢所在，以免夸大其結(jié)論確定性的程度。例如，書中提出的83項(xiàng)措施根據(jù)證據(jù)確定性程度分類，即直接由研究證據(jù)獲得、大體上由此類證據(jù)獲得，以及可能有助于改善健康且至少不會損害健康的實(shí)踐。我們還嘗試解決在缺乏證據(jù)的情況下如何做出決策的問題，并區(qū)分一些普遍的健康結(jié)果和行為。例如，對污染物的身體反應(yīng)，個人、社會或文化方面的健康問題的比較[4]4-7。雖然物理場所對健康很重要，但并不是唯一決定因素，而這也是該書的關(guān)鍵主題。

另一個問題與創(chuàng)造力和專業(yè)判斷力相關(guān)。雖然一些從業(yè)者認(rèn)為在研究現(xiàn)狀和人與場地的各種問題時，循證實(shí)踐會幫助他們更確切地知道怎么做規(guī)劃，而另一些人則認(rèn)為這會削弱他們的創(chuàng)造力。該書和來自同一項(xiàng)目的配套書，尤其是戴維·瑪（David Mah）和阿塞西歐·維羅利亞（Ascencio Villoria）[16]的《生活方式：健康生活與場所》（Life-Styled: Health and Places），試圖改變大家對循證實(shí)踐抑制創(chuàng)造力的看法，提出健康證據(jù)概念化可以激發(fā)想象力的觀點(diǎn)[4,12]。在我較早的一本書里，我將公園設(shè)計中社會與生態(tài)問題之間的權(quán)衡，看作是不同類型的設(shè)計靈感來源，最終的規(guī)劃設(shè)計取決于優(yōu)先考慮什么。盡管項(xiàng)目中健康目標(biāo)不同，但可以產(chǎn)生相同的效益[17]。

3 后疫情時代

營造一個健康的場所到底需要什么？《營造健康社區(qū)》寫于疫情時代之前，雖然明確地指出潔凈的空氣和水的重要性，但更強(qiáng)調(diào)了建成環(huán)境如何影響像肥胖、癌癥這類非傳染性和慢性疾病?？偟膩碚f，該書比我想象中更能經(jīng)受住時間的考驗(yàn)，這在一定程度上得益于這些策略涉及的是較為開放的社區(qū)，而不是封閉的工作場所或室內(nèi)空間。

在后疫情時代，人們對社區(qū)空間的使用發(fā)生了許多微妙的變化[18]。在文獻(xiàn)研究中，戶外空間一直是進(jìn)行體力活動、社會互動、精神恢復(fù)等活動的重要場地，但由于疫情時代下室內(nèi)更易感染，戶外空間變得尤為重要。遠(yuǎn)程辦公的興起讓居住區(qū)成為日常生活的主要場所，這恰恰強(qiáng)調(diào)了該書中對居住和混合用途社區(qū)的關(guān)注。這場疫情給予我們的教訓(xùn)是有所準(zhǔn)備十分必要，就像早先抗擊過重癥急性呼吸綜合征（SARS）的國家在面對新冠肺炎疫情時會先取得初步進(jìn)展[18]。盡管近年來這種觀點(diǎn)流傳十分廣泛，但這不是新的見解。

該書一個更細(xì)分的主題是人口老齡化的規(guī)劃設(shè)計，這也是一個全球都關(guān)注的問題。在人口增長和氣候變化等外部因素共同作用下，老齡化問題愈發(fā)突出[19-20]，新冠肺炎疫情也讓我們清晰地看到這類人群的脆弱性。當(dāng)然，社區(qū)并不是老年人唯一關(guān)鍵的環(huán)境因素——家庭情況、住宅條件及文化要素也扮演重要的角色[21]。我從新冠肺炎疫情中認(rèn)識到，將老年人視為更廣泛社區(qū)潛在資源的必要性，創(chuàng)造能讓他們充滿活力的環(huán)境將有益于整個社會，這也是該書的一個細(xì)小但重要的主題。

在后疫情時代，最后一個需要明確的是創(chuàng)造健康環(huán)境過程中合作和治理的問題。正如我在其他地方所提到的，新冠肺炎疫情刺激了公眾與政府采取緊急措施，如隔離政策、保障必要的醫(yī)務(wù)和后勤工作人員，以便應(yīng)對疫情及產(chǎn)生的后果[18]。我在新冠肺炎疫情暴發(fā)前完成的一篇關(guān)于不同健康場所營造的文章中，探討了大眾和專業(yè)討論中常見的幾種形式。這其中包括最基本的途徑，即與其他機(jī)構(gòu)，如與世界衛(wèi)生組織的健康城市項(xiàng)目（WHO Healthy Cities program）[22]合作進(jìn)行健康建成環(huán)境研究，涉及的議題包含老幼友好社區(qū)規(guī)劃以及在健康城市中應(yīng)用新技術(shù)等[2]。即使不是每項(xiàng)戰(zhàn)略和部署都需要跨機(jī)構(gòu)和區(qū)域的合作，但它們?nèi)允莿?chuàng)造健康城市基本理念的核心，也是《營造健康社區(qū)》的未來愿景。

在疫情期間，即使將健康問題擺在重要的位置，建立這樣的合作關(guān)系顯然也是困難的，因?yàn)樯鐣P(guān)系會遭遇危機(jī)，合作有可能中斷，人們也會對政府的職能感到失望。此外，需要公眾參與的行動本就具有挑戰(zhàn)性，更不用說在新冠肺炎疫情這一嚴(yán)重的形勢下。而規(guī)劃師和設(shè)計師討論典型但細(xì)微的健康影響，讓人們更有可能忽略或否定干預(yù)措施，質(zhì)疑其必要性，這阻礙了創(chuàng)造真正的健康場所所需的合作。即使合作十分困難，我們在《營造健康社區(qū)》一書中仍對合作持樂觀的態(tài)度。該書的大多數(shù)策略和行動除與健康相關(guān)之外，還具有多種益處，以便它更容易被接受。總之，一個關(guān)鍵的要點(diǎn)是，營造更健康的場所需要同時應(yīng)用多種不同的策略，這需要緊密的合作，但新冠肺炎疫情的經(jīng)歷讓合作變得非常困難。

圖片來源：

文中圖片均由安·福賽斯提供。

（編輯/劉玉霞）

著者簡介：

（美）安·福賽斯/女/博士/哈佛大學(xué)設(shè)計研究生院城市規(guī)劃專業(yè)露絲和弗蘭克·斯坦頓講席教授、城市規(guī)劃碩士項(xiàng)目主任/研究方向?yàn)樯鐣用娴膶?shí)體規(guī)劃

譯者簡介：

劉康/女/華南農(nóng)業(yè)大學(xué)林學(xué)與風(fēng)景園林學(xué)院在讀碩士研究生/研究方向?yàn)轱L(fēng)景園林規(guī)劃設(shè)計與理論

劉欣宜/女/華南農(nóng)業(yè)大學(xué)林學(xué)與風(fēng)景園林學(xué)院在讀碩士研究生/研究方向?yàn)轱L(fēng)景園林規(guī)劃設(shè)計與理論

校者簡介：

陳崇賢/男/博士/華南農(nóng)業(yè)大學(xué)林學(xué)與風(fēng)景園林學(xué)院副教授/本刊特約編輯/研究方向?yàn)轱L(fēng)景園林規(guī)劃設(shè)計與理論

FORSYTH A.Creating Healthy Neighborhoods: Reflecting on Places, Processes, and Prospects[J].Landscape Architecture, 2023, 30(1): 12-19.DOI: 10.12409/j.fjyl.202208050470.

Creating Healthy Neighborhoods: Reflecting on Places, Processes, and Prospects

Author:(USA) Ann Forsyth Translators: LIU Kang, LIU Xinyi Proofreader: CHEN Chongxian

Abstract:[Objective]What does it really take to create a healthy place? What are the potentials and limits of evidence-based practice?[Methods]Reflecting on the experience of many years of writing about healthy places, I consider the potential for evidence-based practice.[Results]Neighborhoods can protect from harmful exposures, help people connect to the resources they need to live a healthy life, and support health promoting behaviors.[Conclusion]Creating healthy places involves more than developing environments with features thought to be health promoting, however, but rather also engaging the process of making, maintaining, and using such places.Most challenging for this kind of comprehensive approach is the need to create ongoing collaborations.

Keywords: healthy city; healthy neighborhood; healthy place; built environment;evidence-based practice

1 Healthy Places in Retrospect and Prospect

What does it really take to create a healthy place? Many in urban planning have focused on how the built environment can affect health — from planning for bicycle safety to green space access.But even those who have invested great time in this research area also understand that to make healthy places it is not enough to just build a physical space;rather planners and designers need to address the processes of assessing, designing, constructing,using, managing, regulating, programming,and revitalizing urban and rural areas as well[1-2](Fig.1-4).Such comprehensive approaches,combining places with processes, do more than assume that building a place with features thought to be health promoting will improve health.Rather,they more comprehensively address what should be built, how, and for whom.They not only look at a place as a static environment but as something that evolves over time with different uses and users[3].

圖1 Parks provide settings where people can choose to undertake physical activity and as green areas can enhance mental well-being (Beijing, China)

In 2017, I published a book that while focused on physical places, also addressed the process of making healthier places.Creating Healthy Neighborhoods: Evidence-Based Planning and Design Strategies, co-authored with Emily Salomon and Laura Smead, synthesized research from a variety of fields to create a handbook for urban planning and design practice[4].Targeted at residential areas in middle and high-income countries, and inspired by the challenges of creating healthier environments for an aging population,it aimed to bridge the research-practice gap.Built around eight general principles and 20 specific propositionsit also outlined 83 actions.Five of the major principles focused on the environment —health promoting layouts; access options; supports for positive social connections; protections from hazards and pollutants; and planning for basic needs for the most vulnerable such as housing options,food access, and mobility.Three considered the process of making places and the people inhabiting and using them.These included assessing health’s importance in the specific situation — important health issues and constituencies; balancing physical interventions and other health-promoting activities;and implementing strategies over time.

Several years after completing Creating Healthy Neighborhoods, and in the aftermath of the COVID-19 pandemic, I look back at that work,using it as a lens for considering the potential and limits of evidence-based approaches to making better places.This article is an example of reflective practice, examining prior work to understand how it came about, how it stands up to my own scrutiny in hindsight, and what this might mean for creating healthier environments in the future.Robust evidence-based practice has many benefits but is hard to pull off, not least because it requires collaboration over time.

圖2 Healthy places provide options for gaining access to the resources needed for a healthy life but some options can also can pose problems in terms of safety and pollution(Beihai, China)

2 How It Came About: The History of Creating Healthy Neighborhoods

Creating Healthy Neighborhoodswas not a one-off manual but rather drew on some decades of work trying to make research on health and places more accessible.This included prior work developing research summaries and health impact assessments, conducting original research on health and on innovative communities, and trying to understand the strengths and limitations of evidence-based practice.I and my co-authors had also practiced as planners and those experiences provided an important context for the work.

2.1 Summarizing the Balance of Evidence

Most immediately the book drew on two iterations of developing short practical syntheses of health research.These briefs sifted through many individual studies and review articles, identified key findings supported by the balance of evidence as well as what was up in the air, considered the topic in relation to vulnerable groups, and developed insights for practice[5].Inspired by similar projects in other fields, we did the hard work of synthesizing multiple studies.This would mean that planners and designers could use the results of a whole body of evidence on a topic and would be less prone to relying on one or two highly publicized studies that might not reflect the larger field.The first generation of these summaries,Design for Health (DFH) Planning Information Sheets, came from a project I co-directed in the mid-2000s at the University of Minnesota.The second generation, the Health and Places Initiative(HAPI) Research Briefs, were developed as part of a project in the mid-2010s at Harvard University in a project with an emphasis on the aging population and a geographical interest in China[5].

圖3 Healthy places are as much about how spaces are used as how they are designed.In this image people dance in a pedestrianized street (Oaxaca, Mexico)

While the exact topics explored in each series differed, the summaries generally focused on areas where the environment could expose people to often harmful elements such as noise or poor air quality but alsoprotect them from these effects,connect them to the resources they need to lead a healthy life including community services or social interactions, and support health related behaviors such as eating well and being physically active.Research is unevenly available with many studies on some topics and few on others posing complexities for synthesizing the results.These summaries of multiple studies formed the backbone of theCreating Healthy Neighborhoodsguidebook.

It would be reasonable to ask why these summaries were needed when there are many authors industriously churning out literature review articles? Such reviews are of course tremendously useful but also often quite narrow in scope.For practice one needs to address a wider range of topics at a high level as well as consider which ones are really amenable to planning and design interventions; many are not.

The strategies inCreating Healthy Neighborhoodsalso reflected the experience of developing two iterations of health impact assessments — checklists, workshops, and larger GIS-based processes — created in those same projects[6-8].These emphasized the ongoing process of identifying where health issues may be relevant;engaging local people in to understand specific concerns; and evaluating plans, programs, and existing places in terms of their health outcomes.Developed to assess plans and proposals, they were also potentially used to assess existing places, a form of retrospective health impact assessment (HIA)perhaps better termed as a health assessment.

Over the decade of developing these assessment tools I was hesitant about them, worried the checklist format of some oversimplified the research.However, practitioners expressed gratitude to have an easy way to assess what they were doing,and one tailored to urban planning and design.In each generation the tool I liked the best was the rapid HIA.This was an elaborate workshop format where participants representing different constituencies and sources of knowledge would reflect both on a proposal and existing evidence about it including evidence from research, project investigations, and local knowledge.Creating Healthy Placesadapted elements of both the more checklistoriented assessments and the big idea behind the workshop format which was to bring together various constituencies and forms of knowledge.

2.2 Research on Healthy Places and Planned Communities

Part of the reason I had started along the path of creating such research summaries and health assessments was a desire in the practice world for health and place research to be more easily applied to practice.This is a tricky endeavor.In the health research field large teams often look at small and narrowly defined problems with many studies building on one another.That means any single researcher knows a lot about a relatively narrow topic while for practice many topics and a wide range of contextual factors are likely to be important.There may also be a great many studies to sift through with subtle but important differences.The density debate is one example of this where different densities seem to have differing benefits and problems depending on the healthrelated issue, location, and population group,exemplified by competing critiques of congestion and sprawl[9].Similarly mixed land uses can be beneficial for some populations and some health issues and not for others.A high-density mixeduse area might be quite positive in terms physical activity and access to resources for an able-bodied adult but have challenges for a frail older person with asthma.

圖4 Many strategies for creating healthy places are similar to those achieving other aims such as sustainability or quality of life.Hammarby Sj?stad in Stokholm is an urban redevelopment designed to minimize its ecological footprint but it has many health promoting features such as networked path systems and access to water and green space (Hammarby Sj?stad, Sweden)

My own research on physical activity and food environments gave me an insider’s view of the motivations and practices of conducting health research.From my own work I knew the connections between the environment, total physical activity, and healthy eating are more complicated than many at first thought.Such connections were typically reflected in the research articles though not the press releases about them.I also understood that there was great pressure in some quarters to promote the message of an individual piece of research when it was obvious that the balance of evidence was what mattered.

A second area of my own research, on innovative planned communities including new towns, was also key in framing the book.I came to an interest in health from an initial interest in how to design for sustainability writing a series of books, articles, and chapters investigating planned communities on multiple continents[10-12].These case-study-based projects on multiple continents gave me a strong appreciation of what it takes to undertake innovative approaches to creating urban places[13].This interest in the how to make better places as well as whatto make informedCreating Healthy Neighborhoods.

2.3 Evidence-Based Practice

Finally, was the larger question of evidencebased practice (EBP) — how it might be possible and whether it actually improves planning and design outcomes[14].This is a longstanding question.Practitioners typically make decisions using their own training and experience rather than research knowledge, making EBP unattractive to some.An area with robust research may have few links to planning and design, making it less useful.Results from one type of place or one time period can be hard to apply to another.Studies that do not find effects are less likely to be published, biasing the research record[15].All this makes EBP quite challenging.

Obviously by writing the book I have declared my opinion that evidence-based practice is possible.However, the book does address its limitations.the book’s process orientation allows users to tailor health knowledge to multiple situations.We also clarified the strength of the existing evidence so as not to overstate its level of certainty.For example,the 83 actions in the book are classified in terms of the level of certainty — directly informed by research evidence, generally informed by such evidence, and good practices that might help improve health and at least would not harm it.We also attempted to address how to make decisions in the absence of evidence and to distinguish between somewhat universal health outcomes and behaviors e.g., bodily reactions to pollutants, compared with health issues that were more individual, social, or cultural[4]4-7.While physical places matter for health they are not the only determinant of health, and this is also a key theme in the book.

Another issue is that of creativity and professional judgment.While some practitioners want more certainty about what to do than is possible given the state of research and the diversity of people and places, others chafe at what they perceive as a diminution of creativity in EBP.The book and its companion volumes from the same project, particularly David Mah and Ascencio Villoria’s[16]Life-Styled: Health and Places, tried to move beyond the perceptions evidencebased practice as suppressing creativity.Rather they conceptualize health evidence as a potential spark for the imagination[4,12].In an earlier book I had addressed the tradeoffs between social and ecological concerns in park designs as inspirations for different kinds of designs depending on what is prioritized; different health objectives can have something of the same role[17].

3 The Post-COVID Picture

What does it really take to create a healthy place? Written in the pre-COVID world the book emphasized how the built environment affected non-contagious and chronic diseases like obesity and cancer, although it did point out that clean air and water were important.On balance, this has stood the test of time better than I thought it would.This is in part helped by the situation that the strategies deal with neighborhoods, rather than workplaces or home interiors.

Post-COVID, many of the changes in neighborhood spaces use have been subtle[18].Outdoor spaces became important given the potential for indoor contagion; but they had always been important in the literature, providing space for physical activity, social interaction, mental restoration, and the like.The rise of remote work made residential areas key sites for daily life, but this just reinforced the message of the manual that focused on residential and mixed-use neighborhoods.A lesson of the pandemic was preparedness matters, hence the countries that had earlier faced SARS had initial success in combatting COVID-19[18].Again, however, this was not such a new insight though very powerfully conveyed in recent years.

A more subtle theme of the book was the issue of planning and design for an aging population, a topic of concern globally as the difficulties of aging are combined with demographic shifts and external forces like climate change[19-20].COVID-19 has demonstrated the vulnerability of this population.Of course,neighborhoods are not the only important environment for older people — the home and building are also key as is the wider culture[21].A lesson I eventually took from COVID-19 was the importance of seeing older people as a potential resource for the wider community.Creating environments that allow them to thrive and flourish is important for the whole society and is a theme of the book, if a subtle one.

A final important topic made more clear after COVID is the issue of cooperation and governance to create a healthier environment,something we indicated would be needed.As I have noted elsewhere COVID-19 spurred very notable public and governmental initiatives to address the pandemic and the fallout from the response — from banning evictions to redefining essential workers[18].In an article on types of healthy places, completed pre-COVID, I looked at different types common in popular and professional debates.These included the most basic approach combining healthy built environments and collaborative approaches like the WHO Healthy Cities program[22], along with ageand child-friendly versions, and those using new technologies[2].Collaboration across institutions and constituencies is at the core of the basic idea of the healthy cities and was also key in the larger vision ofCreating Healthy Neighborhoods, if not needed for every single strategy or action.

Even at times when health is front and center, as in the COVID-19 pandemic, it is obvious that collaboration is difficult.Social ties can fray,cooperation might break down, and populations can become disenchanted with government mandates.While some of the actions required of the public were quite challenging, so was the seriousness of the situation under COVID-19.The typical kinds of subtle health effects planners and designers are dealing with make it even more likely that people will ignore or dismiss interventions,questioning their necessity, and undermining the kind of cooperation needed to create truly healthy places.The bookCreating Healthy Neighborhoodsstruck an optimistic tone about cooperation,even as we knew it would be difficult.Most of the strategies and actions in the guidebook have multiple benefits beyond those related to health making them more likely to be adopted.However,a key idea is that healthier places use many different strategies at once requiring very substantial coordination.The COVID-19 experience has shown how difficult this can be.

(Editor / LIU Yuxia)

Author:

(USA) Ann Forsyth, Ph.D., is Ruth and Frank Stanton Professor of Urban Planning and Director of the Master in Urban Planning Program, Graduate School of Design,Harvard University.Her research focuses on social aspects of physical planning

Translators:

LIU Kang is a master student in the School of Forestry and Landscape Architecture, South China Agricultural University.Her research focuses on landscape planning and design,and theory of landscape architecture.

LIU Xinyi is a master student in the School of Forestry and Landscape Architecture, South China Agricultural University.Her research focuses on landscape planning and design,and theory of landscape architecture.

Proofreader:

CHEN Chongxian, Ph.D., is an associate professor in the School of Forestry and Landscape Architecture, South China Agricultural University, and a contributing editor of this journal.His research focuses on landscape planning and design, and theory of landscape architecture.