Living space and health: Does urban design affect our health?

Urban and housing design has intimate connections to health. Poor design choices can worsen health, with underlying issues of inequality a driving factor.

Article 25 of the Universal Declaration of Human Rights states: “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family.”

This includes housing, food, clothing, medical care, social services, and security if events beyond a person’s control affect their livelihood.

Researchers have shown that adequate housing has intimate links to a person’s physical and mental well-being.

According to the Executive Summary of the World Health Organization’s (WHO) Housing and Health Guidelines, poorly designed housing can increase the risk of trips, falls, injury, isolation, and stress for older people or people with disabilities.

Further, insecure or unaffordable housing can exacerbate stress. Housing that is too hot or cold or exacerbates indoor air pollution can cause respiratory and cardiometabolic issues.

Crowded housing or housing with a poor water supply can increase the spread of infectious diseases.

Speaking to Medical News Today, Robert Huxford, Director of the Urban Design Group, London, said that questions around the relationship between health and urban or housing design have a long history.

“It’s often forgotten that the links between housing and urban design and health go back hundreds of years, such as the 19th-century public health movement, including the Health of Towns Association of the 1840s, or the Model Byelaws issued in the 1870s, that governed urban development in England for the next 50 years.”

“They focused on lighting, ventilation, overcrowding, damp, and sanitation. They specified the minimum width of streets, minimum spaces around buildings, and that habited rooms should have a window at least one-tenth of the floor area. Over 100 years on, developers are bringing forward proposals for windowless flats.”

For Huxford, the COVID-19 pandemic has brought historical concerns around housing and infectious diseases back to the fore.

“In the 19th century, the main causes of death were infectious diseases, such as tuberculosis, cholera, and typhoid,” said Huxford.

“The public health works of the 19th and 20th-century saw infectious disease brought under control, further aided by advances in medical science. However, the COVID-19 pandemic has shown that we remain vulnerable to infectious disease; and the prospect of drug-resistant diseases is a grave international concern.”

“It is of the utmost importance that housing and urban design provides resilience to infectious disease risk.”

Backing up Huxford’s point in an article in the journal PLOS ONE, researchers found an association between the amount of poor quality housing in a United States county and COVID-19 incidence and mortality.

Car-dependent development

According to Katja Stille, Chair of the Urban Design Group and Director of Tibbalds Planning and Urban Design, broader urban design choices can have direct adverse effects on a person’s health.

Speaking to MNT, Stille said, “the main urban factors that negatively affect a person’s mental and physical health are air pollution from road traffic as well as noise pollution.”

“Living in a car-dependent development will impact negatively on people’s ability to exercise and encourage a sedentary lifestyle that easily leads to obesity, heart disease, and diabetes. The opportunity to be physically active throughout one’s day-to-day life, such as active transport — walking and cycling — is important to avoid obesity.”

Dr. Steven Fleming, author of Velotopia: The Production of Cyclespace in Our Minds and Our Cities, also highlights the issue of car-centric urban design.

Dr. Fleming said to MNT that a “house with a garage is designed to send you on your way driving, for a day of no exercise whatsoever. An apartment block is only slightly better because the day of walking it was designed to set in motion — with its lift or stairs leading onto the street — will have negligible metabolic equivalent of task (MET) minutes. If you [already have overweight], you’ll be looking for a taxi or bus because walking is painful for [people with obesity].”

The definition of one MET is “the amount of oxygen consumed while sitting at rest.”

“In my book Velotopia,” continued Dr. Fleming, “I detailed, in drawings and architectural jargon, apartment-style housing that would set you on your way on your bike. You would leave your tenth story apartment, and rather than waiting for a slow lift, just ride past all the other apartments arranged around a sloping, typically spiraling, corridor or what we call an ‘access gallery’ or sometimes an ‘aerial street.’”

“That would be the start of a day with far more MET-minutes than the one you started on foot, and that wouldn’t be painful if you [have obesity].”

Robert Huxford also has issues with designs that prioritize motor vehicles:

“The impact of motor vehicles is significant, bringing noise, high intensity street lighting, air pollution, and the risk of injury from collisions into urban areas.”

Mental health

Housing and urban design issues can also adversely affect mental health.

Speaking to MNT, Dr. Layla McCay, Director of the Centre for Urban Design and Mental Health, said that “homelessness and housing insecurity are a key risk factor for mental health problems.”

“For those who do have a home, the affordability of the home is key, as economic concerns have links to mental health problems; so too is the quality of the housing, including dampness, noise, pests, and overcrowding.”

“Location of the housing is also important, including neighborhood quality and safety, access to key facilities, including education, jobs, and healthcare. And any aspect of the housing that stigmatizes its residents can also negatively affect residents’ mental health.”

“Housing that is available, safe, adequate, affordable, and comfortable, and that offers its residents a degree of privacy, while also facilitating multi-generational living where desired, can benefit people’s mental health,” she continued.

“Housing has the opportunity to further support people’s mental health by facilitating residents to develop positive relationships with their neighbors, and to foster feelings of inclusion and belongingness.”

Security and homelessness

As Dr. McCay highlights, the security of housing — whether a person owns their home or cannot keep up with the mortgage; whether they have a long-term rental contract; or whether they face the possibility of eviction with no notice — can be just as important a factor for a person’s well-being as the physical conditions of the home.

Prof. Deborah K. Padgett of the Silver School of Social Work in New York University, an expert on the intersection of homelessness and mental or substance use disorders, spoke with MNT.

She explained that while insecure housing is a complex topic, it has some key root causes.

“Global housing instability is due to severe poverty and lack of institutional support for ‘public’ or ‘social’ housing that is affordable.”

“The United Nations-endorsed concept of ‘housing is a right’ is, in my opinion, the most contested and least attractive of human rights supposedly guaranteed by governments. This is in part because demand so overwhelms supply as world population growth soars.”

“But the last decades (since the Reagan administration here in the U.S.) have seen heavy privatization of housing development, and this naturally excludes the poor. In countries like India, the millions living in slums are not considered ‘homeless,’ but this obscures the deplorable living conditions they endure.”

“From a personal level, day-to-day survival is a struggle to procure food, clean water, sanitary facilities, etc. — whether living in a slum, a shantytown, or on a park bench,” said Prof. Padgett.

For Prof. Padgett, a primary factor that affects the relationship between housing and mental health is homelessness. However, people too often presume that mental health issues cause homelessness when the reality is not straightforward — a point Prof. Padgett recently outlined in an article for the journal BJPsych Bulletin.

Prof. Padgett told MNT that “homelessness and mental health have a bi-directional relationship, but it’s also complicated. While serious mental illnesses, such as schizophrenia, account for a minority of homeless persons, these individuals are more likely to be chronically homeless and have needs that create more costs for the system — hospitals, jails, shelters, and so on.”

“They are also more likely to be visible in public and thus skew public perceptions away from the fact that most homeless people are families with small children, youth, ‘new’ homeless (older Baby Boomers), and others.”

“Sadly, the hyper-focus on serious mental illness diverts attention from the trauma caused by being homeless, and this remains under-studied — in part because it is often trauma compounded by childhood adversity and traumatic events earlier in life.”

Inequality

For Dr. McCay, an underlying issue in poor health associated with urban and housing design is wealth inequality.

“Housing is inextricably linked to mental health and well-being, but access to housing and the quality of that housing varies according to a wide range of factors, particularly wealth,” said Dr. McCay.

“Inequalities in people’s access to safe, affordable, good-quality housing can lead to inequalities in their mental health and well-being. People’s mental health can also be affected by ‘segregation by design,’ for example, where people who own their homes are separated by design features from people who live in social housing, even within the same building, creating stigma and exacerbating inequality.”

“During the COVID-19 pandemic, we saw evidence of housing-related inequalities where some people were able to relax and play in their gardens while others had no outside space; some had good quality local parks, and others had to travel outside their neighborhood to find safe and pleasant green space.”

For Prof. Peter Bishop, a professor of urban design at the Bartlett School of Architecture, University College London, various forms of social deprivation, including poor housing and urban design, correlate with worse health outcomes.

Speaking to MNT, Prof. Bishop said: “There is a clear correlation between physical and mental health and indices of multiple deprivation. Public Health England lists childhood experience, education, stable housing, and secure employment as the core contributing factors to health and well-being.”

Long-term change

For Katja Stille, governments should play a role in tightening housing and design regulations, given the clear links between poor housing design and health issues.

“Governments around the world need to initially acknowledge the link between poor urban environment and housing and reduced life expectancy and higher health care bills,” said Stille.

“The increasing healthcare costs need to be recognized as a consequence of poor and unsustainable development.”

“Governments need to prescribe mandatory regulations that control the quality of homes, including space and light standards, noise insulation, and private outdoor space. Further Health Impact assessments should be mandatory and require every new development to demonstrate how it leads to a net increase in health outcomes for the new and existing communities.”

For Robert Huxford, it is also crucial that urban designers are sensitive to the particular needs of the communities they are working with.

“We all share basic needs, but there are differences, such as the need for privacy, whether families are nuclear or extended, how strong and connected the community is, and so on. This is shown worldwide in differences in housing design, in streets, and in neighborhoods.

“Broadly, homes should be designed to reflect and support family structures, neighborhoods to reflect community structures, and districts and towns economic structures; and all the time responding to the natural environment and local climate.”

“The spread across the planet of a standard global corporate urbanism, driven solely by commercial interest that ignores the differences is not something that we should celebrate.”

“Towns need to be sensitive to catering for different needs at different stages in life, time of day, as well as the needs of people from different cultures and ethnic backgrounds.”

Prof. Bishop suggests that while housing and urban design are key factors in people’s health, the main areas to target are the underlying issues of inequality.

“I would argue that although housing and urban design are important, they are subservient (although related) to more general issues of poverty, education, and equal access to services, particularly health. If society has inequalities within its structure, then the impacts will not be equally distributed.”

For Prof. Bishop, governments should ensure decent housing for all that includes outside space. They should also improve air quality, reduce motor vehicle use, promote sustainable transport, improve education, invest in preventive health care, and extend open spaces and sporting facilities.

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