Tackling Root Causes Upstream of Unhealthy Urban Development (TRUUD)

Our overarching research question is: How might prevention of risk factors causing Non-communicable diseases (NCDs) be considered and fully incorporated into urban planning and development in the UK?

Context: Poor quality urban environments are important contributors to Non-Communicable Diseases such as lung and heart disease, diabetes and mental health problems. This is because they are associated with critical risk factors - including air pollution, noise, lack of physical activity, lack of green space, and obesity. Therefore, one way of preventing these future major chronic health problems is to go "upstream" and improve the urban environment so that it encourages healthy behaviours and reduces adverse risks. However, urban planning and development is a complex system of actors and processes operating over multiple layers of governance. . The driving force in urban planning and development are now the large private sector actors, particularly landowners, investors and developers. Narrow valuation mechanisms and short-term horizons are a central challenge as they do not factor in long-term health. Urban planning faces "super wicked" problems too - where "those who are in the best position to address the problem are not only those who caused it, but also those with the least immediate incentive to act".

Researching these complex systems requires: consideration of whole and interconnected systems; clear visualisation and analysis; effective engagement and 'co-production' with a wide range of stakeholders, including public, private, third sector as well academia and the lay public.

Applications: We aim to transform urban planning and development systems so that health and health inequalities are valued and integrated at each of the main roots of core decision-making. We will develop with urban development decision-makers at city, combined authority and national level interventions and methods for realigning the system for healthier public and private sector operations. The intervention has three components: evidence of health impact including economic valuation; opportunities for change; community-led creative arts media communicating health inequalities. We will identify the best leverage points for introducing the intervention.

We anticipate a range of applications for the evidence and associated tools. They will provide measurable evidence of health impacts to be used in multiple ways including: local and national planning policy; local development management and planning permissions; cost-benefit analysis on infrastructure and other investment decision-making; and policy or legal mechanisms for re-aligning corporate governance towards long-term health outcomes. For example, we will seek to influence and introduce evidence on health impacts of urban planning into the Housing and Economic Land Availability Assessment, which determines what land is to be developed.

Beneficiaries: The beneficiaries of this kind of whole system approach include: a) decision-makers by improving the quality of what they offer (e.g. local government will benefit politically by evidencing societal benefit; progressive investors and developers gain commercially by differentiating their 'product'); b) in the medium to longer term, urban and rural populations should be positively affected by better urban environments (e.g. reduced air pollution, better quality green infrastructure, improved physical environment); and c) taxpayers and central government over the long term due to decreased health burden on the NHS and increased levels of productivity.

There is a clear need to address the quality of urban environments and developments to prevent risk factors (air pollution, noise, lack of green space, physical inactivity, obesogenic food 'deserts) that cause Non-Communicable Diseases.
Our vision is of urban development systems where health is a priority for those who make the key decisions, focusing in particular on control of land, finance and the development process.
Our primary objectives are to: (WP1) map and understand urban systems; (WP2) develop and model the health impacts resulting from changes in decision-making; (WP3) co-produce the intervention and assess corporate governance models; (WP4) develop meaningful and effective ways of involving the lay public in upstream decision making; (WP5) conduct extensive knowledge exchange through workshops, conferences, films, and images and community practitioners; (WP6) develop a meta-research evaluation framework.
Theory of change: By co-producing evidence and ways of integrating health at key tipping points in the planning process - we expect to change attitudes, decisions, and behaviours in the short-term and change policies, practice, adoption of project outputs (medium to long term).
Lines of research and methods: Transdisciplinary research utilizing multiple methods from social science, law, management, systems engineering, and health economics. We will collect qualitative data; co-produce interventions; and undertake actor/network/socio-legal analysis, corporate characterization, and systems mapping and problem structuring.
Plans for user engagement We will undertake multiple focus groups, four annual workshops and three industry workshops, and embed two full time researchers at our partner city and combined authority.
Applications: The evidence and associated tools on valuing health will be applied in local development management; local and national cost-benefit analysis on infrastructure and other investment decision-making.

This grant is funded by the UK Prevention Research Partnership (UKPRP) which is administered by the Medical Research Council on behalf of the UKPRP's 12 funding partners: British Heart Foundation; Cancer Research UK; Chief Scientist Office of the Scottish Government Health and Social Care Directorates; Engineering and Physical Sciences Research Council; Economic and Social Research Council; Health and Social Care Research and Development Division, Welsh Government; Health and Social Care Public Health Agency, Northern Ireland; Medical Research Council; Natural Environment Research Council; National Institute for Health Research; The Health Foundation; The Wellcome Trust.

Our proposal is based fundamentally on co-production. We will undertake three rounds of data gathering and testing of a three component intervention involving >200 interviews and 18 focus groups. We will ensure substantial lay public engagement via training provision, membership on our External Advisory Board, and production of community-led creative media. We plan four large annual stakeholder conferences, three industry conferences and targeted engagement with Parliamentarians through relevant All Parliamentary Party Groups (APPGs): e.g. Corporate Governance; Future Generations; Health in all Policies; Housing and Planning; Land Value Capture; New Towns. We also propose to embed researchers within two significant case study urban regions, both of which are members in the Core Cities network, which represents the nine largest cities in the UK. Our industry workshops will be co-delivered and outputs co-authored with four of the UK's most active industry and professional membership bodies in real estate, planning, and sustainable building construction. Our research team brings together a wide range of disciplines through active and newly collaborative partnerships and will result in new methods being developed and adopted.

Our research team already has well-established relationships with key institutions across the urban development systems, as shown by our letters of support. These include local governments, national government, industry membership bodies, professional membership bodies, private sector investors and developers and major consultancies, agents, NGOs and think tanks. We will continue to build relationships with users and expect user engagement will evolve as new opportunities emerge. Using our established contacts, our research proposal has been developed through an intensive programme of meetings with cabinet members, officers, developer/investor partners and a range of key industry and professional membership bodies.

The beneficiaries of our approach will include: a) key decision-makers improving the quality of what they offer (e.g. local government benefit politically by evidencing societal benefit; progressive investors and developers gain commercially by differentiating their 'product'); b) in the medium to longer term, urban and rural populations should be positively affected by better urban environments (e.g. reduced air pollution, better quality green infrastructure, improved housing); and c) taxpayers and central government over the long term due to decreased health burden on the NHS and increased levels of productivity, which is the primary focus of the current Industrial Strategy).

Our focus on 'root-cause' decision-making far upstream ensures population-level interventions that are large-scale, generalisable and implementable, and the focus on valuation and co-production should ensure their efficacy and adoption. It is via these combined activities that: a) users will have excellent understanding of and access to researchers; b) our findings will be communicated very widely across a range of real world practitioners; c) our research will be mutually beneficial to policy-makers and implementers and d) will have significantly increased visibility.

Our goal is that evidence on health impacts will be incorporated into decision-makers thinking and consideration for urban planning and development. We will evaluate this during the award period -and should our research strategy and impact plan prove effective, investment in activities that impact on NCD prevention will follow.

We have intentionally recruited senior experts and representatives from across the UK's city regions and devolved nations so that we can understand how impactful solutions could be delivered at scale across the UK, and exploring this will be a central part of our impact planning and testing.