How well do Australian government urban planning policies respond to the social determinants of health and health equity?

How well do Australian government urban planning policies respond to the social determinants of health and health equity?

Land Use Policy 99 (2020) 105053 Contents lists available at ScienceDirect Land Use Policy journal homepage: www.elsevier.com/locate/landusepol How...

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Land Use Policy 99 (2020) 105053

Contents lists available at ScienceDirect

Land Use Policy journal homepage: www.elsevier.com/locate/landusepol

How well do Australian government urban planning policies respond to the social determinants of health and health equity? Michael McGreevy a, *, Patrick Harris b, Toni Delaney-Crowe a, Matt Fisher a, Peter Sainsbury c, Emily Riley c, Fran Baum a a b c

Southgate Institute, Flinders University, GPO Box 2100 Adelaide, SA 5001, Australia Research & Evaluation (CHETRE), Part of the UNSW Australia Research Centre for Primary Health Care & Equity, Australia School of Medicine, University of Notre Dame, Sydney, Australia

A R T I C L E I N F O

A B S T R A C T

Keywords: Planning policy Australia Social determinants of health Liveability Transport Housing Government policy

There is now wide recognition and evidence that the built environment affects population health and health equity. This research provides a thematic analysis of 108 urban planning policy documents from Australian state, territory, and federal governments to address the question: How well do Australian government urban planning policies respond to the social determinants of health and health equity? Health and health equity were discussed explicitly in several policies, most often as a secondary or co-benefit to environmental, social, and economic concerns. The most significant themes in the documents associated with health were visions for urban devel­ opment that is compact, mixed use, walkable and transit oriented. These attributes are summed up in the term’ liveable’. However, strategies to improve liveability were largely confined to areas targeted for residential infill and redevelopment, leaving car dependent and generally lower income, outer metropolitan areas potentially untouched. In addition, there were strategies that potentially conflicted with liveability, walkability, and transit orientation; the most notable being major road projects. This thematic analysis of Australian urban planning policies shows that some social determinants of health and health equity are being acted upon. However, policy conflicts and contradictions mean the policies are unlikely to deliver more healthy and equitable cities without further consideration of some of the structural issues likely to undermine healthy and equitable urban development.

1. Introduction Recent Australian research (Arundel et al., 2017) has found that most Australians live in suburbs that fail to meet the most rudimentary design elements, densities and access required for liveability. Despite this and the considerable evidence linking health and health equity with the quality of urban environments, there is limited knowledge about whether and how land use policy making incorporates health and health equity (Harris et al., 2015). The extent to which government urban planning policy documents are inclusive of strategies that will improve health and health equity remains underdeveloped, and is the focus of this paper. There is wide recognition that the built environment shapes heath and health equity (de Leeuw and Simos, 2017; de Leeuw, 2001; Frumkin et al., 2004; Frank and Engelke, 2005; Kelly-Schwartz et al., 2016;

Pikora et al., 2003). The layout of street networks, the connections and aesthetics of places, functions, and buildings and the relationship be­ tween them affect the average amount of time people spend walking, cycling, driving, and engaging in public life, as well as their perceptions of safety and belonging (Cattell et al., 2008; Foster et al., 2012; Handy and Clifton, 2001; Saelens and Handy, 2008). The location of dwellings determines the costs in money and time that residents must spend accessing employment, education, recreation, goods, and services (Frank and Engelke, 2005; Foster et al., 2012; Giles-Corti et al., 2016). The construction, location and orientation of dwellings determines ac­ cess to health enhancing views, light and fresh air as well as the energy required to keep people comfortable and healthy within their homes in hot and cold weather (Howden-Chapman et al., 2012; Huang et al., 2015). Furthermore, urban design contributes to health inequities as urban areas that are more or less health promotive are distributed across

* Corresponding author. E-mail addresses: [email protected] (M. McGreevy), [email protected] (P. Harris), [email protected] (T. Delaney-Crowe), [email protected] (M. Fisher), [email protected] (P. Sainsbury), [email protected] (E. Riley), [email protected] (F. Baum). https://doi.org/10.1016/j.landusepol.2020.105053 Received 30 October 2018; Received in revised form 14 July 2020; Accepted 23 August 2020 Available online 17 September 2020 0264-8377/© 2020 Elsevier Ltd. All rights reserved.

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populations according to a socio-economic gradient (Baum and Gleeson, 2010; Dodson and Sipe, 2008; WHO UN-HABITAT, 2010). Recent health and urban planning research has used the term ‘live­ able’ to encompass the combinations of traits that make cities, suburbs, neighbourhoods and places healthy, equitable and convivial environ­ ments in which to live (Arundel et al., 2017; Hooper et al., 2015; Lowe et al., 2015). Lowe et al. (2015, p. 138) defined a liveable place as one that is: ‘safe, attractive, socially cohesive and inclusive, and environmen­ tally sustainable; with affordable and diverse housing linked by conve­ nient public transport, walking and cycling infrastructure to employment, education, public open space, local shops, health and community services, and leisure and cultural opportunities’. However, there are also other definitions of liveability. One of the most referred to globally and in Australia is the Economist magazine’s Global Liveability Index (GLI) (EIU, 2017; Newton, 2012). The GLI was originally created to assess the comfort of individual cities for expatriate executives not the wellbeing of residents (Conger, 2015; Newton, 2012). While the GLI does contain some criteria potentially relevant to social determinants of health and heath equity such as safety and the quality of public transport, it also contains others that are not, such as the avail­ ability of private schools and private hospitals (EIU, 2017). Lowe et al.’s (2015) definition, and those like it, that link urban form, liveability, and health provide additional support to environmental, social, economic, and equity concerns for urban development that is compact, green, mixed use, pedestrian, and public transport oriented. Liveability also privileges growth via infill and densification rather than extensive expansion on the urban fringe (Frumkin et al., 2004; Frank and Engelke, 2005; Kelly-Schwartz et al., 2016; McIntosh et al., 2014). Many features of urban form are recognised in public health litera­ ture as determinants of health with environmental, economic, social and equity dimensions. Environmental arguments in favour of a liveable urban form are reductions in noise and air pollution from motor vehicles (including greenhouse gas emissions), the preservation of natural envi­ ronments and agricultural land beyond urban fringes, less contaminated run off from hard surfaces such as roads and car parks, a reduction in heat island effects, greater absorption of localised pollution, and more aesthetically interesting and attractive urban environments (Dittmar and Ohland, 2012; Calthorpe and Fulton, 2001; Newman et al., 2009). Economic arguments in favour include reduced travel times, the sus­ tainable use of existing infrastructure, and less need for the costly land consuming infrastructure of roads and car parks (Dittmar and Ohland, 2012; Calthorpe and Fulton, 2001). Social arguments in favour include equitable access to appropriate and affordable housing (Anglicare, 2017; Dowling et al., 2010, Gurren and Phibbs, 2015), quality goods and services, recreation, as well as enhancing public life and the social capital that can arise from it (Cattell et al., 2008; Mehta, 2007; Gehl, 2013; Wood et al., 2017). The research reported here investigates how well Australian gov­ ernment urban planning policies consider health and health equity directly as well as via the social determinants of health (SDH). This paper focusses on an analysis of urban planning public policy in all Australian states and territories across transport, land use planning, housing, and infrastructure. The aim is to assess the extent to which policy goals, objectives and strategies address social determinants of health in ways likely to improve population health and health equity. The findings and analysis presented in this paper have been developed as part of the Australian Research Council (ARC) funded research project (DP160100244) between 2016 and 2019. The aim of the broader research is to understand how whole-of-government action can be used to promote health while still addressing sector-specific goals (Baum et al., 2018). The research reported here is a continuation of prior research and scholarship in Australia focused on ‘The Social Determinants of Health’ and ‘Healthy Public Policy’ (also known as ‘Health in All Policies’). These streams of largely Public Health focused activity are oriented

outward to engaging in policy-making and politics across sectors (Embrett and Randall, 2014), given the known impact of public policies on health and inequity (Marmot, 2018; Smith et al., 2018). Our methods were drawn from earlier research which investigated how Health policy documents addressed the social determinants of health (Fisher et al., 2016). Much of our focus over the past decade as a group of researchers from across Australia has been on urban and land-use planning policy (Harris et al., 2015; McGreevy et al., 2020, 2019) including local gov­ ernment (Lawless et al., 2017) and state government activities in South Australia (Lawless et al., 2018) and New South Wales (Harris et al., 2018a, 2019; Harris et al., 2016). Other public policy related health focused research (Baum and Friel, 2017) has been investigating infra­ structure (Schram et al., 2018; Harris et al., 2018b) international trade (Townsend et al., 2020), Indigenous policies (Baker et al., 2018), work (Browne-Yung et al., 2020), and paid parental leave (Townsend et al., 2019). It has also investigated more generic policy issues like power (Harris et al., 2020) and evaluation (Lee et al., 2018) and processes for considering health impacts from public policy (Delany et al., 2014; Fisher, 2018; Harris et al., 2014, 2018c; van Eyk et al., 2017). 2. Methods 2.1. Document sample Document collection involved a researcher (AA) searching the websites of urban planning, transport and infrastructure departments of every state, territory and federal government in Australia to collect all current strategic policy documents, and Acts that covered areas not addressed in the policies. Documents were regarded as current if they were available on the department website at the time of the search (March 2016 to June 2017) and not archived or identified on the website as being superseded by a more recent strategic policy. AA and BB then contacted all relevant government agencies to check that the lists were complete and current In total 108 strategic policies and acts were collected to provide a census of Australian urban planning documents see Baum et al. (2018) for further detail of the selection processes used). The number of doc­ uments from individual jurisdictions were as follows: Victoria 13, Queensland 9, Western Australia 15, South Australia 11, Australian Capital Territory (Canberra) 9, New South Wales 25, Northern territory 7, Tasmania 9, Federal Government 10. The documents covered a broad range of topics, including but not limited to urban design, land use planning, passenger transport, freight, coastal planning, infrastructure asset planning and management, aviation, community developments and housing. 2.2. Document analysis approach Qualitative thematic document analysis was undertaken. Three re­ searchers (AA, BB and CC) coded the documents with the assistance of NVivo 11 software. Thematic document analysis requires data to be examined and interpreted by researchers to elicit meaning and develop understanding about what is present and not present (or, as we describe it, ‘silent’) in the data, and to what effect (Liamputtong and Ezzy, 2006). It involves researchers seeking to identify and understand commonal­ ities and differences across documents and jurisdictions, and to interpret key themes or patterns in the data (Liamputtong and Ezzy, 2006; Vais­ moradi et al., 2013). Prior to commencement of the analysis, a coding guide was devel­ oped and trialled. All coders were then trained in the use of the coding framework and so applied consistent coding to all documents. Collab­ orative coding was undertaken between team members every two weeks. This involved the selection of a short segment of a policy, which all coders coded independently, and then together. Any differences in the allocation of codes were discussed. In some instances, codes were also added to the framework to capture key information. Regular 2

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collaborative discussion ensured ongoing consistency in the analytic process. The co-investigators on the study, (IA, IB, IC, and ID) reviewed segments of coding and assisted the coders to interpret and theorise the themes that were emerging across sources. Consistent with the critical theoretical approach that underpins the research design (Baum et al., 2018), these meetings involved questioning what impacts were being produced through urban planning policies, and reflection on the con­ texts of each jurisdiction to consider why particular policies were shaped in a given way (Baum et al., 2018; Vaismoradi et al., 2013). In addition, the article’s authors held regular meetings where topics such as how the application of different policy framings may create different, fairer, or healthier social conditions was discussed. As such, all authors were directly and regularly involved in the document analysis, and the associated theorising process. All authors are trained and experienced in the areas of qualitative research, urban planning and/or public health, which supported the rigour of the analysis. The design did not include direct evaluation of the population health impacts of policy interventions. Instead, we theorised causal links be­ tween policy implementation and likely impacts on social determinants of health and health equity using published literature such as Frumkin et al. (2004) and Giles Corti et al. (2016). The analysis has produced empirically informed insights about the alignment that exists between current Australian planning policy and health and equity.

Table 2 List of social determinants of health coded during the thematic coding process. •Welfare system •Transport •Stigma or discrimination •Social relationships •Social exclusion •Safety

3. Findings 3.1. Growth, coordination, and competition in urban development Although urban development in Australia is under the auspices of separate state and territory governments, our analysis indicates that state and territory governments promote similar strategies for urban development. In all jurisdictions, there is a perceived need to continually grow to accommodate predicted and/or desired population growth and associated economic activity. The analysis also reveals a dominant belief that better integration of infrastructure and land use can improve sus­ tainability by reducing government expenditure, reducing vehicle kilo­ metres travelled (VKT), and increasing the use of active and public transport both of which have the secondary benefit of improving health and wellbeing (Frank et al., 2004). This approach is broadly consistent across jurisdictions and documents. A prominent theme is that each state or city in a globalised world is competing for investment, migrants, tourists, and foreign students. This competitive environment leads to what Harvey (1989) described as entrepreneurial responses by governments to enhance their cities’ competitive position. Kaufmann and Arnold (2017) argues that urban governance, particularly for small and medium sized cities, has become focused on ‘hard factors’ such as reducing land, real estate, transport and infrastructure costs and ‘soft factors’ such as image building in search of a competitive advantage. Correspondingly, improving productivity and enhancing the image of the city via liveable and sustainable urban de­ velopments are dominant themes in all jurisdictions. For example, the primary objective of the South Australian Planning, Development and Infrastructure Act (Attorney General’s Department, 2016, p. 27) is: to support and enhance the State’s liveability and prosperity in ways that are ecologically sustainable and meet the needs and expectations, and reflect the diversity, of the State’s communities by creating an effective, efficient and enabling planning system.

During the coding process, the framing of each document was examined and, as shown in Table 1, the goals, objectives, strategies and values articulated throughout the policy were assessed to determine how and whether these aligned with the intent of progressing health and health equity. Given the interpretative approach applied, explicit mentions of words associated with health did not need to appear in order for seg­ ments of text to be coded. Instead, the more implicit meaning of the text was interpreted by the researchers and categorised accordingly based on which social determinant the text related to. Although independently formulated, the coded categories are similar to health focussed live­ ability checklists such as those by Arundel et al. (2017); Harris et al. (2016) and Lowe et al. (2015). Table 2 shows the social determinants that were coded. Following the coding process, a document summary was developed by the researcher responsible for coding each document. At this point, Table 1 Coding approach.

Are the policy’s stated goals consistent/neutral/ inconsistent with: Is the evidence the policy uses to make a case for action consistent/neutral/inconsistent with: Are the policy’s stated objectives consistent/neutral/ inconsistent with:

Are the policy’s stated strategies consistent/neutral/ inconsistent with:

•Food •Employment •Education •Culture •Climate change •Built environment •Open space

the researchers also identified silences within each document. Silences were identified when no aspect of a document could be coded into a particular category within the framework and when the framing and goals were inconsistent with the objectives and/or recommended ac­ tions of the document. Silences rendered some aspects under-addressed or completely ignored within the proposed actions. As explained earlier, the coding and document summaries were checked by other members of the team during regular meetings where themes were identified and theorised. Several of the themes identified during the analytic process are explained in the findings section of this paper.

2.3. Document coding process

Are the policy’s stated values consistent/neutral/ inconsistent with:

•Natural environment •Land or country connection •Income •Housing •Health systems •Gender

health as a value? health equity as a value? improved health as a goal? improved health equity as a goal? evidence on SDH? evidence on health inequities? Outcomes which address a SDH to: Improve average health? Reduce health inequities? Actions addressing a SDH to: Improve average health? Reduce health inequities?

3.2. Liveability, image and health Liveability is a goal or objective in land use, infrastructure, and transport documents in all jurisdictions. The importance attached to liveability is evident in its numerous mentions. In Victoria, the term liveable or liveability was referred to 49 times in 7 documents, in South Australian 41 times in 5 documents, in New South Wales 33 times in 3 documents, in Queensland 36 times in 3 documents, in Tasmania 10 times in 8 documents, in Western Australia 73 times in 9 documents, in the Northern Territory 11 times in 4 documents, and in the Australian 3

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Kenworthy (1999) and Calthorpe (1993) have been highly influential for decades on Australian planners and planning at the state government policy level (Newman et al., 2009). Both smart growth and new ur­ banism, in theory at least, advocate design principles supportive of many social determinants of health (Frumkin et al., 2004). For example, the Southern Tasmanian Regional Land Use Strategy (STCA, 2014, p. 91) outlines the sustainability benefits of intensive infill development as:

Capital Territory (Canberra) 10 times in 3 documents. The federal government documents refer to liveability 16 times in 2 documents. An example is expressed in a goal of Tasmania’s Urban Passenger Framework (DIER, 2010, p. 4): a safe and responsive passenger transport system that supports improved accessibility, liveability and health outcomes for our communities. In particular, liveability is seen as central to image enhancement. For example the Plan for Growing Sydney (DPE, 2014, p. 80) states: Liveability will be Sydney’s continuing competitive advantage in the decades ahead. It will contribute to the city’s ability to foster innovation, develop thriving centres and attract investment and skills from across the world. In all jurisdictions, the definition of liveability most often used is along the lines of that provided by Lowe et al. (2015) which accord with healthy city principles (Frumkin et al., 2004, Giles Corti et al., 2016). For example, the Western Australian State Planning Strategy (WAPC, 2016, p. 86) defines liveability as: A liveable place is safe, attractive, affordable and environmentally sustainable, with a socially cohesive and inclusive community, good access to public open space, employment, education, shops, healthy food, arts and culture, accessible and frequent public transport, and walking and cycling infrastructure. However, there is also some ambiguity about the term. In the Thirty Year Plan for Greater Adelaide (DPTI, 2017), Plan Melbourne (DELWP, 2014), and Plan for Growing Sydney (DPE, 2014) there is confusion be­ tween a definition similar to that provided by Lowe et al.(2015) and that used in the Economist magazine’s much publicised Global Liveability Index (EIU, 2017). For example, Plan Melbourne (DELWP, 2014, p. 111) has a goal to: create healthy and active neighbourhoods and maintain Melbourne’s identity as one of the world’s most liveable cities.

• More efficient use of physical and transport infrastructure; • Reduced ecological footprint of urban development and reduction in loss of biodiversity; • Increased opportunities for social interaction and reduction in social segregation; • A greater proportion of the population living in proximity to services and employment opportunities; • Increased economic viability of public transport, and subsequent exten­ sion thereof; • Better utilisation and revitalisation of other public infrastructure, including parks and open spaces; • Provision of a greater range of housing options to suit the decreasing size of households and ageing population; • Promotion of health and wellbeing by eliminating distance as a barrier to walking and cycling as preferred modes of transport; Despite references to the benefits of infill, greenfield expansion is envisaged to be a major component of urban development well into the future. In Hobart, South East Queensland, and Perth there is an objective to reduce greenfield development from current levels of 70–80 % to 50 % (DPI, 2009; STCA, 2016; WAPC, 2016). In metropolitan Adelaide, the aim is to reduce greenfield development from 25 % to 15 % (DPTI, 2017). In Sydney and Melbourne, where infill accounts for approxi­ mately 70 % of growth, there are objectives to retain the current balance between infill and greenfield residential development (DELWP, 2014; DPE, 2014). There are no infill targets in Darwin or Canberra. However, there is an expectation that significant levels of extensive expansion will continue.

3.3. Sustainable urban growth A theme in all documents is that urban planning that privileges motor vehicle use is not environmentally, socially, or economically sustainable and an alternative model is required. Motor vehicle-oriented forms of previous development and the car dependency it spawns is argued to have created sustainability problems requiring amelioration. In the preamble to the Plan for Growing Sydney (DPE, 2014, p. 4), for instance, the then Minister for Planning states: It is critical not to repeat the mistakes of the past – dispersed housing growth that resulted in a sprawling and poorly connected city. Problems of the previous growth commonly cited include traffic congestion, lengthy and growing commutes, excessive greenhouse gas emissions, and poor access to social services and employment in middle and outer suburbs. The inefficiencies of the car in relation to fuel use and infrastructure requirements such as roads, bridges, car parks etc. are also commonly mentioned as problems. For example, the Queensland State Infrastructure Plan (DILGP, 2016, p. 21) highlights the economic costs of congestion: Road connections within SEQ [South East Queensland] are increas­ ingly under pressure, with congestion and delays reducing economic efficiency and costing industry millions per year. The association between the urban environment, motor vehicle use and physical health is also widely acknowledged. For example, Plan Melbourne (DELWP, 2014, p. 116) states: At present in Australia, the built environment often does not encourage active lifestyles, but reinforces sedentary behaviour and car dependence. The favoured ‘sustainable’ urban development approach articulated in all land use and transport plans is characterised as intensive infill within the current urban footprint rather than continued extensive greenfield growth on suburban fringes. In particular, new urban and ‘smart growth’ options of the style advocated by Newman and

3.4. Creating policy contradictions – active and public transport vs roads While support for walking, cycling and public transport is evident in all jurisdictions, there is also in most jurisdictions an equally strong or stronger commitment to road infrastructure as a means of alleviating congestion. This is despite the evidence that building road infrastructure induces greater use of private motor vehicles and less walking, cycling and public transport use and poorer population heath as a result (Ewing and Cervero, 2010; Ewing et al., 2015; Ewing and Handy, 2009; de Dios Ortuzar and Willumsen, 2011, Frank, and Engelke, 2005). Nevertheless, in all jurisdictions, a causal relationship is drawn be­ tween the designs of urban environments, reductions in vehicle kilo­ metres travelled (VKT), and health and wellbeing. In particular, documents refer explicitly to the benefits that walking and cycling (for both recreation and active transport) can have on physical activity levels and health. The NSW Long term Transport Plan (Transport for NSW, 2012, p. 36) includes the following statement: The NSW Centre for Population Health [a government department] has observed that public transport use, walking and cycling are associ­ ated with a number of health benefits, including a reduced incidence of obesity, higher levels of exercise and improved mental health. A common objective in all documents is to reduce VKT for health and other environmental, social, and economic reasons. The major strategy to achieve this is to integrate new land uses with active transport and public transport infrastructure. Most metropolitan area plans have goals or objectives to increase walking and cycling via strategies such as building and upgrading paths and end of journey cycling facilities at major destinations, such as activity centres and transit hubs. Neverthe­ less, public transport is expected to be the main means by which private 4

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motor vehicle journeys are substituted. To this end, there is a common objective to target new residential and commercial development around existing or proposed high-frequency public transport corridors. There are also numerous strategies to upgrade and expand existing public transport facilities and infrastructure such as bus rapid transit corridors, light rail and heavy rail tracks, and interchanges. For example, Plan Melbourne (DELWP, 2014, p. 89) has a strategy to: Complete planning for a metro system, including planning of rail links to Rowville and Doncaster and assess the feasibility of a second rail tunnel from Clifton Hill via Parkville to the Fisherman’s Bend Urban Renewal Area. However, there are also major developments underway or proposed in all jurisdictions to expand motorway networks, upgrade arterial roads, and clear chokepoints with intersection upgrades, flyovers and railway level crossing removals. The stated aim and justification often provided for these road focused policies is to reduce congestion as a means of improving freight movements and productivity. However, such policies also induce increased use of private cars which can nullify any congestion improvements over the medium to long term (Ewing and Cervero, 2010; Ewing et al., 2015). For example, the NSW Long term Transport Plan (Transport for NSW, 2012, p. 102) states: City-wide road congestion and travel delays are impacted by gaps in Sydney’s motorway network. Our motorways – and the arterial road network that feeds into them – are the major routes used for direct access to Sydney’s major centres from other parts of the city and from our re­ gions. They are also critical to the efficient operation of the road freight network. An efficient motorway network must support major growth areas in the North West and South West and support the productivity of the freight and logistics industry and its connections to the ports and Sydney Airport, intermodal hubs and freight activity centres. 3.5Linking sustainability with proximity and accessibility and the role of major destinations Linking sustainability, proximity and accessibility to major destina­ tions is used as a justification for urban intensification and infill over fringe greenfield expansion in most documents. Destinations highlighted include community and education facilities, and public transport and activity centres where a diversity of services, facilities and places are agglomerated. Two main strategies were advocated in the policies analysed to place residents nearer quality destinations. The first is increasing residential densities in Central Business Dis­ tricts, inner suburbs and some middle suburbs where hard and soft infrastructure is in place, and service sector employment is high and growing. For example the South Australian Integrated Transport and Land Use Plan (DPTI, 2015, p. 12) states: Prioritising transport infrastructure and services to encourage mixed-use development in inner and middle Adelaide. Providing adequate transport services to low density, new outer metropolitan growth areas can be expensive and inefficient. With more people wanting to live in inner and middle Adelaide, providing transport that facilitates higher density, mixed-use development in the inner and middle areas needs to be a priority. This strategy increases the numbers of residents in already liveable and often commercially attractive places. Encouraging greater numbers of people to live in already liveable locations means new residents will be supported to adopt healthier lifestyles compared to if they had been housed in new estates on the urban fringe. However, this policy alone does nothing to improve the liveability of other less liveable established suburbs in the middle and outer suburbs. The second strategy is to facilitate an increase in services and service sector employment in middle and outer suburbs where most people live but where service sector employment levels are comparatively low. This is a positive initiative for health and health equity as, if successful; it improves access by reducing distances between middle and outer sub­ urban residents and services and employment, and results in less time

spent in cars. The focus of increased development and services in the middle and outer suburbs of Sydney, Melbourne, South East Queens­ land, Perth and Adelaide is predominantly large district and regional activity centres. The objective is for targeted activity centres to become more than shopping centres (which many currently are) and incorporate a comprehensive range of social, civic, educational, entertainment and commercial premises, as well as high and medium density residences in order to create significant mixed use centres at the scale of, and in the form of, small city or major town centres. For example, the South East Queensland Regional Plan (DPI, 2009, p. 100) states: Transform activity centres that are dominated by enclosed retail into a main-street format as redevelopment occurs by including active street frontages, integrating development with surrounding public spaces and activities, and introducing more employment opportunities and a wider range of services. Activity centres targeted for regeneration and expansion are also typically close to railway stations in order to facilitate transit-oriented development. However, the well documented tension in transit ori­ ented developments between their often conflicting functions as public gathering places and transit interchanges is not acknowledged (Daisa, 2010, Mees, 2009). Prioritising the public gathering place function re­ quires a focus upon liveability and the diversity, connection, design and fine grained detail of buildings and the places between them in order to facilitate walking and social engagement (Gehl, 2013). On the other hand, the transit interchange function prioritises increasing transit use by making interchange access, and movement between transport modes, as easy and convenient as possible. This often involves expansive bus transfer areas close to platforms, ride drop-off areas, and park-and-ride facilities (Daisa, 2012; Mees, 2009). While these facilities increase public transport patronage, they also detract from the features required for walkability, liveability and diverse public life (Mees, 2009). An indication of intended leanings in this regard is that Sydney, Melbourne, Adelaide, Canberra, and Perth’s transport plans all advocate park-and-ride facilities at railway stations as a means of increasing public transport patronage. Fig. 1 from the NSW Long term Transport Plan illustrates a favoured development model where transit node is priori­ tised over the walkability, human scale, and fine grained integration and mixing of diverse uses required for liveability and/or transit oriented development (Calthorpe, 1993; Gehl, 2013). In all jurisdictions, infill is promoted through proposed changes to land use regulation and infrastructure investments in targeted locations. The targeted growth options include apartments within the Central Business District and inner suburbs, major brownfield redevelopments on former industrial sites and small site redevelopments along rail routes and arterial road transit corridors. Other targeted areas are the pedes­ trian catchments of major suburban activity centres and redeveloped public housing estates. In all jurisdictions, there is a strong association between urban regeneration projects, consequent improvements to liveability, and targeted infill. While targeted infill is prominent in policy goals, objectives and strategies, there are notable policy silences in all jurisdictions regarding the common practice of the ad hoc demolition of older detached dwellings and their replacement with one or more new dwellings. Land use regulations have been shown to affect the extent of this phenomenon and the yield, diversity and affordability of new housing produced from it (McGreevy, 2018; Wiesel et al., 2013). 3.5. Variable definitions of what constitutes neighbourhood walkability Although precise figures vary in the academic literature, a ten min­ ute walk or around 800 m in a pedestrian oriented suburb is widely recognised as the maximum distance between home and destinations likely to facilitate widespread neighbourhood walking (Adkins et al., 2012; Gunn et al., 2017, Mouden et al., 2006). The significance of neighbourhood destinations, distance and walking is recognised in Melbourne, Perth, South East Queensland, Canberra and Adelaide. The 5

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Fig. 1. Example of node significantly trumping liveability (Transport for NSW, 2012, p. 37).

Thirty Year Plan for Adelaide refers to a ‘walkable’ distance of 800 m (DPTI, 2017). However, activity centre destinations within this desig­ nated proximity are described as shops rather than the diverse activity centres that the Plan champions elsewhere. In the South East Queens­ land Plan (DPI, 2009), transit oriented developments encompass areas within a comfortable 10-minute walk. The ACT Planning Strategy (EPSD, 2012) defines walking distance as 10 min. The WA Liveable Neighbour­ hood Policy (WAPC, 2009, p. 11) provides the most comprehensive strategies for the developments of walkable neighbourhoods : • Local structure plans should show: walkable neighbourhoods, rep­ resented by approximate circles of 400− 450 m radius around proposed neighbourhood and town centres, superimposed over the structure plan; Plan Melbourne (DELWP, 2014) designates neighbourhood proximity to destinations other than public transport stops as being within 20 min by any transport mode. In the NSW Long term Transport Plan (Transport for NSW, 2012) accessibility to destinations other than public transport stops is seen as being within 30 min by any mode. Both 20 and 30 min travel distances are well beyond those commonly referred to as walkable (Adkins et al., 2012; Gunn et al., 2017, Mouden et al., 2006). The issue of distance becomes increasingly relevant to walkability in middle and outer suburbs where infill is targeted within walking dis­ tance of large well connected regional and district activity centres. For example the NSW Long term Transport Plan (Transport for NSW, 2012, p. 78) states: Medium and high density housing will be encouraged within the walking catchments of larger centres well serviced by public transport and infrastructure. Some of the most effective measures for health and health equity occur at the level of the home neighbourhood. Research shows that

residents who live in neighbourhoods of pedestrian oriented streets within walking distance of a diversity of destinations (e.g. shops, res­ taurants, services, community facilities, schools, parks or public trans­ port stops) are more likely to walk and do so more often for both recreation and active transport than residents in car oriented suburbs (Boulange et al., 2017; Hooper et al., 2015; Moudon et al., 2006; Saelens and Handy, 2008). Residents walk even more and also partake in ‘sta­ tionary’ optional and social activities such as reading, talking, listening, watching, playing and enjoying the company of strangers where a di­ versity of destinations are agglomerated into traditional town centres and high streets (Cattell et al., 2008; Gehl, 2013; Mehta, 2007; Saelens and Handy, 2008). Thus, the quality of neighbourhood is at least as important for health and health equity as access to large activity centres and metropolitan wide destinations. Therefore, a healthy equitable city would be a metropolitan area of pedestrian oriented neighbourhoods connected to each other and major metropolitan wide destinations via networked road, public transport, walking and cycling infrastructure. In Australia, most middle and outer suburbs do not have the desti­ nations, design, residential density or access to public transport required for maximum walkability and metropolitan wide access (Arundel et al., 2017). Therefore, maximizing improvements in population health and health equity requires a triple pronged policy focus of; improving the walking infrastructure, increasing housing density via infill, and retro­ fitting destinations and neighbourhood precincts in all automobile ori­ ented suburbs as an alternative to greenfield expansion. We did not find any evidence of this approach being proposed in any of the documents reviewed. Instead, in established suburbs, regenera­ tion initiatives to improve liveability are attached to broadacre green­ field and brownfield developments and targeted residential infill and 6

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densification. Areas targeted for infill are predominantly in inner and middle suburbs. In outer suburbs, the large activity centres targeted for infill and associated liveability improvements are spaced many kilo­ metres apart and have large suburban catchments well beyond walking distance. Fig. 2, a map from the 30 Year Plan for Adelaide, highlights the contrast between the breadth of targeted corridors (highlighted in yel­ low) within 10 km of the city and the relative sparsity of potential

activity centre targets (highlighted as red and blue dots) beyond ten kilometres. The importance of density in providing destination viability and the contribution this makes to neighbourhood walkability is recognised in most planning documents. However, the minimum suburban density target in all major cities is 15 dwellings per hectare which in most research is either the bare minimum or too low to facilitate

Fig. 2. 30 Year Plan: Activity centres and mass transit routes (DPTI, 2017, p. 131). 7

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neighbourhood walkability (Boulange et al., 2017; Calthorpe, 1993; Giles-Corti et al., 2014; Handy, 2005; Ewing and Cervero, 2010; New­ man and Kenworthy, 2015). In addition, only the ACT Planning Strategy (EPSD, 2012) has objectives to use infill to increase population densities in all suburbs not just those targeted for growth.

and soft surfaces within existing urban footprints as detached dwellings on large allotments with low site coverage are progressively replaced by multiple dwellings with high site coverage (Brunner and Cozens, 2013). This paradox and/or the potential loss of private open space and its health implications are not mentioned in any document. Nevertheless, the importance of green streets to health and walkability is generally recognised and there are strategies in some documents, in particular the 30 year Plan for Adelaide (DPTI, 2017), to increase the green canopy via new plantings.

3.6. Targeting infill to balance demands Of the targeted development options countenanced, arterial corridor focussed redevelopment has the potential to spread the benefits of associated renewal and liveability the widest. This is simply because there are far more arterial road corridors than rail corridors or major activity centres, and bus and tram stops can be spaced much closer together than heavy rail stations. However, arterial transit corridor development creates tensions between the role of the road as a high street or pedestrian ‘place’ and that of a traffic arterial. One major issue is noise and air pollution. Pollution is not spread evenly across metro­ politan areas but rather heavily concentrated within a few hundred metres of arterial roads; precisely the locations targeted for higher densities and renewal (Oakes et al., 2016; Tayarani et al., 2016). Schweitzer and Zhou (2010) show that living, working or routinely travelling through areas with high concentrations of exhaust emissions is detrimental to health, and can nullify the fitness benefits obtained from increased walking and cycling. Thus, while intensive development done well decreases average VKT and associated emissions, it places greater numbers of people, for greater amounts of time, in areas where pollution is concentrated and most damaging (Tayarani et al., 2016). Overcoming the paradox and its negative health implications means that a focus on corridor infill requires a complementary objective to reduce emissions from individual vehicles. There are no such objectives or strategies in any of the documents. In addition, Adkins et al. (2012) note that one of the greatest barriers to walking at the neighbourhood level and the use of ‘high streets’ as gathering places are arterial roads full of fast moving traffic. While there are silences on the tension between arterial roads and place in most documents, the Thirty Year Plan for Adelaide and Perth’s Directions 2031 and Beyond offer a policy of link (traffic arterial) and place (pedestrian oriented gathering place) (DPTI, 2017; WAPC, 2010). The Thirty Year Plan for Greater Adelaide (DPTI, 2017, p. 89) asserts: Link and Place approach advocates that both these functions should be given equal consideration, with the balance guided by the street’s role within a wider street network hierarchy.

3.8. Housing as an influence on social equity The availability of affordable housing for low income earners and disadvantaged groups is viewed in most jurisdictions’ planning and housing policies as a major component of equity. However, only South Australia provides a price definition to clarify what constitutes ‘afford­ able’. In general, ensuring a sufficient supply of development ready sites for new housing construction is seen as the primary means of avoiding affordability problems. In addition, noting the imbalance between household size and the style and size of the established housing stock, Western Australia, South Australia, Tasmania, and Victoria see increasing housing diversity within well located infill as a means of increasing affordability. On the other hand, demand-side fiscal issues that produce house price inflation are not mentioned. There are some references to inclusionary zoning to increase affordability. The Plan for Growing Sydney (DPE, 2014) advocates using zoning incentives for developers who include social and affordable housing in projects. Western Australia’s Affordable Housing Strategy 2010–2020 (WAHA, 2010) and The Plan for Growing Sydney (DPE, 2014) include a requirement that a proportion of new developments and land releases with direct government involvement have affordable al­ locations. The Thirty Year Plan for Greater Adelaide (DPTI, 2017) mandates that 15 % of dwellings in all major developments be afford­ able). Many jurisdictions also have specific strategies to construct new housing for disadvantaged groups. However, none of the documents analysed had objectives or strategies to lift the numbers of public or community rental housing as a proportion of the overall housing stock as an equity measure. In most jurisdictions, housing affordability also includes the extra access costs that occur by being forced to live in poorly located dwell­ ings. For example, the South East Queensland Regional Plan (DPI, 2009, p. 79) has a strategy to: ensure the planning and development of residential areas avoids creating communities of social and locational disadvantage. Good location and access generally conforms to a liveability defini­ tion and includes easy access to employment, education, public open space, local shops, health and community services, and leisure and cultural opportunities. For example the WA State Planning Strategy 2050 (WAPC, 2016, p. 95) states: The affordability of living takes into consideration not only the cost of housing but also the financial cost of living (price of food and trans­ port costs associated with travelling to work, education, shopping and community facilities), and basic household running costs of utilities (such as water and energy). The Thirty Year Plan for Greater Adelaide (DPTI, 2017) and Perth’s Directions 2031 and Beyond (WAPC, 2010) acknowledge the role that the design, size, and orientation of individual dwellings can have upon household energy costs. However, in general, the specific details of design, location and orientation, required to make individual dwellings healthier via access to sun, fresh air and views, as well as climatically comfortable and energy efficient, are not included in these higher order strategies. While there are detailed strategies for the design of neigh­ bourhoods in some documents, the responsibility for the design of in­ dividual dwellings, if mentioned at all, is delegated to other documents.

3.7. Green space The importance of parks and open space for health and wellbeing, particularly physical activity, is widely acknowledged within land use related documents and ensuring open space is a feature of development and redevelopments is highlighted. For example, Plan Melbourne (DELWP, 2014, p. 113) has a strategy to: Prepare a metropolitan open space strategy. The strategy will include measures to improve the provision and protection of open space, and determine the need for new open space in areas that are expected to grow substantially; and will update regulations outlining the role of all levels of government. In addition, protecting significant natural environments, ecosystems, habitats, coasts, and waterways, as well as agricultural land and water catchments, from urban encroachment is routinely used as an argument for infill over continued extensive expansion. However, despite the health benefits the documents and research espouse from living close to parks, urban forests, green corridors, waterways and coasts (Giles-Corti et al., 2005, Hooper, 2015) there are no strategies in any of the docu­ ments to increase residential infill in areas adjacent to these places. Urban consolidation reduces extensive urban growth and the consequent loss of natural environments and and/or agricultural land on urban fringes. However, it can also lead to a loss of trees, green spaces 8

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4. Discussion

improvements in housing affordability or accessibility.

This article has provided a detailed assessment of the extent to which Australian state and federal government urban planning related policies have the potential to improve health and health equity. Our document analysis shows that all jurisdictions acknowledge the links between urban environments and the health of individuals and populations. In general, improved population health is viewed as a co-benefit and cojustification (along with environmental, social, and economic benefits) for urban development that is compact, mixed use, walkable, transit oriented, and liveable. One of the greatest challenges for Australian cities to become healthier and more equitable is moving from an evolved vehicle oriented metropolitan form to one that combines liveable pedestrian, cycling and public transport orientations. Such a transformation requires the latter modes to be prioritised in policy intent with concordant funding and implementation (Frumkin 2004, Mees, 2014, McIntosh, et al., 2014, Pucher et al., 2010). There is however no evidence of such a prioriti­ sation in the documents analysed. While there are numerous objectives and strategies to improve and increase active and public transport, there is no evidence of these being prioritised over (or even to the same extent as) infrastructure that facilitates private motor vehicle use. Most notably all jurisdictions propose substantial upgrades to road infrastructure and additional road lanes across the road network to relieve congestion. Although often justified upon productivity grounds in the policies, research shows the most significant result of adding road capacity is inducing greater levels of vehicle use rather than reducing congestion (Cervero, 2002; Ewing and Cervero, 2010; McIntosh et al., 2014). The goal of redeveloping large suburban activity centres into large, complex, mixed use places containing networked transit nodes has the potential to improve accessibility and increase the numbers of people using public transport (Badland et al., 2014; Handy and Clifton, 2001; Piatkowski et al., 2015). The targeting of infill and associated liveability improvements along transit corridors in inner and to a lesser extent middle suburbs, and around significant activity centres in middle and outer suburbs has the potential to produce healthier environments for existing and new residents in these areas. However, no jurisdiction has a goal to improve liveability in all established suburbs. This is particularly problematic for equity, given outer and middle suburbs, which often lie outside targeted infill areas, are usually the least liveable places within Australian cities (Arundel et al., 2017) and house the most disadvan­ taged people. Broadly, equity is evident in two commonly expressed objectives; access to affordable housing and reasonable proximity to services, fa­ cilities and employment from that housing. From a health equity perspective, this is a very narrow understanding (for instance see WHO UN HABITAT, 2010). In general, most jurisdictions seem to subscribe to the notion that housing affordability is best achieved by ensuring supply continually matches demand. The importance of ensuring an ongoing supply of developable sites is often emphasized to this end. There is also a dominant assumption that encouraging housing diversity in infill de­ velopments will lead to more affordable housing. Some jurisdictions also have inclusionary regulations to encourage or mandate the development of affordable housing. However, the numbers likely to be produced in these schemes are small compared to the numbers of houses built annually. No jurisdiction has a mandated target for a proportionally rising supply of social housing, despite the current supply of affordable rental accommodation for low income households being grossly inade­ quate and contributing in a major way to poverty and homelessness (Anglicare, 2017; Gurran and Phibbs, 2015). The desire for an ongoing supply of developable land also means that in all cities other than Adelaide greenfield development on the urban fringes will continue to accommodate a large portion of new housing. This potentially un­ dermines the other components of affordability they articulated like easy access to services, places, and employment. Therefore, it is difficult to see the policies reviewed leading to increasing equity via substantial

5. Limitations A strength of this research is that a census of all relevant policies was included in the study. This allowed us to develop the first ever a comprehensive, qualitative, investigation of Australian land use plan­ ning through a determinants of health lens. However, to ensure that the policy analysis was rigorous, and remained manageable, we applied transparent, time bound criteria for document collection. Given that the planning policy landscape is dynamic (reflecting its political roots) (Harvey, 1989), we were conscious that the policy landscape would likely change as we conducted the research. There are also issues that are peculiar to single jurisdictions that a nationwide thematic analysis is unable to be explain. In addition, our research focussed on the agenda setting point in the policy cycle (Howlett et al., 2009). Capturing how effectively the goals, objective and strategies outlined in the documents analysed are imple­ mented or delivered was beyond the scope of this research. Future research should focus on this, although the focus is likely to shift from technical inclusion of issues to the institutional reasons (likely to concern power, resources and governance) behind effective or ineffec­ tive implementation. We also note that urban planning is a highly contested area in which the requirements of private developers and the health needs of the population can conflict. The Australian urban planning policies and acts that are examined here do not make this potential conflict evident (although we are investigating this in other phases of the project where we focus on the institutional influences on urban planning). 6. Conclusion This paper has examined the extent to which key determinants of health and health equity have been included in urban planning policy and acts. We found a widespread acknowledgement of the links between urban environments, the policies that shape them and health and well­ being. However, in all jurisdictions, goals and objectives that advance health exist alongside others that have the potential to undermine or weaken health enhancing efforts. In particular, continued strategies to expand and improve road networks have the potential to undermine objectives to improve neighbourhood liveability, and increase the use of active transport and public transport. In addition, the association be­ tween liveability improvements and targeted infill means liveability deficiencies in the most car dependent and non-liveable of suburbs are overlooked. Equity is only marginally considered and most frequently in relation to housing affordability and physical proximity to services, employment opportunities, and public transport for disadvantaged groups. To our knowledge, this research is the first census of all land use planning related policies in a single country to understand their poten­ tial impact on social determinants of health and health equity. Our findings facilitate understanding of the crucial and complex in­ tersections between land use planning policy and the social de­ terminants of health and health equity. This is important since optimised, systemic action on social determinants of health and health equity has significant potential to improve population health as well as make better use of public funds in a number of policy sectors. Overall, the findings demonstrate health and health equity are on the urban planning policy agenda but are more visible in the rhetoric and aspirations of acts and policies than the recommendations. Our detailed analyses show that more work is necessary to develop the required detail for these policies to create healthy and equitable places, regions and cities.

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CRediT authorship contribution statement

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