Improving Value

Social Determinants of Health - Community Infrastructure

What is the “Built Environment?”

The “built environment” is the human-made environment that surrounds us as we go about our daily lives. It is widely recognized that the environments in which we live, work, learn and play have strong ties to personal health.

Certain neighborhoods have environments that are conducive to healthy living—they have safe outdoor spaces to exercise; areas for children to play; and allow community members to walk and bike safely so they do not solely depend on cars for transportation. Other neighborhoods that are not conducive to health and well-being, for example, are those that have limited availability of healthy foods, few safe places to exercise, poor housing conditions and high levels of pollution. How our built environment is designed is key to promoting good health and preventing poor health outcomes.¹

Urban Planning

Interventions to affect population health through improvements in the built environment include targeted urban planning to create green spaces and more walkable mixed residential and commercial areas. Urban planning that supports bus routes and other public transportation options that help people travel, in an affordable way, to their jobs, grocery stores and medical appointments is another important concern.

Inclusionary zoning policies can be used to help overcome barriers to access that negatively impact social determinants of health. Mixed-use zoning, in particular, would allow grocery stores, restaurants and health clinics to be located in the same building or neighborhood as affordable housing units to reduce the need for cars and public transportation. Additionally, tax incentives could be designed to bring grocery stores and healthy food options to areas that might otherwise not have them. Establishing health-focused building standards (similar to LEED Green certification in the environmental space) for new developments would incorporate factors that improve health into the building process.²

Urban planning to change the built environment should not only address ways to improve health, but also existing health inequities within the community. Planning decisions must involve collective decision-making with community members to ensure decisions include diverse and, particularly, underserved populations. When communities are not designed with low-income, people of color and disabled residents in mind, it can marginalize, and ultimately harm, them. For example, urban heat islands³ and poor air and water quality, which disproportionately affects low-income communities, can make it dangerous for people to go outside and be active in their community.⁴ As our understanding of the health impacts of the built environment evolves, we should seek to remedy, rather than perpetuate, disparate health outcomes among various populations.⁵

Evidence suggests that adjusting current practices to include strategies to improve the built environment have little or no cost and have the potential to significantly improve health outcomes.⁶

Environmental Nudges

“Our decisions are constantly shaped by subtle changes in our environment. Even choices that feel deliberate and conscious can be swayed by cues that we may not even notice, such as social norms or the setting of a default option. Behavioral scientists use the phrase “choice architecture” to describe the ways in which the environment influences how we decide.” - Jon M. Jachimowicz and Sam McNerney⁷

What are Environmental Nudges?

 Environmental nudges promote certain behaviors through subtle changes in the choice environment. The choice environment, or choice architecture, is a component of the built environment. Choice architecture is the context in which people make decisions; it refers to how an environment is shaped to present, and influence, choices to a decision-maker.⁸ Nudges can be divided into two categories: passive and active.

• Passive environmental nudges involve changing the architectural landscape to create unconscious bias towards desirable (for example, healthy) options. An example would be changing the layout of a school cafeteria to promote more nutritious foods.⁹
• Active environmental nudges focus on promoting desirable choices when a person is deciding if they want to engage in a particular behavior. An example would be labeling the caloric content on food menus so low-calorie options are easy to identify for people wanting to eat healthy. Active nudges require individuals to have a prior intention to change their behavior so that the prompts remind them of their previous plan.¹⁰

Environmental nudges relating to health can take a variety of forms, including: the availability of green spaces for play and exercise; the ways in which entertainment media subtly promote healthy behaviors; the portion sizes of meals provided in restaurants; the layout of supermarkets and cafeterias; and the availability of safe and accessible bicycle lanes and sidewalks.

How do Environmental Nudges Impact Health?

Behavior scientists have investigated how environmental nudges can influence health.

One study found that a small passive nudge, like changing the accessibility of various foods in a pay-by-weight cafeteria salad bar, impacted weight loss in a work setting. Specifically, making less healthy options more difficult to reach and changing the serving utensil reduced consumption of high-calorie foods by 8-16 percent.¹¹ Another study examined the effects of pricing strategies on the selection of low-fat snacks in vending machines. When low-fat options were promoted with reduced prices, sales increased. This effect was observed with both adult and adolescent populations.¹²

To date, efforts to use environmental nudges to improve health have been relatively small-scale in the United States. Many health advocates argue that we should incorporate this technique into broader legislative and regulatory actions, such as improving school nutrition, menu labeling, altering industry marketing practices and sin taxes that disincentivize certain behaviors.¹³ The United Kingdom’s Behavioural Insights Team—also known as the “nudge” unit—has found a variety of techniques to cue people to act in their own self-interest, and thus lessen the burden that bad habits place on society.¹⁴

One example of their work is setting up a nudge to encourage people to complete a screening for type-2 diabetes. An easy and cost-effective way to test for type-2 diabetes is through capillary glucose testing, however it requires fasting for accurate results. A nudge team set up diabetes screening stations outside of a mosque for the afternoon prayer during Ramadan, when adult Muslims fast during the day, in order to encourage those going to the mosque to participate in the screening. This intervention nudged people who already satisfied the testing requirements to participate in the screening for the chronic condition. Almost one-third of those screened were identified to be diabetic or pre-diabetic and were then referred to dietary and lifestyle education programs to manage the disease progression—thereby reducing the burden on society by preventing uncontrolled management of the disease and the accompanying health complications, healthcare costs and reduced participation in the workforce.¹⁵

There is No Neutral Choice Architecture

Those who adopt a more individualistic perspective on public health argue that it is inappropriately paternalistic for the government or private companies to use nudges to influence people’s behavior.¹⁶ However, there is no such thing as a neutral environment that does not affect our decisions; the environments in which we live inevitably influence our choices, whether that be good or bad.¹⁷

Environmental nudges that improve health are not a means of limiting choice, but rather provide people with the information and resources needed in order to make healthy decisions. Policymakers should give serious consideration to consumer-friendly, evidence-supported practices that retain choice but nudge consumers towards healthier behaviors.

Notes

1. Urban Land Institute, Building Healthy Places Toolkit, Washington, D.C. (2015).

2. The Urban Land Institute’s “Building Healthy Places Toolkit” offers 21 evidence-based recommendations for urban planning that promotes health, divided into 3 categories: physical activity; healthy food and drinking water; and healthy environment and social well-being. Urban Land Institute (2015).

3. Heat islands are areas in urban communities that experience higher temperatures due to infrastructure, such as buildings and roads, that absorb and re-emit the sun’s heat more so than the natural landscape does. Urban areas are concentrated with this type of infrastructure and have limited greenery—becoming an “island” of higher temperature compared to surrounding areas. Environmental Protection Agency, Learn About Heat Islands, https://www.epa.gov/heatislands/learn-about-heat-islands (accessed on Nov. 11, 2020).

4. Chronic lack of investment in low-income communities beginning in the early twentieth century have had lasting impacts on these communities. There is a strong body of evidence documenting low-income communities’ greater likelihood of exposure to the heat island effect, poor air and/or poor water quality; these environmental phenomena can harm, rather than support and improve, residents’ health. See: Naparstek, Arthur J., and Dennis Dooley, “Countering Urban Disinvestment through Community-Building Initiatives,” Social Work, Vol. 42, No. 5 (September 1997); Hoffman, Jeremy S., Vivek Shandas and Nicholas Pendleton, “The Effects of Historical Housing Policies on Resident Exposure to Intra-Urban Heat: A Study of 108 US Urban Areas,” Climate, Vol. 8, No. 1 (January 2020); American Lung Association, Disparities in the Impact of Air Pollution, https://www.lung.org/clean-air/outdoors/who-is-at-risk/disparities (accessed on April 20, 2022); McDonald, Yolanda J., and Nicole E. Jones, “Drinking Water Violations and Environmental Justice in the United States, 2011–2015,” American Journal of Public Health, Vol. 108, No. 10 (October 2018).

5. Bloomberg CityLab, ‘Safe Streets’ Are Not Safe for Black Lives (June 8, 2020).

6. Urban Land Institute (2015).

7. Scientific American, Governments Need to Nudge Citizens to Make Good Choices ​​​ (July 14, 2015).

8. Thaler, Richard H., and Cass R. Sunstein, Nudge: Improving Decisions About Health, Wealth, and Happiness, Yale University Press, New Haven, C.T. (2008).

9.  Kremers, S. P. J., F. F. Eves, and R. E. Andersen, “Environmental Changes to Promote Physical Activity and Healthy Dietary Behavior,” Journal of Environmental and Public Health (Sept. 6, 2012). 

10. Ibid.

11. Rozin, P., et al., “Nudge to Nobesity I: Minor Changes in Accessibility Decrease Food Intake,” Judgment and Decision Making, Vol. 6, No. 4 (2011).

12.  French Simone A., et al., “Pricing and Promotion Effects on Low-Fat Vending Snack Purchases: The CHIPS Study,” American Journal of Public Health, Vol. 91, No. 1, (2001).

13. Brownell, Kelly D., et al., "Personal Responsibility and Obesity: A Constructive Approach to a Controversial Issue," Health Affairs, Vol. 29, No. 3 (March 2010).

14. Quigley, Muireann, “Nudging for Health: On Public Policy and Designing Choice Architecture,” Medical Law Review, Vol. 21, No. 4 (2013).

15. Hallsworth, Michael, et al., Applying Behavioral Insights: Simple Ways to Improve Health Outcomes, The Behavioral Insights Team, London, U.K. (Nov. 2016).

16. Brownell (2010).

17. Kleimann Communication Group and Consumers Union, Choice Architecture: Design Decisions That Affect Consumers’ Health Plan Choices, Washington, D.C. (July 2012).

More on this Topic

• ​​​​International Journal of Behavioral Nutrition and Physical Activity (2017) Systematic literature review of built environment effects on physical activity and active transport – an update and new findings on health equity
• Build Healthy Places Network (2019) Principles for Building Healthy and Prosperous Communities
• Families USA & Build Healthy Places Network (October 2020) Webinar: Combating Health Disparities through Equitable Development
• Urban Institute (October 2020) The Unequal Commute
• Bloomberg CityLab (August 2019) CityLab University: Zoning Codes
• Food Quality and Preference (December 2019) Increasing healthy food choices through nudges: A systematic review
• NPR (April 2015) When You Make Kids' Meals Healthier by Default, They Still Eat 'Em Up
• Health Affairs (February 2013) Choice Architecture is a Better Strategy Than Engaging Patients to Spur Behavior Change
• BMC Public Health (February 2020) Health and the built environment in United States cities: measuring associations using Google Street View-derived indicators of the built environment
• Nature Sustainability (March 2022) The potential of implementing superblocks for multifunctional street use in cities