Urban Ecology and Human Health
Urban Ecology and Human Health
Abstract and Keywords
Contact with nature is a determinant of health. In order to promote the health benefits of contact with nature in cities the design, management, and maintenance of urban green space require integration of ecological, public health, and planning knowledge. The aim of this chapter is to provide an overview of the role that urban ecological knowledge can play in health promotion and disease prevention. This is achieved through a critical review of the literature and of public health activities from a range of countries. The first part of the chapter focuses on physical health and addresses the contributions of urban green space, through opportunities for physical activity, to the prevention of cardiovascular disease, some types of cancer, and type II diabetes. The effects of urban green space on the mental health and wellbeing of people may have a role to play in the treatment of depression and anxiety. Thus the psychological health effects of contact with nature are outlined in the second part of the chapter. The third part is concerned with the contributions of urban green space to the social determinants of health such as community wellbeing, social inclusion, and quality of life. This chapter highlights that urban ecological knowledge can play a principal role in improving the physical, biological, and social urban environments. Furthermore, it establishes how ecological knowledge can be integrated in the planning, design, and management of cities and of healthcare facilities and initiatives.
The aim of this chapter is to provide an overview of the role that urban greenspace can play in public health approaches, which are aimed at creating the broad social and environmental conditions that promote human health and well-being. Cardiovascular disease and mental health problems are major public health challenges facing urban populations in the twenty-first century. Public health approaches to dealing with these issues may be ‘downstream’, focusing on treating the symptoms of ill health through the acute healthcare system; or they may be ‘upstream’, focusing on creating the social, economic, and environmental conditions which promote health and prevent illness and disease. McKinlay (1979) first used the term ‘looking upstream’ in an address to the American Heart Association. It refers to the analogy of a rapidly flowing river to represent ill health, whereby many patients fall into the water only to be rescued downstream by doctors who have no time to look upstream to consider why the patients are falling in. He characterized ‘downstream’ activity as short term and related to specific problems at the individual level, and upstream as long term and related to the prevention of problems and the promotion of health.
Urban ecosystems can make a significant contribution to ‘upstream activity’ in public health. Urban ecosystems are inextricably linked to providing and maintaining the broad environmental conditions that are central to the liveability of cities (i.e. climate, hydrology, soils, and the natural and built environments; see Sections 1 and 4). Understanding the dynamic interaction between environmental, ecological, and social systems in urban areas is key to the understanding of public health determinants. So, knowledge of urban ecosystems could be used to inform ‘upstream’ public health interventions.
Urban ecosystems comprise mosaics of habitats including forests, grasslands, formal parks and gardens, churchyards, incidental greenspace, private gardens, and wetlands (see Section 2), as well as numerous ecological processes that determine their functioning (see Section 3). In this chapter, the term ‘urban greenspace’ is used as an umbrella term for all the different, natural and human maintained, urban habitats and their ecological processes. Urban greenspace provides opportunities for urban residents to be in contact with the natural environment. Pretty et al. (2005) suggested that there are three ways in which people can gain health benefits from nature. The first way is through active participation, such as sports, gardening, or conservation work. Secondly, people gain health benefits by the presence of nearby nature which is incidental to their personal activity (e.g. cycling or walking near a greenspace). Thirdly, people can gain health benefits by simply viewing natural scenes.
Evidence presented in Chapter 5.1 (Douglas and Ravetz) suggests that human interaction with urban greenspace may have a key role in the prevention of disease and the promotion of health and well-being. Indeed, urban greenspace plays a central role in a number of public health activities focusing on improving human physical health, and psychological and social well-being. Table 5.2.1 outlines examples of such public health activities across different spatial levels.
Table 5.2.1 Examples of public health activities that involve contact with greenspace and corresponding ecological knowledge that could be integrated into their design
Example of public health activities
Relevant ecological knowledge
Environmental, nature conservation and public health policy and/or legislative frameworks; Ecosystem management approaches to public health (EcoHealth);
Application of ecological and landscape ecology knowledge in habitat creation and restoration and in green infrastructure planning;
City/wider population & Neighbourhood
Walking for Health Initiative;
Riding for the Disabled;
Casting for Recovery;
Knowledge of the distribution and abundance of habitats and species (including infectious diseases);
Use of applied veterinary knowledge;
Use of nature conservation knowledge and skills;
Natural play areas;
Use of applied ecological knowledge of plants and habitats (i.e. in horticulture, gardening, and vegetable growing);
Creation of interconnected networks of urban greenspaces;
Creation of natural play areas, school gardens, green roofs and green walls;
Neighbourhood & Individual
Quality of management and maintenance of greenspace;
Creating therapeutic landscapes and healing gardens;
Incorporating green elements into indoor and outdoor healthcare facilities.
Green exercise routines;
Post traumatic stress recovery activities.
Key: The list of examples and of relevant ecological knowledge is not exhaustive and is mainly drawn from examples within the UK; there may be significant overlap between the physical, psychological, and community health outcomes of different public health activities; EcoHealth: public health initiatives that incorporate community involvement as well as ecological, veterinary, and human health knowledge in ecosystem management; Walking for Health Initiative (previously known as Walking the Way to Health Initiative): encourages the enjoyment of natural spaces through participation in local health walks; Green Gym ®: an initiative that integrates nature conservation, human health, community well-being and environmental improvements; Riding for the Disabled: a scheme that improves the lives of people with disabilities through the provision of opportunities for riding and/or carriage riding; Sure Start: a government programme to deliver the best start in life for every child by bringing together early education, childcare, health, and family support; Casting for Recovery: an outdoor programme which provides fly fishing retreats for women who have, or have had, breast cancer; Mosaic: builds links between ethnic communities and national parks; Forest Schools: an innovative educational approach to outdoor play and learning; Natural play areas: are greenspaces innovatively designed for children’s play; Community allotments: plots of land leased from the local authority by people to grow their own fruit and vegetables; Nature trails: paths that run through greenspaces; Horticultural therapy: programmes that use planting and caring of plants as a therapeutic method; Sensory gardens: gardens specifically designed to stimulate all of human senses; Hospital gardens: greenspaces incorporated in the outdoor design of hospitals, which may or may not follow the principles of therapeutic landscape or healing gardens design; Prison gardens: greenspaces provided by prisons for inmates to care for; Green exercise routines: formal or informal physical activity taking place in greenspaces; Pet therapy: programmes that incorporate the caring of pets as part of therapy for psychological ill health; Post traumatic stress recovery activities: that incorporate contact with greenspaces.
(p.265) Contact with urban greenspace can also help to alleviate stress, restore attention capacity, and provide opportunities for people to self-regulate their emotions. The effects of urban greenspace on the psychological health of people may have a role to play in the treatment of depression and anxiety. These aspects and related practical schemes, such as green exercise and ecotherapy initiatives, are outlined in the second part of the chapter.
The third part of the chapter is concerned with the social determinants of health. Enhancing feelings of community well-being, social inclusion, and improving quality of life are effects of urban greenspace that could improve the liveability and enjoyment of urban areas. Green Gym® in the UK is a good example of an initiative that integrates nature conservation, human health, community well-being, and environmental improvements. Therefore, this chapter will highlight that urban ecological knowledge integrated into the planning, design, and management of cities and of healthcare systems and initiatives, can play a principal role in improving the physical, biological, and social urban environments.
5.2.2 Urban ecology and physical health
Greenery is seen as a factor that may increase walking and physical activity patterns in neighbourhoods (Jackson 2003). The structure, composition, and management of urban greenspaces can influence how they are perceived and used by people. Urban habitats that are not perceived as threatening can provide both physical and psychological health benefits to people who may be in passive contact with, and to those who are physically active in, them. The application of ecological knowledge is central to maintaining the structure, complexity, and composition of urban habitats that are necessary to meet both human aesthetic and nature conservation goals.
Irrespective of peoples’ socio-economic background, contact with urban greenspace can improve life expectancy (Takano et al. 2002) and self-reported health (de Vries et al. 2003). These health effects may be related to the effects of urban greenspaces in reducing air pollution (Patrick & Farmer 2007) and urban noise (Gidlof-Gunnarsson & Ohstrom 2007), as well as in ameliorating the urban heat island effect (Whitford et al. 2001). Furthermore, urban greenspaces provide opportunities for people to engage in formal and informal physical activities which can have additional health effects to those gained from improved environmental conditions.
Sedentary lifestyles are associated with increased risks for morbidity and mortality. The World Health Organization (2002) estimated that, globally, physical inactivity causes 1.9 million deaths annually and that 22 per cent of these mortality cases are attributable to ischaemic heart disease; and between 10 and 16 per cent are caused by breast, colon, and rectal cancers, and diabetes mellitus. The proportion of mortality associated with physical inactivity is highest in the American, European, and Western Pacific regions. In Eastern European countries the proportion of all deaths that can be attributed to physical inactivity can be up to 10 per cent and in the rest of Europe and Northern America (including Canada) it can be up to 8 per cent (World Health Organization 2002). Empirical studies have shown that people engaging regularly in moderate to vigorous physical activity have a reduced risk of developing hypertension, ischemic heart disease, diabetes, colorectal and breast cancers, and depression. Furthermore, they are more likely to maintain healthy body weight and musculoskeletal health (World Health Organization 2002). Hence, incorporating physical activity in lifestyles is key to maintaining good health.
The minimum amount of physical activity required by adults to gain any health benefits is at least thirty minutes of moderate intensity physical activity on at least five days a week (moderate intensity physical activity is expenditure of 3 to 6 times the rate at which adults burn 4.187 Joule, i.e. 1 kcal, at rest; Dawson et al. 2006). People who do not reach these levels of physical activity are classified as physical inactive (having a sedentary lifestyle). Although physical activity can be taken at gyms, motivation to continue physical activity is more likely to be sustained if this is taken in the natural environment (Bird 2004).
There is some evidence that proximity to urban greenspace may be associated with increased levels of physical activity even after controlling for education levels, age, and sex (Humpel et al. 2004). (p.266) However, another study that also controlled for socio-economic characteristics found that the amount of greenspace in the neighbourhood did not necessarily make people more physically active (Maas et al. 2008). Even if the role of urban greenspace in increasing levels of physical activity is disputed, it has been argued that appropriately designed urban landscapes and gardens could be used to increase physical activity in sedentary and vulnerable patients or residents (Bird 2004).
The concept of green exercise refers to the synergy of physical activity in natural settings and the consequent gain in health benefits (Pretty et al. 2005). Consequently, green exercise includes any informal physical activity that takes place in natural settings, such as walking or cycling in a local park, undertaking conservation work in local woodlands, gardening in private gardens, mountain climbing or kayaking in rivers. Green exercise has been found to improve self-esteem and overall physical fitness; have a positive effect on feelings of anger, confusion, depression, fatigue, tension, and vigour; and help people achieve more than the recommended amounts of weekly physical activity (Pretty et al. 2005). Common types of green exercise that are used in targeted public health initiatives for improving the physical and psychological well-being of people include walking in greenspaces and undertaking nature conservation work.
Walking is a simple way by which people can increase their physical activity levels. Recognizing this, William Bird, a UK-based General Medical Practitioner, developed the concept of health walks in 1995, that is, a brisk walk taken regularly and with the purpose of improving health (Dawson et al. 2006). In 2000, this concept gave rise to the Walking for Health Initiative (previously known as Walking the Way to Health Initiative; funded by The British Heart Foundation and the Countryside Agency until 2005, and subsequently by Natural England). This initiative has been endorsed by the UK Department of Health. The aim of Walking for Health is to engage physically inactive people, and particularly those living in areas of poor health, in walking to improve their health. Characteristically, Walking for Health schemes have been using local greenspaces to undertake health walks.
A national evaluation of the changes to physical activity levels amongst adults who participated in Walking for Health schemes, undertaken by Dawson et al. (2006) on behalf of Natural England, found that the initiative was successful in attracting people who had been affected by ill health (physical or psychological) and in particular disadvantaged groups (i.e. living in areas of poor health, non-white groups, high socio-economic deprivation, and registered disabled). Furthermore, the evaluation found that the initiative played a key role in the rehabilitation and social and psychological support of people recovering from ill health, and that it helped participants achieve and retain the recommended levels of weekly physical activity. Overall, the Walking for Health Initiative made participants feel healthier and more socially connected (Dawson et al. 2006).
On the other hand, the Walking for Health evaluation found that the most frequent worries of people who did not engage in walking in local greenspaces were about perceptions of personal safety in terms of both crime and health and safety issues (e.g. tripping and falling; Dawson et al. 2006). Therefore, it is essential that urban ecologists and planners understand different social perceptions of personal safety and apply this knowledge in the development of urban greenspaces.
The planning of ecological networks, green infrastructure, greenways, and green hearts (see Pauleit et al., Chapter 5.3, Colding, Chapter 4.5), as well as local parks and greenspaces, is particularly well placed to create interconnected regional to local networks of greenspaces that people can use to walk in. Connectivity between different greenspaces is important as this could increase the potential length of different health walks. Incorporating paths, and/or steps, on slopes at various gradients into the design of urban greenspace could provide health walks of different intensity. Furthermore, the creation of different habitats designed according to local communities’ needs, perceptions, and values would allow for differences in visual scenes and so promote a variety of aesthetic responses. These effects of contact with urban nature could enhance the social, physical, and psychological health benefits gained from purposeful brisk walking in urban greenspace.
Taking part in activity in urban greenspaces does not only confer physical health benefits but also brings about psychological health benefits. The report Ecotherapy – the Green Agenda for Mental Health (Mind 2007) identifies the need for greenspace to be a part of mental healthcare planning and assessment, and for General Medical Practitioners to consider referring patients for green exercise.
Mind, a UK based mental health charity, has introduced ecotherapy activities in many of its 200 local associations in England and Wales as an alternative to antidepressants (Mind 2007). This charity sees ecotherapy as a free, accessible, and clinically valid treatment of stress, anxiety, and depression through being active in nature (Mind 2007). A study of patients taking part in ecotherapy, that is, gardening, conservation work, cycling, and running found that such activities had a significantly positive effect on their psychological well-being (i.e. decreasing levels of stress and depression), and on their overall fitness and self-reported health (Mind 2007). Furthermore, improvements in self esteem, depression, and tension were greater from physical activity taken outdoors than indoors (Mind 2007).
The psychological health effects of nature are underpinned by a dual theoretical background based on stress recovery and attention restoration theories. The first of these theories stipulates that even passive viewing of natural environments after psycho-physiological stress produces stress-ameliorating effects which may ultimately confer health benefits (Ulrich 1984). The second theory suggests that contact with nature, or natural views, can confer psychological well-being benefits through attention restoration (Kaplan & Kaplan 1989). These two theories have been supported by numerous experimental studies (Sustainable Development Commission 2008).
Ulrich (1997) proposed the theory of supportive design for healthcare facilities. According to this theory positive distractions (i.e. access to greenspaces, natural views, or even indoor plants) in healthcare facilities could aid the recovery of patients (Ulrich 1997). This suggests that improvements in psychological health from (even passive) contact with nature may also lead to enhanced recovery from physical illness. If this is so, then incorporating greenspace elements in the design of healthcare facilities and green exercise in the treatment of patients becomes central. Hence, ecological knowledge could be used to inform the design, planning, and development of both outdoor and indoor healthcare facilities.
The stress reduction (Ulrich 1984) and attention restoration (Kaplan & Kaplan 1989) effects from contact with nature may be central to understanding other psychological well-being benefits gained from it. In a study on the self-regulation of mood, Korpela et al. (2001) found that visits to natural favourite places are associated with an increase in positive feelings, with forgetting worries and random thoughts, and with recovering attention focus and relaxing. Furthermore, adults with negative mood (Korpela 2003) and those with health complaints (Korpela & Ylén 2006) were more likely to visit natural favourite places than sporting, commercial, or other venues. These studies indicate that contact with urban greenspace can be a key factor in controlling negative mood as well as in improving overall self-reported health. Therefore, it is critical to create a variety of urban open and greenspaces that allow people to have informal and individual restorative experiences.
Studies have shown that the greener the play area of 7 to 12-year-old children with attention deficit disorder the better their attention focus was (Faber-Taylor et al. 2001). Another study found low-income children who had recently moved into neighbourhoods with natural views had higher levels of attention capacity than children who had moved to neighbourhoods that did not have as many natural views (Wells 2000). The Swedish concept of Forest Schools has been utilizing opportunities presented by local greenspace for integrating play activities, practical ecology, and therapeutic theory in the outdoors children’s curriculum. This concept has been adopted in other Scandinavian and European countries. Forest Schools integrate outdoor play and learning and so they engage pupils and adults with the natural environment. Forest Schools could not exist without access to appropriate greenspaces or natural areas. Integrating green roofs, green walls, and school gardens, with neighbouring formal and informal greenspaces in the planning, design, and (p.268) development of educational establishments could facilitate the development of innovative educational approaches such as Forest Schools. Additionally, promoting contact between pupils and the natural environment may have a beneficial effect on their educational achievement (Wells 2000).
In healthcare establishments in North America, healing gardens and therapeutic landscapes are used to promote the psychological and physical health benefits from contact with nature (Larson & Kreitzel n.d.). Healing gardens are associated with general healing, not necessarily referring to the cure from a given illness, and may be mainly associated with spiritual healing. On the other hand, therapeutic landscapes are specifically related by design to a particular aspect of a disease or healing process. These landscapes are designed to produce a measurable outcome, similar to the effects of medication, with regards to an illness (Larson & Kreitzel n.d.). Successful healing gardens and therapeutic landscapes include the following design principles: variety of spaces; prevalence of green material; encouragement to exercise; the provision of positive distractions; minimal intrusions; and minimal ambiguity (Larson & Kreitzel n.d.). Design principles like these could be incorporated into the planning requirements for the development of new healthcare facilities, or in the design briefs of new urban greenspaces.
5.2.4 Urban ecology and social well-being
Quality of life is a broad term that encompasses social, economic, environmental, and health factors. Greenspace can contribute to quality of life by enhancing feelings of psychosocial well-being and by improving the ambient environmental and social conditions. Shafer et al. (2000) evaluated peoples’ perceptions of how greenways may contribute to quality of life and found that reduced air pollution and access to recreational facilities were amongst the most significant contributions to quality of life. The highest contributions were the opportunities for health and fitness activity (Shafer et al. 2000). However, the importance of greenspaces for the social well-being of urban communities may be as fundamental as providing recreational and fitness opportunities.
Social relationships and community feelings are central to personal well-being. Urban greenspace can enhance such feelings and consequently contribute to the well-being of individuals. For example, a study by Kuo (2003) found that well-maintained urban greenspaces in residential areas can foster social ties between neighbours, enhance community safety and children’s play, and reduce anti-social behaviour and crime. Another study found that urban greenspaces can increase residents’ feelings of attachment towards the community and their interactions with other residents (Kim & Kaplan 2004). Furthermore, Westphal (2003) demonstrated that, although dependent on local community and organizational characteristics, engaging people in urban forestry projects can be a tool for community empowerment at the individual, organization, and community level. Therefore, urban greenspace can be a main factor in strengthening community interactions and social support. These in turn are central to individuals’ feelings of well-being (Rioux 2005).
A project that illustrates the benefits of community engagement through participation in local greenspaces is the Healthy Parks, Healthy People Campaign, run by Parks Victoria, Australia. This campaign aims to develop a community understanding of the value of parks to the health of the community. The slogan ‘Healthy Parks, Healthy People’ indicates that the health of local parks is related to the community’s health and well-being (de Kievit 2001). The campaign involves good promotion and branding; partnerships with key health organizations; graded walks (for asthma and arthritis sufferers); publications in journals; a social isolation and post-natal depression scheme; children and families bike days; engagement and participation schemes (e.g. environmental interpretation, friends’ of groups, and educational activities; de Kievit 2001). So, urban greenspaces can provide a stimulus for local community development, public health initiatives, and for developing healthier lifestyles.
Residential quality is an essential aspect of social well-being. Residential quality may be assessed on the basis of six evaluative scales comprising urban planning and design, security and social relationship, (p.269) transportation and commercial services, residential atmosphere, environmental health, and facility management (Tu & Lin 2008). Within these six evaluative scales, design and quality of urban greenspace can be a key component. Peoples’ appreciation of naturalistic (Fig. 5.2.1) or designed (Fig. 5.2.2) urban landscapes may differ, but people are more likely to prefer natural elements in urban areas, that is, natural versus designed and green versus built (Özgüner & Kendle 2006).
Lee et al. (2008) found that residents were likely to prefer neighbourhoods where the areas with trees were interconnected and varied in size and shape. On the other hand, there is also evidence to suggest that multilayered woodland edges and naturalistic looking landscapes in close proximity to where people live may not be preferred by urban residents (Jorgensen et al. 2007). Urban ecologists can play a key role in creating and maintaining urban habitats, but also in interpreting them and making them relevant to peoples’ lives, especially so when they create natural looking landscapes in close proximity to residential areas. Therefore, urban ecological knowledge can have a central role in the design of high quality urban environments.
A good example of an initiative that uses nature conservation work to improve the health of people and the local environment is the Green Gym® organized by the British Trust for Conservation Volunteers (BTCV). The BTCV is a charity dedicated to local community engagement in nature conservation work. A Green Gym® is a scheme that supports ‘people in gardening or local environmental improvement while providing opportunities for exercise and developing social networks’ (Department of Health 2004, p. 79). Green Gym® schemes are endorsed by the UK Department of Health.
Green Gym® sessions are led by trained leaders and incorporate a range of outdoor practical projects and physical jobs, such as building stone walls, maintaining paths, or habitat creation or maintenance. Participants can join independently or by referral from their General Medical Practitioner. An early evaluation of the Green Gym® has shown this scheme to be successful, but there remains scope for physical activity specialists in the National Health
The national evaluation of the Green Gym® covered 52 projects across the UK that had been established between 2003 and 2007 (Yerrell 2008). Like the earlier evaluation (Bird 2004), the national evaluation also found that the main reasons for people joining were to be outdoors and to help in local environmental improvements, while improving health was one of the least frequent reasons for joining (Yerrell 2008). People who joined the scheme having already compromised health showed significant improvements, with those having the poorest health showing the most significant improvements (physical and mental health were measured with SF12, an international standard survey covering physical and social functioning, and general physical, emotional, and mental health, pain, and vitality; Yerrell 2008). Furthermore, participants reported that the scheme improved their feelings of self-worth and that they felt they had contributed to the local environment by habitat creation or biodiversity conservation (Yerrell 2008).
The BTCV Green Gym® demonstrates the dynamic synergy between ecology and health. Participants acquire and use practical skills in applied ecology to improve local habitats and maintain species. These improvements in turn provide health benefits to other users of greenspaces. Importantly, while the participants engage in practical conservation work they gain health benefits from being in contact with nature and from being physically active.
Imaginative and creative provision of greenspaces with high quality maintenance and community engagement is salient in creating neighbourhoods that people would like to be active in. Different configurations of greenspaces have been associated with different types of experiences. For example, people may visit forest-type landscapes out of curiosity or interest, and park-type landscapes with a local café to socialize (Cottrell et al. 2005). Urban (p.271) planners have a key role to play in integrating urban ecological knowledge of habitats and species in urban design in order to create settings for a variety of social activities and experiences as well as for biodiversity.
5.2.5 Summary and conclusions
It is impossible to control the array of confounding personal, genetic, temporal, and cultural factors that affect health. So, the mechanisms that underlie the positive effects from contact with greenspace are not clear (Croucher et al. 2007). Further interdisciplinary research amongst ecologists, sociologists, biologists, public health practitioners, psychologists, and anthropologists is required to start clarifying the underlying mechanisms by which urban greenspace contributes to human health and well-being.
Some authors have argued that, despite the lack of clear causal relationships, there is sufficient evidence to conclude that urban greenspace can be a significant factor in enhancing public health (Tzoulas et al. 2007). This assumption is based on the speculation that environmentally induced changes in physiological, emotional, and cognitive processes may induce, or mediate, changes in well-being and health (Tzoulas et al. 2007). However, further empirical research is required to evaluate this assertion.
The contributions of urban ecology to physical health are mediated through opportunities for physical exercise. Physical exercise has both preventative and curative effects on, for example obesity, cardiovascular disease, and type II diabetes. Furthermore, physical exercise taking place in urban greenspaces can be more sustained than indoor activity and confers additional psychological well-being benefits. Psychological well-being benefits from taking exercise in urban greenspace may be facilitated through and/or include stress recovery; attention restoration; self regulation of mood; and children’s cognitive, physical, and emotional development. Moreover, while many of these physical and psychological health benefits depend on direct engagement with urban greenspaces, many can be gained by passive viewing. The contributions of urban ecology to social well-being are based on enhancing feelings of community well-being and satisfaction; improving quality of life; and providing preferred environments. Nonetheless, further research that integrates social, ecological, biological, and health systems is needed to establish the physical and psychological mechanisms that control the contributions to health from contact with urban greenspace (Sustainable Development Commission 2008); and to establish how ecological knowledge can be integrated in the planning, design, and management of cities and of healthcare facilities and initiatives.