Lessons learned from co-constructing a guide on healthy urban planning and on integrating health issues into environmental impact assessments conducted on French urban development projects

Abstract

Recent regulatory evolutions gave the opportunity to professionals and academics from the health, urban planning and environment sectors – within a working group – to conduct in-depth research at a national level on health challenges in the field of EIA procedure and urban planning. This work resulted in the publication of a guide aimed at all actors involved in the urban planning decision process, which has now become a national reference document. Among the key findings of this project, three main concrete outputs caught our attention: a reference framework for Healthy Urban Planning (HUP); an all-encompassing tool for analysing urban planning projects ‘with a health lens’; an operational tool aimed at French regional health agencies (ARS) to help them formulate their health statements within the framework of the EIA regulatory procedure applied to urban development projects. This paper reviews the process of co-constructing the guide with special attention paid to the ARS tool, present the key findings and outputs and discuss the potential of the EIA process in promoting HUP in the current French context.

Keywords:

• Environmental impact assessment
• human health
• tool
• healthy urban planning
• urban development project

Introduction

Today, it is widely recognised that choices made in urban planning and development influence the health and quality of life of populations (Giles-Corti 2006; Vlahov et al. 2007; WHO 2010; Barton et al. 2015). Nevertheless, in view of the complex relationships existing between the numerous determinants of health and the different aspects of urban development, how this scientific knowledge can be deployed on the ground remains a significant challenge. Consequently, public health considerations are only marginally taken into account in urban planning documents and development projects (Carmichael et al. 2012).

In France, whereas the latter have been subject to environmental impact assessments (EIA) since the French Nature Conservation Act (1976), health has only gradually come to the forefront over the last few years in regulatory texts at national and European levels (French Act No. 96–1236 or ‘LAURE Act’ dated 1996, Act No. 2010-788 or ‘Grenelle II Act’, Directive 1985/337/EEC, Directives 2011/92/EU and 2014/52/EU, and their transcriptions into French law) (Capolongo et al. 2016). The Grenelle II Act is a key text law for the protection of the environment. It brought changes to the French EIA legislation: in particular, it states that EIA has to assess development project’s impacts on environment and human health. Therefore, human health appears in French EIA legislation in 2010. The transcription of the Directive 2014/52/EU in French law furthermore states the relevance to integrate health in EIA and supports the actions that had been undertaken in this perspective. However, health stakes are still only partially integrated into EIA reports¹ and throughout the EIA process, and their full integration remains a real challenge (Steinemann 2000; Bhatia and Wernham 2008; Harris et al. 2009; Cave 2015; Mahboubi et al. 2015).

Regulatory evolutions in France – triggers for dealing with this challenge

In 2009, French Act No. 2009-879, called the ‘Hospital, Patient, Health and Territories Act’, led to the creation of new regional health bodies called Agences Régionales de Santé (ARS). These agencies were made up of former decentralised services linked to the French Ministry of Health and Social Affairs. Therefore, current regional health representatives previously worked in bodies answering directly to central government. These new agencies are now independent bodies, but have tended to maintain the professional culture and practice of a decentralised service. This said, they are progressively taking on other activities, such as guiding local authorities in establishing heath policies (Local Health Contracts), financing health prevention and promotion projects and so on (Roué Le Gall and Legeas 2014). In 2011, French Order No. 2011-210 designated these ARS’s as the health authority for the majority of urban development projects, as well as most land-use plans.

Furthermore, as of 2011, three Orders concerning French Act No. 2010-788, or the ‘Grenelle II Act’, and bringing French law in line with EU law engendered important reforms in the environmental assessment (EA) process. Within this context, the environmental authority, when reviewing the EA report and the project/plan itself, must consult ARS’s for a health statement on an increasing number of urban development projects, as well as land-use plans. These regulatory developments are an opportunity for ARS’s to clarify their role and their purpose within the scope of the regulatory procedure governing the EA of these plans and projects, and to position themselves as a key player in healthy urban planning (HUP) (Roué Le Gall and Cuzin 2014).

The issue

At the time of these changes, as ARS’s did not have a methodological framework to guide them in forming a health statement, the Ministry of Health called on Ecole des Hautes Etudes en Santé Publique (EHESP) in December 2011 to create a practical tool for analysing impacts on health that they wished to be applicable both to urban development projects and land-use plans; and to initiate research and studies on the levers for promoting health in the field of urban planning. This work resulted in the publication of a guide in 2014 called ‘Agir pour un urbanisme favorable à la santé’ (Working towards HUP). In this article, we will review the process of co-constructing the guide with special attention paid to the ARS tool which was at some point reframed to EIA of urban development projects, leaving the matter of EA of land-use plans to a subsequent project. We will present the key findings and outputs and contextualise them by drawing on international literature on this subject. More specifically, we will question the potential of the EIA process in promoting HUP in the current French context.

Developing the ‘Agir pour un urbanisme favorable à la santé’ guide

Implementing the project: methodology

Our work was structured around two main lines: on the one hand, the analysis of existing urban planning, health and environmental practices, and on the other, the development of the ARS tool.

In fact, to be able to develop the tool, we had to: (1) agree on the definitions attributed to concepts; (2) understand the urban planning and EIA procedures involved; and (3) grasp the existing practices of the different actors on the ground. This would enable the windows of opportunity to be identified more efficiently, and ensure that health stakes were given a more prominent place in EIA procedures along with, more generally, the levers for HUP.

These two avenues were explored in a parallel yet non-linear fashion. What we learnt from our analyses constantly nourished and modified the tool being developed.

A project team from EHESP was set up to lead the project, in close relation with a larger steering committee which included decision-makers from the Ministry of Health. A national working group (WG) was created right from the project outset. Made up of 19 members, including the EHESP project team, it brought together academics and professionals from the fields of public health, environment and urban planning. All the fields of expertise required for undertaking this type of project were present, even though we can underline the importance of the field of environmental health. The representational balance was good between the academic (47%) and professional (53%) sectors (see Figure 1).

Figure 1. About the 19 members of the WG.

The purpose of the WG was to contribute both to analysing existing practices and developing the tool. The starting point of this project being a very technical matter, no representative from the civil society was included in the WG. The members were also asked to submit issues they encountered in the field to the rest of the group for discussion, and to deliberate on a coherent output with not only the constraints borne by various actors in mind, but also the complex nature of the subject.

While the project was underway, the WG met up six times in all during workshops. The workshops took various forms: presentations by each member concerning their profession and main aims; discussions about the description of concepts relating to health, the environment, urban planning and health inequalities; learning about impact assessment methodology; case-study testing; on-the-ground visits, etc. Outside of these workshops, WG members were regularly asked to cast a critical eye on the choices and progress made by the project team (see Figure 2). The inputs from these discussions are described hereafter.

Figure 2. Timeline of the project’s activities and key moments.

An iterative process

Structuring complexity to promote action: towards an all-encompassing tool

Urban planning, health and the environment are three complex subject areas with numerous variables that interlock more or less directly. The first challenge in meeting the request made was in structuring the complexity. To do this, the WG worked on developing an all-encompassing tool for analysing all types of urban development project and land-use plans (both were concerned at this stage).

Sharing the same definition for concepts

From the very first exchanges between WG members, it became clear that work was required on finding definitions that suited everyone for the main concepts: health, determinants of health, environmental health, health promotion, environment, urban planning and health inequalities. Initially, definitions varied considerably depending on the sector and the field of expertise. In a general manner, health was narrowly defined by the main determinants explicitly linked to each member’s field of expertise. For example, the members from the health promotion field concentrated on social determinants of health, whereas those from the environmental health field were focused on bio-physical determinants. This was applicable to all the WG members, including the project team.

This realisation, coupled with the initial wish of the project team to take an integrated approach to health and environment matters, led the WG to explore the different dimensions of health (social, environmental and economic) with the aim of reaching a consensus on how to define health. It was decided that the basis for subsequent work would be drawn in part from the WHO’s 1946 definition of health, and in part from the diagrams for determinants of health proposed by Whitehead and Dahlgren (1991), and by the Ministry of Health and Social Services in Québec (2010). These would be the basis for a global and positive approach to health.

Developing the all-encompassing tool

At the same time, the WG also discussed which determinants of health were relevant in the context of urban development projects. These discussions were based on: works dealing with the concept of HUP and the WHO key objectives (Barton and Tsourou 2000) for urban planners; and works offering an analysis framework for determinants of health via spatial planning questions drawn from the ‘A health map for the local human habitat’ diagram (Barton and Grant 2006; Barton 2009; Barton et al. 2009). The WG eventually selected 15 determinants and 19 key objectives for HUP. During specific workshops based on study cases, the WG drew up a list of project elements to assess for each of the 19 objectives (Table 1).

Table 1. Fifteen determinants and 19 key objectives for implementing Healthy Urban Planning.

	Determinants of health	Objectives for implementing Healthy Urban Planning	Project elements on which the assessment can be based
Group I : lifestyles, social and economic structures	1 Healthy lifestyles	Promote active travel and lifestyles	• Cycle paths • Footpaths • Public transport • Functional diversity and density
		Encourage sport and leisure activities	• Leisure and recreational infrastructures and spaces
		Encourage healthy diets	• Local shops • Community gardens or allotments
	2 Social cohesion and equity	Promote social, age and functional diversity	• Cost of housing • Type of housing • Housing, services, shops, facilities and other activities (tertiary, farming, industrial, craft trade)
		Construct spaces for social interaction, providing support and assisting vulnerable populations	• Places for exchanging and socialising, community gardens or allotments
	3 Local democracy	Promote participation in the democratic process	• Citizen consultation/participation
	4 Ease of access to facilities, public services and economic activity	Promote ease of access to services and facilities	• Offer and ease of access to health services; school and extracurricular services; public and administrative services; sport, cultural and leisure activities and facilities; shops; place of work; information and communication technologies
	5 Economic development and employment	Ensure the area is economically attractive	• Vitality of economic activities • Property available for economic activities
Group II: living environment, buildings and landscape	6 Housing	Build or renovate quality buildings	• Natural light and ventilation • Thermal and acoustic insulation • Healthy materials • Salubrity of housing
	7 Urban design	Develop good quality urban spaces (street furniture, urban shapes, urban surroundings, green spaces, etc.)	• Street furniture • Urban shapes • Urban atmospheres • Offer in terms of green and recreational spaces
	8 Safety and a sense of security	Ensure a safe environment for inhabitants	• Natural and industrial hazards • Travel safety • Safety in public spaces
Group III: environment and resources	9 Natural environment	Protect biodiversity and the existing landscape	• Fauna and flora • Ecological corridors • Landscape
	10 Adapting to climate change	Promote flexibility in relation to extreme weather events	• Risk of urban heat islands (UHI) • Risk of flooding, mudflows, etc
		Fight against the spread of vector-borne diseases	• Risk of larval habitats developing
	11 Outdoor air	Improve the quality of outdoor air	• Anthropogenic sources of emission (transport, major accident hazard site, heating, air conditioning, farming, etc.) • Natural sources of emission (pollens) • Olfactory pollution • Sensitive populations
	12 Water	Improve/protect water quality and management	• Water and drinking water resources • Wastewater disposal • Rainwater • Water for leisure purposes • Flood risk
	13 Waste	Encourage quality waste management (municipal, household, industrial, health care, construction site, etc.)	• Waste production sources • Collection systems • Waste processing systems
	14 Soil	Improve soil quality and management	• Polluted sites and soil • Management of farming land and green spaces • Land management
	15 Soundscape and electromagnetic fields	Improve the quality of the soundscape and manage the risks related to electromagnetic fields	• Noise sources • Soundscape • Sensitive populations • High-voltage power lines, transformers, etc • Radio base stations

The WG selected assessment criteria and indicators for each project element with final input provided by numerous experts. The result was the creation of an all-encompassing tool structured as per the standard steps shown in Figure 3. Table 2 is an extract of the all-encompassing tool developed for analysing urban development projects and land-use plans with a broad health lens concerning one objective from the ‘Healthy lifestyle’ determinant.

Figure 3. Standard steps for analysing an urban development and urban planning projects for each of the 15 determinants.

Table 2. Extract from the all-encompassing tool developed for analysing urban development and urban planning projects with a broad health lens for the ‘Promote active travel and lifestyles’ objective, from the ‘Healthy lifestyles’ determinant.

	Objectives for implementing Healthy Urban Planning	Project elements on which the assessment can be based	Assessment criteria	Indicators	Plans, schemes, programmes, etc
Determinant 1 Healthy lifestyles	Promote active travel and lifestyles	Cycle paths	• Presence of cycle paths • Continuity of cycle paths • Inter-connection of the cycle network • Intermodal transport • Quality of cycle path surfaces and signage • Presence of secure cycle parking (private and public)	• Total length of cycle paths (km of lanes and/or paths) • Interruptions, obstacles (average time for routes and stops) • Proportion of road surface area occupied by 'active travel' routes (%) • Number of parking spaces for bikes: surface area dedicated to cycle parking	In the French document, for each project elements, this last column provides a list (non-exhaustive) of plans, schemes and programmes linked to the objectives
					These plans, schemes and programmes can be regulatory or not
		Footpaths	• Continuity of footpaths (interruptions, obstacles, etc.) • Inter-connection of the footpath network • Inter-connection of the footpath network • Intermodal transport • Quality of footpath surfaces and signage, taking into account of PRMs	• Total length of footpaths/total length without footpaths ratio • Walkability
		Public transport (PT)	• PT offer • Organisation of PT network • Intermodal transport • Financial plan giving everybody access to the PT offer • Information and 'access to mobility' system within the PT network	• Type, frequency (PRM accessibility) (route and where stops located) • Fare offering (for students, job seekers, company employees, etc.) • Multi-modal offer ( combined travel passes for all modes, bus, train, tram, underground)
		Functional diversity and density	• Diversity of activities (shops, services, leisure and cultural facilities, etc.) • The 'permeability' of urban fabric (short cuts, 'open block' principle)	• No. of dwellings/ha • Distribution (surface area in m2) of existing activities • Diversity of activities (food offer, leisure offer, public services, etc.)

By establishing a shared analysis rationale that could be used by any actor, this reference tool has become a basis for rolling out methodologies adapted to operational purposes and constraints of actors on the ground, such as the ARS tool developed within this project. Other tools have subsequently been created, especially for actors in the field of urban planning.

Observations following the analysis of procedures and practices

Examining urban planning procedures and how they are established and assessed in terms of health and environment quickly revealed the complex nature of the subject. It was clear that here also the members of the WG would need to reach a shared understanding of urban planning and EA processes. As a result, the project team, assisted by members of the WG, organised discussions as of the second WG meeting to: (1) elucidate the main urban planning tools (tools for drawing up urban development projects and land-use plans); (2) understand the different stages in establishing them along with their regulatory specificities; (3) identify all the actors involved and understand their roles and relationships; and (4) ascertain the perception of health in the field of urban planning and during the regulatory EA procedure.

Alongside these discussions, more in-depth work was carried out to pinpoint the moments when, and degrees to which, ARS’s could provide input during the process of preparing urban development projects and land-use plans. This enabled us to better understand their role and their relationship with the government’s decentralised environmental services (DREAL) who prepare the statement signed by the environmental authority (EAuth). This investigative work consisted of studying regulatory texts and meeting directly with ARS representatives to discuss their practices.

This analysis stage gave rise to certain observations that progressively served to adapt the scope of the initial request, and provided a guideline for the content and structure of the guide. The following is a review of the observations made and their impact on how work progressed.

•	The analysis of urban planning processes identified a large range of urban development projects and land-use plans differing in terms of scale, time scale, objectives, components, preparation procedures and EA. For example, whereas land-use plans govern and condition potential future development, urban development projects lead to actual implementation.
•	The analysis of EA procedures pinpointed the procedures that differed according to the type of plan or project to be assessed. Without going into details, here we would like to emphasise that EIA procedures are used for urban development projects, whereas different procedures, called in the international context ‘strategic environmental assessment’ (SEA), are used for land-use plans (Fischer 2014).
•	The analysis of current practices of the multiple actors involved not only in drawing up urban development projects and land-use plans, but also in their EIA or SEA, revealed that these professionals work ‘in silos’. This is not ideal in implementing a systemic approach to health which is fundamental in promoting HUP. This silo mentality is explained by the complexity of the subjects these professionals have to deal with. Their work is highly specialised and difficult to combine with a systemic approach, notably due to the constraints individually faced (in terms of time, money, mandate, laws, etc.). Consequently, environmental actors focus on protecting habitats and resources, whereas health actors are essentially preoccupied with preventing risks from pollution and disturbances. As for urban planning actors, they have to organise the preparation and management of projects while also taking into account the all-important technical, legal and financial aspects. For the latter, sustainable development concerns linked to the environment have been increasingly taken into consideration over the last 10 years or so. Even if the well-being of populations is included in their aims, it is not dealt with in and of itself where health and health promotion are concerned.
•	The more specific work undertaken on ARS practices identified three specific entry points to the EA process for these regional health agencies: a compulsory one, when the DREAL asks for a health statement; an optional one at EA scoping; and only for land-use plans, at the ‘State notification to the developer’ stage. The entry point for providing health recommendations based on the EA report sent to them by the DREAL is almost during the last stage of the project, just before the public survey. The other two entry points clearly provide a leverage for health at an earlier stage in the procedures. The EA scoping (cadrage préalable) stage is optional and defined by the French Environment Code (Art. L122–1–2). The authority in charge of the project can ask the environmental and health authorities for precisions on the level of detail and the specific stakes that will have to be developed in the EA report. During discussions with in-the-field operatives, it became clear that as this procedure is optional, it is rarely used. The main arguments given for this are time constraints, routine report-writing practices and a lack of awareness of the opportunity embodied by this exchange both for urban planning and public health. The ‘State notification to the developer’(Porter-à-connaissance) stage is governed by the French Urban Planning Code (Art. L121.2 and R 121.1) and is a procedure whereby the government provides local authorities preparing or revising land-use documents with all the information required for them to fulfil their urban planning obligations. This includes forwarding: (1) information concerning legal elements (such as public easement, existing protection in terms of the environment and heritage, public interest projects, etc.); (2) information concerning government projects (national infrastructure projects relating to the government’s policies on roads, railways and airports); and (3) existing studies, especially on risk prevention or protection of the environment, as well as available data on housing, travel, demographics and employment. This information is provided very early on and is updated throughout the procedure. It must be made available to the public and can be appended to a public survey along with the statements provided by different actors, the EAuth included. Even if the ‘State notification to the developer’ stage can become a veritable roadmap for preparing projects, in practice, it is seldom used to its full extent.
•	The analysis of ARS practices and their interaction with other actors also pinpointed several stumbling blocks to integrating health into EA: (1) the relatively short times that the DREAL and ARS are given to form their statements. As soon as they receive the file to be assessed, the DREAL has only three months to form its statement which includes health recommendations from the ARS. The ARS has just one month on receiving the file from the DREAL to form its statement and return it; (2) the varying degrees to which ARS recommendations are included in the final statement, which is the only statement given to the developer and the only one publicly available during the public survey phase. It is worth noting here, that the EAuth is free to include (or not) all or part of the recommendations made by the ARS. Furthermore, the statement emitted by the EAuth is neither prescriptive (it simply contains recommendations that the authority in charge of the project decides to take into consideration, or not), nor conclusive (the EAuth statement emitted is not favourable or unfavourable). More details on these aspects can be found in the article written by Capolongo et al. (2016).
•	The analysis of the content of health statements emitted by the ARS’s points to differences in practices concerning the determinants of health examined. Generally speaking, biophysical determinants of health relating to the environment (air, water, soil, etc.) are those most analysed. However, some of these determinants are only partially analysed or not at all, with the depth of analysis being more often than not based on the competences of the assessment expert from the department of environmental health. Furthermore, although there are health promotion competencies at hand in other ARS services, this expertise is not sought in forming the health statement.

This in-depth analysis also revealed that the involvement of an ARS was the only mandatory opportunity for regulatory input from a health point of view when preparing an urban development project or a land-use plan. As a result, by giving ARS’s the means of analysing determinants of health other than biophysical ones, the EA could play a major supporting role in the preparation of plans and projects that promote health.

Focus on the levers for HUP

The project team gave a lot of thought to the concept of HUP concomitantly with all the WG meetings. There was a double objective: to agree on a definition of HUP and integrate it into the ARS tool, and to thoroughly identify the levers for HUP to evaluate the potential of EA as a means for promoting HUP.

The in-depth research conducted to understand the role and purpose of the different actors involved in urban planning procedures and EA showed that when preparing one and the same project, entry points to the project development process for the different professionals are disconnected. In the end, they rarely get the opportunity to meet and collaborate despite working towards the same end result: well-being and good quality of life leading to healthy populations. Consequently, thinking of ways to break down the barriers to enable exchanges and open up the different social, environmental and economic dimensions of the project became part of the lever identification process. The result was a list of levers that we have channelled into five pathways for breaking down barriers: (1) undertake projects with a systemic approach to health, environmental and territorial development stakes; (2) share a common culture and develop competences around the HUP concept; (3) encourage partnerships and anticipate health issues as early as possible in the decision-making process; (4) develop tools to encourage questioning and evaluation with regard to the different determinants of health taken into account to ensure they are adapted to everyone’s objectives and aims; and (5) use the regulatory approach of EA to introduce more health into plans and projects.

Furthermore, using the work of Butterworth (2000) and Barton (2009) (Butterworth 2000; Barton 2009) as a springboard and the results of the analysis of procedures and practices as food for thought, a reference framework for HUP saw the light of day. It is targeted at all actors and aims to share the guidelines for implementing HUP. Initially structured around five simultaneous courses of action for working towards HUP, it was recently broadened to eight. (1) Reduce the amount of pollutants, disturbances and other types of pollution (emissions and exposures); (2) promote behaviour that is beneficial to the health of individuals (physical activity & diet); (3) contribute to changing the social environment to promote social cohesion and the well-being of inhabitants (public spaces); (4) redress the health inequalities existing between the different socio-economic groups and vulnerable persons within an area (avoid the build-up of exposure to risk factors, encourage exposure to protective factors); (5) identify and manage, as much as possible, conflicts and synergies arising between different public policies (environmental, green spaces, travel, housing, etc.); (6) establish strategies promoting intersectorial collaboration and the involvement of all stakeholders, including inhabitants; (7) conceive an adaptable project taking into account evolving lifestyles and behaviours; (8) allow access to health care and prevention services. The five original lines fed the ARS tool presented below.

This work enabled all the members of the WG to shed light on the opportunities, but also the limits of EA as a means of working towards HUP. The results of this deliberation provided the guidance for the content of the guide and its specific layout.

Co-constructing the ARS tool

With the specifics of the procedures in mind, along with their complexity and the practices of the different actors, by the end of the second WG meeting, it was unanimously decided that the ARS tool should be dedicated to the EIA of urban development projects, with land-use plans provisionally put to one side.

The challenge for the project team was to provide support for the development of an operational tool that took into account the on-the-ground constraints, the practices of each and every one, and the need to make these practices evolve in step with HUP guidelines.

Process for developing the ARS tool

To meet this challenge, the tool was developed in close collaboration with actors in the field. Initiated as of the fourth WG meeting, a co-construction approach was taken, alternating workshops, exchanges with various professionals (ARS, DREAL, etc.) via one-to-one interviews or group discussions (symposiums, seminars, etc.), and two visits in the field for live testing to enable any subsequent adjustments to be made to the tool (see Figure 2).

The all-encompassing tool developed for analysing urban development or urban planning projects with a broad health lens acted as the methodological framework for developing the ARS tool. The aim was to guide ARS representatives in forming and emitting a statement not only based on the biophysical determinants as a whole, but also on a more in-depth analysis of other determinants of health (living environment, housing, transport, etc.). The first stage consisted of studying the 15 determinants and selecting those that should be adapted for the ARS tool (see Figure 4), and then discussing the assessment process to implement (see Figure 5). Initiated as of the fourth WG meeting, the development process ran over several months. It was constantly adjusted as and when exchanges took place.

Figure 4. Selection of the determinants for the Regional Health Agencies’ tool.

Figure 5. Standard steps for analysing the impact of the urban development project on one determinant with the help of the EIA report.

Components of the ARS tool

The tool is made up of three main components. (1) The urban development project’s assessment matrix which is an Excel workbook with several tabs. The first tab, labelled ‘Details’, is for providing information on the nature and administrative characteristics of the urban development project. The second tab, labelled ‘Health stakes’, must enable the assessment expert to rank the project’s health stakes and prioritise the determinants of health to be assessed. The next nine tabs are used to independently analyse the nine determinants of health presented in Figure 4. The tool’s seven first determinants are the same as those from the all-encompassing tool as they correspond to the determinants usually analysed by ARS’s. The other determinants are grouped under two themes in the ARS tool – ‘Housing and living environment’ and ‘Mobility-Transport-Facilities’ – giving access to a broader range of determinants of health to be analysed. A ‘Go a step further’ tab offers a summary table and the opportunity to go above and beyond a straightforward health statement by developing an argument for giving health a more central role in urban planning. The article by Capolongo et al. (2016) gives further details on how the matrix functions. (2) Leaflets prepared for each determinant enable the assessment matrix to be completed. Each leaflet is structured in the same way as follows: a reminder of the links between the determinant and health; a report on current regulations; a list of enforceable and non-enforceable framework documents for the territory; and supporting elements and indicators for the assessment. (3) An analysis document to ‘Go a step further’ bringing together a range of questions based on the five courses of action for HUP.

Project outputs

Content of the ‘Agir pour un urbanisme favorable à la santé’guide

This work resulted in the publication of a guide in 2014 called ‘Agir pour un urbanisme favorable à la santé’ (Working towards HUP) (Roué Le Gall et al. 2014). It is the culmination of all the hard work involved in condensing and structuring everything the project team learned. It was revised several times by all the people involved in the project as well as by external actors such as the sub-department of the Ministry of the Environment in charge of housing, urban planning and landscape design.

It showcases the main results of all the thought that went into the project. Even if the regional health agencies (ARS) are the primary audience for this guide, it was designed to be accessible and adapted by urban developers, local authorities, DREALs (decentralised environmental services) and any other actor involved in the urban planning decision process. As well as in printed format, this version is also available for free online in digital format.²

It is divided into two parts. The first part: (1) explains the different concepts involved; (2) illustrates the complex nature of the links between urban planning and health via a few examples, such as the various mechanisms by which green spaces influence health; (3) presents the levers for promoting health in urban development and the main lines leading to HUP. The elements that are subject to change are presented separately in leaflets. They explain certain aspects of the regulatory framework for preparing a number of land-use and urban development documents, especially elements related to the EA process. It also features the all-encompassing tool developed for analysing urban development or urban planning projects with a broad health lens.

The second part of the guide corresponds to the methodology for analysing the impacts of urban development projects on health, and is aimed at ARS’s. It consists of: a user guide; the analysis matrix, also available in Excel format; and a leaflet per determinant.

Other outputs

Other outputs are also worth highlighting such as the creation of various training courses and the further development of decision-making aids as an extension of the work already undertaken.

Training courses

In 2015, an online training course based on the guide was created. Trainees can practise using the ARS tool with a real-life case study. To do this, they access the EIA report of an urban development project. Some ARS’s have organised group training sessions based on this online course.

Several training sessions have taken place for professionals already working for an ARS, or more broadly within the public health sector. The length of these sessions ranges from two to five days. Furthermore, as EHESP is in charge of the initial training of newly recruited civil servants in the field of environmental health, the project team takes part in their training programme.

The development of the ‘Healthy Urban Planning’ research subject within EHESP has also led to a six-week training programme dedicated to this topic established in partnership with the Institut d’Aménagement et d’Urbanisme (Institute of Urban Planning and Development) in Rennes. It has been designed for a range of professionals from the fields of health, environment and urban planning.

The project team also partakes in initial training courses in public health and in urban planning and development to give students an introduction to the concept and implementation of HUP.

The development of other decision-making aids

On the one hand, in 2016, an adaptation of the ARS tool dedicated to analysing a specific type of land-use plan, followed. It will be the subject of a future paper. On the other hand, working collaboratively with a developer within the context of an urban development project, the ‘all-encompassing tool’ was deployed and adapted to the aims of this actor of the urban sector.

Discussion

Combining a cross-analysis of procedures, practices and representations with in-depth deliberation on the concept of HUP highlighted a number of EIA strengths and limits and opened up a constructive pathway for ensuring health has its place in the field of urban planning. We would like to discuss a few key points we identified and show how the project outputs were devised to help overcome these EIA limits.

Recent developments in the mandatory legal framework for EIA have provided an opportunity for better integration of health considerations, an objective that has often been put forward, but rarely attained in reality (Ahmad 2004; Bhatia and Wernham 2008; Fehr et al. 2014; Mahboubi et al. 2015). European Directive 2014/52/EU makes the obligation to assess impacts on human health in EIA more explicit. As a result, it provides a stronger regulatory framework considered by many authors as one of the key points in attaining this objective (Ahmad 2004; Harris et al. 2015; Mahboubi et al. 2015). Besides, in France, an increasing number of projects now undergo EIA.

Including a broader range of determinants of health

All the determinants of health need to be examined when implementing HUP. However, the analysis of practices revealed that actors tend to focus on biophysical determinants and take a risk-based approach. This observation is shared by several authors (Bhatia and Wernham 2008; Fischer et al. 2010; Morgan 2011; Harris and Haigh 2015). It is largely explained by the lack of involvement of the health promotion sector and the complex nature of methodologies for measuring the impacts on social determinants of health, contributing to an ‘EA quantification syndrome’ (Mahboubi et al. 2015). If EIA is to provide leverage for HUP, the range of determinants of health needs to be broadened. Therein lies the challenge.

In the ARS statements

The ARS tool was developed with these complications in mind. The project team advocated a tool that would tackle questions of health in the broadest sense possible, over and above current practices. However, the aim being that each ARS representative should be able to progressively adapt their practices to include more determinants, the project team opted for a tool in Excel format giving more room for manoeuvre. There is no obligation to fill in all the assessment tables corresponding to each determinant (see Figure 4) and each table can be modified – a representative can rework the presentation, add input data, etc. (see Figure 5). In this way, the tool gives the representative the freedom to explore other less familiar determinants as and when they understand their value.

ARS’s are also confronted by the difficulty of building arguments for their recommendations: in practice, their opinions refer to regulatory documents, thresholds and guide values. These references seem indispensable to ARS’s. However, this may well work for biophysical determinants, but relying on standards is trickier for other determinants. The main concern here is to provide ARS’s with key arguments for these other determinants. The guide provides two solutions for this. On the one hand, through leaflets provided for each determinant, and on the other, through the guide in itself as a reference document that is approved and supported by the Ministry of Health. It is worth noting here, that this Ministry is co-author of this guide with EHESP and has issued an official notice to all ARS’s encouraging them to use the guide – especially the ARS tool.

The approach adopted by the project team is to encourage, rather than constrain, ARS representatives to broaden the range of determinants. They are invited to take an interest in the quality of the living environment, mobility and health inequalities.

Other stumbling blocks linked to organisational constraints render the process more difficult: as well as the time constraints imposed for emitting a health opinion, only the environmental health services handle the files. The question arises of associating other ARS services and, more generally, the need for resources and support from within the organisation as mentioned by Harris et al. (2015) in the international context, and underlined by Mercier et al. (2016) in the French context. Despite HUP becoming a more familiar topic for ARS’s, implementing an approach where all determinants are included in a health statement is a battle far from won in these organisations.

In the EIA reports

Information on health is often incomplete and dispersed in the EIA report. This is largely due to a lack of guidance on health for consultancy firms appointed to produce the report, and who take an environment-centric approach. These practices lead to reports that are difficult to decipher and analyse with a health lens, especially as nowadays, they tend to be in digital format only, making them hard to read – maps in particular.

The aim of making the guide available online for free is to enable as many actors as possible to access and read it, including the actors in charge of projects and the consultancy firms appointed to prepare EIA reports. Since putting it online, it appears that some of the actors in charge of projects have requested that these consultancy firms take health more into account, and have forwarded the guide to these firms. As a result, we now see some EIA reports that better assess the effect of the project’s on human health and that bear witness to a change in consultancy firm practices.

Encouraging ARS’s to seize other opportunities both within and outside of the EIA context

The EIA process and ARS’s statement occur rather late in the project preparation process (Roué Le Gall and Jabot, 2017). Yet, if we want to work towards HUP, a concerted and organised approach is required from all actors throughout the urban development project elaboration period.

Consequently, it is up to ARS’s to seize other opportunities for getting involved in the project: not only is there the ‘scoping’ stage of the EIA process, but also the different entry points that appear earlier, be they regulatory (like the ‘State notification to the developer’ stage) or not. These earlier entry points can prove to be more ‘effective’ for ARS’s in that they enable the project and its stakes to be taken in hand more effectively. Exploiting these entry points implies that ARS’s will need to partly adjust their role more towards providing guidance, rather than just fulfilling their time-honoured ‘supervisory’ role. They could position themselves as a major player in promoting health, which in turn, would enable them to implement this global approach to determinants more easily (Roué Le Gall and Legeas 2014). However, this change in position would require a few organisational overhauls.

As a general rule, partnerships between the different actors early on would require a shared culture to be established. The project outputs, within due proportion, could help provide a solution for this:

•	Today, the guide is mainly used by ARS’s, but also by other actors such as the DREALs and local authorities. ARS’s notably use the guide as a tool for exchanging with actors from different fields: it has become a means of initiating dialogue from a legitimate position.
•	The various tools developed during the creation of the guide, and after, are based on the all-encompassing tool. This tool is the shared basis that can subsequently be deployed and adapted to a relevant actor and their constraints.
•	Over the long term, the different training courses offered will equally be opportunities for building a common culture, especially when courses target a public that includes actors from the fields of urban planning, public health and the environment.

Meanwhile, simply familiarising other actors with health stakes is not enough. The analysis of practices revealed that ARS’s lacked knowledge of the details involved in drawing up projects for which they provide statements. For example, they have difficulty pinpointing where the health statement is situated along the whole project timeline. Without knowledge of the regulatory constraints, the time scales, the legal elements, etc. of these projects, it becomes all the more difficult to steer effective action (within or outside of the EIA framework). Other authors, at the international level, also note the need to complete the technical knowledge of the links between build environment and health with a minimum understanding of urban planning (Harris et al. 2014; Cave 2015). It is therefore necessary that ARS’s and, more broadly speaking, public health sector actors wishing to get involved in HUP understand urban planning practices and processes. This is also a condition that would ensure professionals can contextualise their action, hone in on opportunities and develop collaborations with urban planning and environment actors.

Conclusion

Two points deserve to be highlighted, one regarding the inclusion of health in the EIA process, the other on the need to combine EIA with others levers to reach HUP.

As we previously stated, health has been included in EIA in France since the Grenelle II Act in 2010. At the same time, an EAuth was designated to review the EIA report, and in order to do so, has to consult a health authority. Therefore, our entry point was the role played by the authorities reviewing the EIA report, rather than the integration of health in the EIA report in terms of health assessment methodology, which is under discussion in the international context (Dunwoody and Johnson 2016). The Directive 2014/52/EU is clearly including health, as well as detailing the EIA process and the role of each competent authority involved (Polönen 2016). Each member state could decide to go further and designate a health authority. For instance, whereas in France the health authority gives a statement to the EAuth, in Italy, the health authority’s statement is on par with the EAuth’s statement, both are send to the developer (Capolongo et al. 2016). On this specific point, in Italy, health is placed on an equal footing with environment. The outcomes of this reviewing process by authorities can contribute to the effectiveness of EIA. However, reaching a consolidated statement remains a challenge (Mercier et al. 2016). In this matter, the roles and regulatory constrains given to these reviewing authorities, as well as their own organisation and resources are important points for EIA effectiveness. They are tipping points regarding the inclusion of health in the overall EIA process.

In the perspective of HUP, a whole chain of events has to be considered: from the first steps of the project to the actual urban development which will take place years later. The matter of the inclusion of health in the review of the EIA report is to be considered as one of many levers that will have to be implemented in order to reach HUP. Therefore, the inclusion of health in EIA is part of a larger strategy which includes many other levers, as the international community of experts has pointed out: fostering collaborations, setting professional training courses, selling HUP concept to decision-makers, etc. (Kent and Thompson 2012; Harris et al. 2014; Cave et al. 2016).

The publication of the guide is the result of a long process of co-construction which involved a wide range of motivated actors from different sectors convinced their practices has to change to better consider health issues. Despite this stated intention, this work has not always been easy, in part because of a certain resistance of some actors on the ground insofar as the use of the new tools implies to get out of one’s comfort zone.

However, since the publication of the guide, many HUP initiatives are taking shape and even though the way ahead is still long and strewn with obstacles, they show that the conditions for change are there.

Disclosure statement

No potential conflict of interest was reported by the authors.

Funding

This work was supported by the Ministry of Health.

Acknowledgements

The authors would like to thank the Ministry of Health for their support in this project and the long list of members who collaborated in this work (professionals and academics from public health, urban and environment sectors). We are also grateful to Annick Paisley for the English translation.

Notes

1. In the international littérature, it is also called ‘Environmental impact statement’ (EIS). We decided to use the expression ‘EIA report’ in order to match the language used in the European directive 2014/52/EU.

2. Link to the guide’s web page (in French): https://www.ehesp.fr/2014/09/16/nouveau-guide-agir-pour-un-urbanisme-favorable-a-la-sante-concepts-outils/