The Public Health Residency: a Novel Way to Focus Attention on Sustainability and Wellbeing in the Architectural Studio

Abstract

Creative residencies have been used in many different settings to provide new perspectives amongst communities, in a workplace, historic site or cultural venue. This project took the concept of the ‘scholar-in-residence’ to experiment with a new pedagogic approach in the educational architectural studio. With the aim of bringing issues of health and well-being into architectural education, a joint fifth and sixth year studio cohort was provided with a public health practitioner in residence. The practitioner framed lines of enquiry and contributed to design investigations through the use of learning materials, seminars, workshops and tutorials. Architectural projects were developed on selected sites in Stroud, Gloucestershire, UK. Using a mixed methods approach, assessment of this experiment was provided from analysis of students' reactions, a final reflective workshop, presentations to the community in Stroud and the project work itself. Findings show that this intervention was successful in widening students' notions of the role of the architect as an actor in creating a healthy society; it also proved valuable as a means of unlocking sustainable development in new ways to these architectural students. The public health practitioner in residence is presented as effective new design training where architectural education meets the wider challenges of sustainable development, through a focus on population wellbeing and health equity across the whole community.

Keywords:

• Sustainability
• Health
• Architecture
• Wellbeing
• Public Health
• Architectural Education

Introduction

This paper describes and discusses a project that sought to use an architectural studio ‘residency’ by a public health practitioner as a vehicle to introduce broad public health issues, concepts and approaches into the curricula of a group of fifth and sixth year architecture students. As a pilot for possible future educational practice, dissemination and discussion of this project is valuable, an evaluation of its effect on students is also presented. A public health academic practitioner held this part time residency over a semester, getting involved in a full range of studio teaching on a live student project. Student responses to this intervention were collected, a final reflective workshop was held and the outcomes were tested with members of the community in Stroud in Gloucestershire, England, where the student project sites were located.

The approach was found to be very effective in terms of the degree to which concerns for public health and wellbeing were responded to and articulated within the final schemes. Unexpectedly, this approach was also found to be valuable in bringing alive the concept of sustainable development for students in a new way. The project was designed to test this ‘scholar-in-residence’ model as a way of engaging built environment students with interdisciplinary enquiry and exposing them to a range of built environment and design issues that effect public health and wellbeing. Reflection on this pilot suggests ways that the approach could be further explored to provide an avenue by which built environment students re-conceptualise public health and sustainability and re-assess their future professional activity to support better population level wellbeing and sustainable development.

The opening section of this paper outlines what is meant by ‘public health’ and reviews the background drivers that led to this initiative. This is followed by a discussion of ‘residency’ as a pedagogic tool and the research approach chosen to examine this pilot. This is then supplemented by providing additional context in terms of health and its relationship with the built environment. This section ends with a discussion of the role of values, in particular supra-client values, in the built environment and public health professions. The next section describes the intervention in its three phases, preparation, immersion and reflection. Concluding sections contain the findings of the evaluation, a discussion, and final reflections and next steps.

The Emergence of this Initiative

Three sources can be identified as drivers for the creation and shaping of this public health residency. Firstly, public health concerns about the built environment; secondly, a desire to broaden the disciplinary exposure of architecture students; and finally, an established body of work in establishing inter-disciplinary learning environments between the public health and built environments profession. These are discussed below, following a briefing on what is meant by ‘public health’.

Public health as a profession is often seen as a medical specialism but it is very distinct from clinical medicine. In broad terms, clinical medicine focuses primarily on the individual, whereas public health also centres on populations or communities. In clinical medicine the focus is a biomedical model with much emphasis placed on cure rather than prevention. In public health, prevention of disease and reducing avoidable health inequalities is the focus, with tools drawn from a range of sciences including sociology, epidemiology, cultural anthropology and economics.

Those outside the field of health also commonly associate the word ‘health’ with health service provision. Public health, in its means of service delivery contrasts with, and should not be confused with, primary and secondary medical services where the prime purpose is to be available for sick people and to cure illness. Many public health services are aimed at ‘well’ people and are provided in order to prevent illness. Of course, both hospitals and general practices also have public health responsibilities in addition to their medical health role, such as giving out information on healthy diets or exercise regimes.

Public health professionals seek to improve health. The key objectives of the public health profession are to:

• improve health and well-being in the population;

• prevent disease and minimise its consequences;

• prolong the value of life;

• reduce inequalities in health (Orme at al., 2007).

Public health concerns about the built environment. It is without question that many important advances in public health have come through improvement of the built environment (Ashton and Seymour, 1998). In the past, great reformers of unsanitary conditions, slum dwellings and ‘bad neighbour’ issues understood that health was inextricably linked with people's surroundings, and that a transformation of those surroundings was necessary to improve health and wellbeing (Rosen, 1993). During the twentieth century, the relationship between those concerned with public health and those planning our towns and cities fractured. Public health took an increasingly biomedical approach to health improvement, while those concerned with the built environment replaced their health focus with a more economic perspective (Orme et al., 2007).

Since 1995 in Europe, through the World Health Organisation (WHO) Healthy Cities ‘healthy urban planning’ theme, and increasingly in the UK, public health has sought to reconnect to its old allies in the built environment professions; in recognition of the need to ensure that the environment in which we live promotes rather than hinders health aspirations (Barton, 2005). Attention on public health issues such as obesity has strengthened the desire for engagement with those who design the places and spaces where we live, work and play (Butland et al.,2007; Hill and Peters, 1998). This is witnessed by the coining of the term ‘the obesogenic environment’, an obesity-promoting environment (Larkin, 2003). The reviews into the social determinants of health carried out by Marmot for the WHO and the UK government recognised the key role that the built environment has to play in tackling health inequalities (Marmot, 2008 and 2010); these have certainly helped to maintain the momentum.

Broadening the disciplinary exposure of architecture students. The architectural design studio has been described as isolated from outside influence and collaboration (Sara, 2004), which is contradictory to professional practice where teamwork and multi-disciplinarity are at the core of the architectural profession (Cuff, 1991; Worthington, 2000; Lawson 1999). Further criticism of the profession has included that it is isolated from the public's needs (Stansfield-Smith, 1999) and this also suggests a need to change the way the design studio was structured and taught in architectural education. By bringing in expertise from a health professional, who the students wouldn't normally meet, a framework for introducing aspects of health into the curriculum was created whilst at the same time providing a programme that would support an interdisciplinary design environment. When designing the brief for the studio, the aim was to cultivate the students' identities as designers by ‘framing’ (Schön, 1987) the design situation in a very particular way to tease out distinctive design solutions related to health. The objective was to explore how the public health practitioner ‘in residence’ could engage architectural students to improve population health through the design of their projects. The residency involved real-time coaching and encouragement that was intended to lead to lateral thinking and critical reflection (Brookfield, 1986) in this new and unfamiliar field for the students, thus, turning an experience into learning through the promotion of reflection (Sara, 2004). While the role of the public health practitioner was to provoke, mentor and challenge the students in their health related perceptions, they also tried to create a more supportive learning environment for the students (Trigwell and Ashwin, 2002).

Interdisciplinary learning environments in public health and built environments professions. In recent years, public health in the UK has sought to reconnect the profession to the built environment agenda (Barton, 2005). The Department of Health even funded the establishment of a network of built environment educators who have interests in public health; the Education Network for Healthier Settlements. This network has provided support and dissemination for leading practitioners in this field. Ellis has published a good example of this kind of working, where an inter-professional methodology was successfully employed to introduce health into the curriculum for urban planning (Ellis et al., 2008). Case studies collected by the network include a range of cognate work: a diploma in planning at Newcastle University where public health issues of community diet, exercise, well-being and carbon footprint are explored through projects with an allotment society; environmental science undergraduates at the University of East Anglia using the potential importance of access to green spaces for health to understand epidemiology; a masters in a planning course at Liverpool University which looks at embedding cultural and sporting opportunities for health in the development of villages and towns; and a unit reviewing the relationship between sustainable school design and the wellbeing of children for fourth year engineering students at the University of Warwick. Outside the UK there are a number of examples of leading practice in this field such as the Healthy Planning course at University of New South Wales, Sydney, Australia; the Built Environment and Public Health Model Curriculum that has been developed at the University of Virginia, USA; the Joint Master of City Planning and Master of Public Health degree programme at the University of California, Berkeley, USA; and joint programmes of the School of Urban Studies & Planning and the School of Community Health at Portland State University, USA.

In Bristol, UK, the WHO Collaborating Centre for Healthy Urban Environments has been undertaking a wide-ranging programme of inter-professional public health learning with a focus on the built environment since 2005. The original focus was to add ‘healthy urban planning’ to undergraduate and post-graduate courses. This soon expanded to include workforce development initiatives that have brought together senior public health and planning professionals to share learning, develop relationships, and experience sites of good practice (Pilkington et al., 2008; Grant, 2008, 2009). More recently, attention has shifted to include other built environment professionals during their education and training; particularly architecture and transport students at undergraduate and postgraduate level.

The Residency and Research Approaches

Scholar-in-residence programmes of different forms are widespread in many countries. Due to the wide variation in programmes, the generic term ‘scholar-in-residence’ is used mainly to indicate various funding streams rather that being the focus for pedagogic examination. For this initiative, the conception a ‘Public Health Residency’ was based on the concept of the ‘Artist in Residence’ schemes that started to appear in their current form in the 1960s. In these schemes, artists (of all kinds) work outside their ‘normal’ working environment and are in contact with people that might not normally have been considered as the artist's audience (Cret, 1941). The residencies hoped to influence society, with the expectation that both the artist and the audience would gain from one another's perspectives and approaches (Hercombe, 1986).

The public health residency was undertaken as a piece of research. A research group was formed which consisted of three researchers: a public health practitioner; the leader of the architecture studio; and an action researcher, who works in the interfaces between the built environment and public health field. The group was chaired by a reader in public health. The project was part of on-going work being carried by the WHO Collaborating Centre for Healthy Urban Environments in bringing public health and the built environment agendas (back) together (Pilkington et al., 2008; Rao et al., 2007). The research aim was to infuse architectural teaching with public health issues, concepts and approaches. The research question being examined was whether a ‘scholar-in-residence’ would be a valuable pedagogic approach in supporting inter-disciplinarity in this context.

Multi-disciplinary refers to research in which each specialist remains within her/his discipline and contributes using disciplinary concepts and methods. Inter-disciplinary contributions can be interpreted as the bringing together of disciplines which retain their own concepts and methods that are applied to a mutually agreed subject. Inter-disciplinarity can be considered as the mixing together of disciplines.

(Lawrence, 2004, p.489)

The research team wanted to develop a studio teaching approach, and consequently a student learning experience, that went beyond Lawrence's multi-disciplinarity. Although not under evaluation in this pilot, the intention behind the longer-term programme in creating these spaces for public health and built environment interaction is one of the supports for trans-disciplinarity. Trans-disciplinarity implies a fusion of disciplinary knowledge that creates a new hybrid that is different from any specific constituent part (Lawrence, 2004). ‘Trans-disciplinarity is not an automated process that stems from the bringing together of people from different disciplines or professions. In addition, it requires an ingredient that some have called “transcendence’” (Lawrence, 2004, p.489).

We argue here that the added ingredient in this pilot project is the use of ‘residency’ in a novel form through placing a health practitioner into a creative studio context. Residency programmes fall into two distinct areas of practice which relate to two pedagogic forms, having either a ‘settings’ focus or a ‘resident’ focus. The ‘settings’ focus practice centres on what the resident brings to a particular setting. Typical examples are ‘artist or craftsperson-in-residence’ programmes which started in their current form in the 1960s (Silverstein, 2003) with the notion of creating a culturally relevant pedagogy within a setting (Ladson-Billings, 1995). By contrast, with ‘resident’ focus practice, the locus of interest switches to what the resident themselves can learn from immersion in a setting. This type of practice can be seen in health and law training, particularly in the United States, where there are widespread residency programmes of this type. The aim is to support the trainee's learning through giving an experience of working in professional or community settings.

This pilot displayed elements of both:

• As a settings focussed residency: In its intention, this pilot fits with this model. The plan was for the architecture students within the studio setting to benefit from the knowledge, skills and experience of the resident. However, unlike the typical residency of this type, the identities of artistry and craft were embedded in the setting rather than with the resident. The secondary research question was therefore: can this placement add value to an architectural studio in terms of public health outcomes?

• As a resident focused practice: In terms of the longer-term programme, this model was also of interest. A residency of this type might be a valuable addition to the training of health practitioners by supporting the trainee resident in grasping a better understanding of how to put theory into practice (Styhre and Eriksson, 2008). The secondary research question was therefore: could this type of residency play a useful part in public health training?

In the evaluation on this pilot the emphasis has been placed on viewing the intervention as a settings focussed residency. The student reaction has been the focus. However, since the completion of the pilot and its evaluation, we have been able to run a full six-month residency with a student on the public health speciality training course. This has provided the opportunity to run the residency in both modes concurrently. At the time of writing this second residency is still being evaluated.

Settings focussed residencies come in a variety of forms. Residents have included visual artists, poets, writers and musicians; and settings have included art galleries, schools, churches, prisons, universities, natural areas and historic cultural sites; and even whole cities. There are many examples of inter-disciplinary residencies, but pedagogic evaluation in the academic literature is rare. A widely acclaimed series of artist in residence projects at the Xerox Palo Alto Research Centre, set up to help both artists and Xerox engineers develop their creative skills has been widely written about (Styhre and Eriksson, 2008) and recently an evaluation report has been published for an artist in residence project at a prison, HMP Grendon (Caulfield, 2011). With little to rely on in the literature, this project was undertaken as a piece of exploratory action research. Early conceptualisation in action research was carried out by Lewin. He posed the idea that social practices could only be understood and changed by involving the practitioners themselves throughout an inquiry — this he termed ‘action research’ (Lewin, 1948). For this piece of research, the research team consisted of an academic public health practitioner, the academic lead of the architecture studio and an action researcher who works in the field of public health and built environment trans-disciplinarity. Since this team both designed the intervention, evaluated this pilot and had the intention of changing educational practice in their department, this fits the paradigm of action research.

Health and the built environment

At the root of this project is the definition of health taken from the Constitution of the World Health Organisation, ‘Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ (WHO, 1946, s2 p. 100). Flowing from this, the focus has not been placed on infectious disease, or on the services that treat illness; but the ‘wider determinants of health’ as seen through the eyes of built environment interventions (Barton and Grant, 2006). Factors such as climate stability, lack of everyday physical activity, poor access to healthy food, problematic community infrastructure, non-inclusive public realms, environments perceived as unsafe, poor air quality and noise pollution, are now all widely acknowledged to present risks and challenges to health in our towns and cities (Braubach and Grant, 2010).

Reports such as the National Endowment for Science, Technology and the Arts funded report ‘Danger and Opportunity’ (Murray, 2009) clearly identify the spiralling costs of the country's deteriorating health and the economic benefits that incorporating health into the public realm and building design could have, as well as the dangers of not acting quickly. This echoes the warnings given in the Wanless (2004) report to the UK treasury, that unless wider societal action is taken, with engagement across a broad range of professional sectors, to better prevent ill-health, healthcare in the future will become unaffordable. All the built environment professions need to see themselves as part of the wider public health workforce.

Health, well-being and the environment are interdependent and we need the skills and understanding to design for them together. In this context it is important to distinguish between architecture for health and architecture of healthcare. The founder of Maggie's Centres, Charles Jencks, emphasises the importance of reconnecting architecture with drivers based on health, which go right back to the Enlightenment, when it was first proposed that good design of the built environment could do more for public health than the medical profession could (Jenks and Heathcote, 2010).

In poorly planned settlements diseases of infection can be rife. Good city planning, well designed housing and urban civil engineering have seen an end to cholera, dysentery and tuberculosis as a constant background to urban life, at least in the developed world. It is without question that many important advances in public health have come through improvement of the built environment (Ashton and Seymour, 1988). However, in virtually all cities in the developed world there is now an increasing focus on the financial and human cost of the so called non-communicable diseases such as asthma, type 2 diabetes, obesity, cardio-vascular disease, stroke, mental health issues and even some cancers. These are on the increase and their rise has been associated with the design and form of urban environments (Braubach and Grant, 2010; Butland et al., 2007). Moreover, health outcomes and healthy environments are not evenly distributed; the pattern of avoidable outcomes in health (healthy inequity), closely follow the income gradient (Marmot, 2010). These unhealthy and inequitable environments haven't just happened by themselves, but are the resolution of market forces driving continual development and decisions by a plethora of built environment professionals including architects, urban designers, transport professionals, landscape architects, town planners and civil engineers; as mediated by a planning system, or the lack of one. Each development or design intervention can probably be justified on its own parameters, however we can assume that population health was rarely a concern since we have been left with a legacy of unhealthy urban environments.

The important role that the built environment and its professionals have to play in public health is recognised by several key built environment institutions such as the Commission for Architecture and the Built Environment (CABE) (2009) and the Royal Town Planning Institute (2009). The Centre for Education on the Built Environment has published a briefing guide, entitled ‘Bringing Public Health into Built Environment Education’, arising from the Education Network for Healthier Settlements project (Bird and Grant, 2011). To date, less attention has been paid to the role of the architect and debate often seems trapped by discussing the design of healthcare settings themselves (CABE, 2009). Architects can play a vital role in ensuring that the design of a building is health promoting; and not only for healthcare settings or in physical environmental terms such as lighting, ventilation and heating.

Supra-client values and the professions: architecture and public health

All professions develop a professional ethos within their own distinct culture. A unique element of this project was a bringing together of two professional disciplines that rarely interact. However, it is not just the fact of the interaction that is important, but its intention. Both ‘health’ and ‘sustainability’ as issues have the potential to enliven debates about supra-client values. A supra-client value is having a commitment to a principle concern beyond the concern of the immediate client. In medicine, we find an influence from the Hippocratic oath that provides a long-standing articulation of values for all health professionals. In sustainable development, we find the concept of futurity, whereby decisions should take into account their effect on future generations. In the built environment professions, an example of this would be one principle in the code of ethics that existed in the Landscape Institute until the mid-1980s. This stated that the ‘environment’ was the first client of a landscape architect. Members of the profession were obliged to sign up to this as a duty of care which went beyond their paymasters (the ‘client’), this is truly what is meant by a supra-client value.

Universities too face similar pressures in their case to accept the values of ‘academic capitalism’ (Slaughter and Leslie, 1997). However, as a longstanding commentator, Barnett suggests that ‘universities enjoy large pools of space in which to take up value positions of their own’ (2003, p.119). Barnett's plea is for faculty staff to use those pools of space to communicate a set of values with the potential to redefine the university as an institution that can challenge private interests and work toward the public good (Hanson, 2004). Barnett talks of academics being quiet on too many issues of public importance and goes on to voice that within the void of silence, universities have slipped into the habit of disregarding social problems. Scott (2004), commenting on education for sustainable development, also laments a ‘conspiracy of silence and/or culture of disinterest with regard to ethical issues in higher education’ (p.439) and Peel (2009) brings this discourse to the built environment by making the case for a better articulation of ethics as ‘a foundation for research integrity in built environment education’ (p.1). This ‘apparent void’ of a disciplinary ethical stance in built environment education (outside the more legally based business and professional ethics) is not at all evident in public health education.

Whereas for a built environment professional a duty towards the public or the environment in general would normally be classed as a supra-client value, for the public health professional both the public and the environment are the clients. The definition of health in the constitution of the World Health Organisation, cited earlier, is both aspirational and carries a strong normative stance. A ‘state of health’ is defined, not only in relation to the absence of disease, but as a state in which we are less likely to succumb to illness, whether through stress, pathogens or accident. This ‘state of health’ is also referred to as salutary health (Antonovsky, 1979) and through this definition the profession engages with issues beyond the individual, out into society, the local environment and the global environment as factors considered to be the wider determinants of health and influencers of heath inequalities. Explicit recognition of values is evident within the public health profession, both in its practise and in its education. Moreover advocacy, both for, and of those values, is also deeply embedded as a professional competency within the Faculty of Public Health and the skills and career framework (Public Health Resource Unit, 2008).

To start to examine embedded values within architectural education, we can learn from the instruments controlling the professional curriculum. In the UK, three bodies shape the nature of professional education in the UK; the Quality Assurance Agency for Higher Education, the Architects Registration Board and the Royal Institute of British Architects. In practice, stemming from these three bodies, three separate but closely related documents constitute the guidance to higher education institutions offering professionally recognised courses in architecture. The result is guidance on course content with the aim of achieving professional education that meets an overarching European Union Qualifications Directive (Council Directive 2005/36/EC). Article 46 of the Directive contains a statement of the skills and knowledge that all professional qualifications in architecture in the European Union must deliver. It is concise; just eleven points in 291 words. There is little specific guidance on values or how public health should be covered in the education of architects. However, the broad definition of the nature of architecture contained in the eleven points of the directive offers huge opportunity for the evolution of education to take into account emerging knowledge and new priorities. Sustainability is a strong theme running through the profession, though with a main emphasis on environmental aspects and less on the core social principles, such as population health and social equity. The framework directing the architectural profession has allowed educational practices to develop that have wide, divergent, and even conflicting, approaches to values. There is no explicit support for supra-client values but also, notably, there are no barriers to individuals, practices, and higher education institutions developing their own ethical stance within the profession.

The Pilot Residency

Approach

The method chosen to examine bringing public health into architectural education was to pilot the introduction of a public health practitioner to an architecture studio as a residency. The studio was run as in previous years, but with the additional resource of the public health resident. The project spanned one entire academic year and was run as a ‘vertical studio’, with 34 students in both first and second years of the BArch (Part II) course taking part (this is during the fifth and sixth years of architectural education). The design project had a real client with a real brief. The Stroud District Local Strategic Partnership had tasked one of its members, the community group Stroud Common Wealth, to draw together ideas, concerns and issues as seen by the many community groups in and around Stroud. Students were then asked to address these through the scoping, analysis and proposal stages of their programme.

Stroud is a market town of some 50,000 people, if close by villages and associated nearby urban areas are included. It is located in Gloucestershire, a predominantly rural county in the Cotswold Hills to the southwest of the English Midlands. The community in Stroud wanted some input for local planning processes, and particularly sought design innovation. In discussions they asked for unfettered imagination to be brought to bear on architectural solutions for their infrastructure problems and offered the students the opportunity to address real challenges and to influence the emerging community vision. The community group wished to create community cohesion and saw the project as an opportunity to create an exemplar partnership with professionals, experts and others; ‘a project to feel proud of’. The research team believed this challenge would present the student cohort with a unique opportunity to explore Stroud's potential as a model of healthy living and would fit well with the Public Health Residency methodology.

The residency as an intervention was supported by the Centre for Education in the Built Environment through an Innovative Projects in Learning and Teaching grant. The approach can be seen as following on from Ellis et al. (2008) who reflected on the experience of bringing together undergraduate students from medicine and planning to explore the concept of Healthy Urban Planning in a real life context of an urban motorway extension. Their study reported a number of unexpected positive outcomes of such a collaboration and their conclusions endorsed the value of promoting inter-professional education, both as a way of increasing interest in key challenges now facing society and in order to induce greater academic professional reflection. As a pilot, the project team were very interested in evaluating the residency to inform future development of public health teaching in the design studios of the department. The research team met to reflect on outcomes and steer the direction of the research at critical points in the process. The project had three distinct phases of activity:

1. Preparation — whereby the students and the public health practitioner started to engage with the subject area. A baseline survey of the students was undertaken at this time to assess their attitudes and knowledge regarding architecture and its relationship to health.

2. Immersion — during which the public health practitioner actively engaged with students in the design studio, both individually and as a group, through delivering short lectures, group tutorials, and one-to-one support for students.

3. Reflection — characterised by the involvement of a wider team during a one day evaluation workshop. It also included a post-project student survey, and a number of community engagement activities.

Description of the case study

Preparatory phase

Before developing their proposals, the students analysed the town of Stroud in depth, including undertaking field visits.

Using a structured approach, drawn from the book ‘shaping Neighbourhoods’ which brings together public health, sustainability and urban design (Barton et al., 2010), students assessed the strengths and weaknesses of the town through its physical form and function, considering issues such as health and well-being, social inclusion and community, movement, economic vitality and environment. They also learnt about health systems through a process of creative self-directed systemic enquiry. Coming from architectural mindsets, this process provided some striking and new images that conceptualised heath systems and concepts in ways that were insightful but unfamiliar to the public health practitioner (Figures 1 and 2). Students then developed a master plan for Stroud, and began to plan their individual designs.

Figure 1 The NHS as machine for curing illness (Luke Young)

Figure 2 Concepts of Public Health (Charles Wellingham)

As an initial encounter with Stroud, the students were asked to analyse the town in a qualitative manner, and to record their first impressions, where often, otherwise unseen, elements of truth are embedded. From this analysis emerged a number of strong themes of particular relevance to Stroud. These were then turned into a set of proposed strategies that the regeneration of the town should follow in order to provide a healthy and sustainable environment for its inhabitants. This strategy was also incorporated into an overall masterplan for regeneration of the area.

A final part of the preparatory phase was the use of the SPECTRUM appraisal tool (Barton and Grant, 2008) which sought to assess firstly the baseline situation, and then the possible negative and positive health effects of the proposed masterplan. Detailed criteria were developed and analysed under five broad headings:

• Health and well-being;

• Social inclusion and community;

• Movement;

• Economic vitality; and

• Environment.

This allowed the students to appraise the current situation and to consider in what way their projects would help the town to become a ‘Model of Health’. This may seem an ambitious goal but it was chosen as it sets up an important dynamic which helps take the students beyond a ‘business as usual’ mentality (Senge, 1990).

Immersion phase

This phase signalled the introduction of the public health practitioner into the design studio, as students began to develop their individual proposals within Stroud.

The public health practitioner was a senior lecturer in public health at the university. As a registered public health specialist on the UK Public Health Register, he had worked and trained in public health in the NHS. The practitioner had worked closely with colleagues in the Department of Planning and Architecture over the past few years in a number of built environment action learning projects, but had not until then engaged with architecture students.

His time was paid for by the research grant that compensated his host department for the use of his time in another faculty. The public health practitioner was involved in student tutorials and group crits. He also delivered seminars on three selected health topics: the life-course approach to health; equity of access to and utilisation of services; and social capital. These topics were chosen as they are key aspects of current community health and well-being that the project team felt could be influenced by the architectural profession. They are also strong themes in the influential Marmot Review (Marmot, 2010), which acted as a policy focus for this project due to its call to transform the built environment for public health.

The Marmot Review recognises and highlights the importance of addressing health through prevention efforts across the life-course. Particular attention is focused on critical life points, such as the early years, parenthood and transition through the education system. Taking a life-course approach in architecture includes considering how the form and function of buildings influence particular life points and identifying how positive impacts across the life-course can be maximised (Figure 3).

Figure 3 Life-course circus (Rachel MacFadden)

The conceptual framework of the Marmot Review seeks to promote equality and health equity in all public policies, of which equity of access to and utilisation of services and amenities is a key aspect. Architects can contribute to this by considering carefully how developments might target hard-to-reach groups through the design of buildings and the activities taking place within them. The aim was to maximise the health benefits of any proposed development to the advantage of the community by ensuring that physical, social and cultural accessibility issues are considered. This included issues such as developing social capital, whereby strong community ties and relationships can help to mitigate the impact of other negative health determinants. The architectural students sought to build social capital within and across communities through careful design of buildings to encourage social mix, for example, through housing activities that sought to bring the community together for shared benefits.

As part of this immersion phase, the practitioner helped students understand the health baseline of Stroud and analyse it from a number of viewpoints (Figure 4). He prepared a series of reflective questions for the students, setting them challenges to incorporate the three aspects of health into their designs. This aimed to open up students' minds, and empower them to make choices and take decisions based on a holistic view of the complexity of the systems and processes that impact on people's health. This helped to foster a much needed understanding of common purpose between built environment professions and public health (Pilkington et al., 2008).

Figure 4 Stroud health profile (Luke Young)

Reflection Phase

The public health practitioner concluded their input with a ‘reflection-on-action’ focus group workshop. For this an external review team came in from 00/:architects, a London based strategy and design practice, to provide additional lines of enquiry. The students joined the focus group as did members of the research team and other tutors on the unit. All of these participants spent a day exploring why the students responded to the project in the way that they did.

A post-project survey also gathered student views of the residency pilot and assessed changes in their knowledge and attitudes towards integrating health considerations into their design studio work. Finally, an event in Stroud offered the opportunity for staff and students to report on their work to representatives of the Stroud community. The student projects were exhibited in both Stroud and the city of Bristol.

Findings

Evaluation data was collected from the student body and this section focuses on those findings. The impact of the project was measured through pre-intervention and post-intervention questionnaires, and a focus group. Twenty-six students out of thirty-four completed the pre-intervention questionnaire, and twenty-eight students completed the post-intervention questionnaire. Qualitative comments were subjected to a thematic analysis.

The student participants were asked to rate their agreement to three statements relating to the issue of architecture and wider determinants of health, before and after the input of the public health practitioner (Figure 5).

Figure 5 Agreement with statements, pre and post public health practitioner input 26 students responded to the pre-intervention survey, response rate of 26/34 = 76% 28 students responded to the post-intervention survey, response rate of 28/34 = 82%

In both the pre- and post-intervention surveys, students were most likely to agree with each of the three statements. The high level of agreement in the pre-intervention survey may be explained by the fact that students had worked for one semester on health-related themes before the residency intervention and they had also self-selected to be part of the project. There was however a noticeable increase in the number of students who agreed or agreed strongly that they were, “able to successfully integrate considerations of the wider determinants of health into my work in the design studio”, rising from 17 (65%) to 28 (100%). This suggests that the intervention achieved its aims. The vast majority of respondents agreed (61%) or strongly agreed (36%) that they were more likely to consider aspects of health when designing developments in their future career as an architect as a result of undertaking this project (Table 1).

Table 1 Agreement with statements, post residency input

Statement	Strongly disagree	Disagree	Neutral Agree	Strongly agree	Total
Through undertaking
the Health Unit, I am
now more likely to
consider aspects of	0	1	0	17	10	28
health when designing		(3.6%)		(60.7%)	(35.7%)	(100%)
developments in my
future career as an
architect.
In the current economic
and political climate, I
feel that health is going	0	0	7	13	7	27
to become more of a			(25.9%)	(48.1%)	(25.9%)	(100%)
driver for sustainability.

Students were asked in both questionnaires to give their opinion of the three most important health issues for an architect to consider when designing a healthy and sustainable building. In both questionnaires there was a focus on the traditional concerns of architects, namely issues relating to aesthetics, physical indoor environment and materials. However, after the project there was a noticeable increase in students recognising the need for architects to consider the social nature of their development, and its impact on social capital. There was also an increased reference to wider health promoting issues such as encouraging physical activity. This was picked up in a range of comments about better visibility of staircases in buildings and making use of routes on site, also contextual issues such as links to active travel in the surrounding environment. Such comments were conspicuously absent from the first survey. It was clear that students were now thinking more about the community who would use the building, rather than just the building itself.

The final survey also included a class of comments in relation to the wider determinants of health that were not at all evident in the initial survey. Some examples can be found in Box 1.

Box 1 : Examples of students' comments referring to the wider determinants of health after the project.

Question 1: In your opinion, what are the three most important health issues for an architect to consider when designing a healthy and sustainable building?

Students were asked this question twice, once before and again after the project (some three months later). Below is a selection of student responses after the project, they are indicative of a demonstrable acknowledgement of the wider determinants of health, a concern completely missing from the first survey.

‘An appreciation of the complexity and far reaching consequences of health.’

‘An appreciation of how health can be influenced by so many variables and the mechanisms by which it can occur.’

‘How the building will perform for its inhabitants’ life-course. ’

‘Create and define strong and definite links to the natural world.’

In the post project questionnaire students were asked to reflect on the usefulness of the public health practitioner's input, some specific comments are quoted in Box 2.

Box 2: Examples of students' comments referring to specific aspects of the public health practitioner's input.

Question 7: What input from the public health practitioner did you find most helpful for supporting your work in the design studio?

Following the project, students were asked about the value of the public health practitioner's input. Responses ranged across themes dealing with social capital, wider determinants of health, underpinning good design decisions and helping to understand issues of inequalities and exclusion. This selection of responses gives a flavour of a few of those answers.

‘Finding out about the ways inequalities are reinforced throughout a person's lifetime.’

‘The isolated groups that we did not think of before.’

‘The idea that health and well-being relates to everything around us.’

‘Thinking about how you can influence people's health at different life stages.’

‘An advanced understanding of health considerations outside of typical construction and building design.’

‘Understanding and becoming aware of wider health implications I was unaware of.’

In general, students were extremely positive about the experience and had enjoyed being exposed to the ideas and concepts from another discipline. They felt that the input had added to their design project, and they now understood more about the wider determinants of health and the role that they, as architects, could play in promoting health and well-being. Students had also thought that it would be better if input from the public health practitioner started earlier in the design process.

In the final reflective focus group, it was clear from the students' responses that having a public health practitioner in residence had been invaluable in helping them to focus on the theme at hand. When examining overall experience of the project, they saw public health as a way of revealing the environmental thinking behind the architectural education they have received. As one student commented, “Health unlocks how to apply sustainability as architects”.

Discussion

First, it is worth reviewing the research questions stated earlier.

Primary question:

• Is a ‘scholar-in-residence’ intervention a valuable pedagogic approach to support interdisciplinarity?

Secondary questions:

• Can this placement add value to an architectural studio in terms of public health outcomes?

• Could this type of residency play a useful part in public health practitioner training?

In addressing the answers to these questions, it is useful to discuss Silverstein's pedagogic model for residencies. In discussing artistic residencies, Silverstein (2003) proposed three distinct instructional purposes. These are set out below substituting the words ‘public health’, in the place of ‘the arts’.

• To spark students' interest in public health.

• To develop students' knowledge and skills in public health and/or help them learn other subject areas through public health.

• To build teachers' capacity to teach in, through, and about public health.

If the conditions have been created to allow each of these purposes to be fulfilled, then the answer may well be a resounding ‘yes’ to each of the research questions. Each of these three proposed purposes are discussed in turn, in relation to the public health residency.

To spark interest: As an innovative example of a residency, our approach also incorporated aspects of a ‘scholar in Residence’ programme, anticipating that the public health specialist would act as an agent-of-change to inspire students to immerse themselves in public health agendas, and to bring science into their creativity. The aim was to encourage the students to see things in a ‘different light’, so the studio environment could become a ‘fully transformative’ learning experience (Marton and Tsui, 2004, p.139).

With input from the public health practitioner, feedback showed that the students developed new ways of learning appropriate to the project at hand and were able to change earlier conceptions they had relating to health and design (Entwistlea and Peterson, 2004). Analysis of the feedback also demonstrated that considering health in the design stages of a development can also achieve sustainability outcomes. By using a ‘public health practitioner in residence’, the project has:

• Impressed upon architecture students the important role that architects can play in affecting the health of individuals, communities and populations.

• Introduced key public health concepts that should be considered when designing an architectural project.

• Encouraged students to consider how their proposals can be modified so as to maximise the potential benefits for the health of the population.

To develop knowledge and skills: Showing a concern for the wider determinants of health in their work, gave students the confidence and understanding to explore how a building influences social mixing, equity of access, and addresses (or not) the health and well-being needs of a variety of groups across the human life-course. If it is important for architects in practice, then it is certainly vital for architecture students in training to understand more about health and well-being, and how their profession can contribute positively to the public health agenda.

The student learning experience was enhanced through this inter-professional residency, as can clearly be seen from their project work. The project teaching staff also benefited by understanding more about an allied profession and being exposed to a novel way for fostering effective multi-professionality in their teaching. The Department of Planning and Architecture has also strengthened the link between the World Health Organisation Collaborating Centre and its wider teaching staff, as well as the Department Health and Applied Social Sciences.

To build the teaching capacity: The practitioner expected that students would be interested in public health issues and concepts, but he was surprised by the enthusiasm of the students and how clearly they saw the links between architecture and health. The main challenge to be overcome by the resident was to adapt to working with students in an unfamiliar way — the design studio approach is very different to traditional teaching in public health, which is primarily lecture and workshop based. Logistically, it meant being in the studio for several hours in order to be fully embedded in the studio culture and processes. Engagement in a studio setting was therefore time consuming, but ultimately very rewarding.

Not captured in data here, but it became apparent through team review discussions, that the impact of the project has not been limited just to the students. The steering group reflected on how it has also affected the public health practitioner, the research team, the planning and architecture department and stakeholders outside the education system. For example, the architecture studio leader now has a much deeper understanding of the public health paradigm and, in Stroud, the stakeholders have a better understanding of the impact that architects and architecture can have on the wider determinants of health. In any repeat of this project the impact on the wider teaching team at the University of the West of England (UWE) and other stakeholders could certainly be evaluated.

Creating inter-professional learning situations for health can be complex and fraught with difficulties (Lewy, 2010). The success of this innovative project was referred to in the joint research councils' publication of innovative research ‘Big ideas for the future’ (Research Councils UK and Universities UK, 2011, p.39). As a pedagogy, the residency provided a ready-made scientific input to a creative process and promoted reflective behaviour. Reflection-in-action is perceived as a key skill by Schön and defined as the ability of professionals to ‘think what they are doing while they are doing it’ (Schön, 1987, p.xi). By taking the architecture students into less familiar professional territory, it allowed them a freedom to role play and experiment in new ways — perhaps the architect as community level ‘healer’ or ‘physician’.

As research of a pilot intervention to evaluate the concept of a ‘scholar-in-residence’ in an architectural studio, this study has a number of limitations. Due to timing in the securing of funding, and the presence of an active WHO Collaborating Centre in the department, students had been ‘exposed’ to a degree of public health input prior to the residency. This will have adversely influenced the pre-intervention attitudinal surveys that were undertaken. In addition, it would be valuable to have been able to extend the length of follow-up to detect longer term change in students' working practises.

The evaluative methodology, based on student surveys, also had great limitations. Survey itself as a method is limited in scope and depth. Relevant to both these issues; the final daylong workshop with external reviewers could, with a better design, have captured valuable data about the impact of the intervention. Changes in the teaching team and department have not been adequately studied, in a longer residency these would especially be of interest. Other evaluative aspects of the project have already been published, a review of architectural praxis (Marco et al., in draft) and of public health advocacy (Pilkington et al., in press).

Further Reflection and Next Stages

For future work we would consider introducing the public health practitioner in residence at an earlier stage in the teaching unit. As reported, a number of students thought that this would have been helpful. In the example, the introduction of the practitioner (in the middle of the unit) was due to limitations on the amount and timing of the funding. In the future, arrangements could be made to ensure that the practitioner would be present regularly throughout the teaching period.

As noted in the introduction, current public health challenges necessitate the closer working of public health professionals with the wider public health workforces — a concept that includes built environment professionals. Professional training efforts directed at practicing professionals can be effective at bringing together such groups. However, targeting those still in primary training offers a more fundamental, embedded and wider reaching model for spreading public health skills, knowledge and understanding amongst built environment professions. Although we feel that this project offers a valuable model for such efforts, the work described here represents only a first step in engaging architecture students in public health issues and concepts, and was only made possible through external funding to cover the costs of the public health practitioner.

New ways need to be found in order to ensure the future viability of the public health practitioner in residence approach. An option, which the WHO Collaborating Centre is developing, is to offer the public health practitioner in residence position as a placement for graduates who are undertaking higher specialist training in public health, such as those on the ‘UK Specialist Public Health Training Programme’. This is the training programme run by the Faculty of Public Health, the institutional professional body for public health in the UK. It is a five year training programme and trainees in the fourth and fifth year would be eligible for a six-month placement. Project placements are a key part of their training, and therefore opportunities do exist to offer such placements in order to further this agenda.

Such a placement, designed also with a wider package of training about determinants of health in the built environment by the host institution, could offer an ideal training opportunity. This could see the public health practitioner in residence model applied to a wider range of students across other disciplines in the department's built environment teaching portfolio such as urban design, transport and planning. The goal would be to cultivate a cadre of graduates from built environment disciplines who affect public health for good, and not for ill, throughout their professional lives.

The staff and students involved in the project presented the results of their work at a symposium in Stroud on May 13th 2011 that focussed on local strategies for regeneration and renewal. The symposium provided an opportunity to liaise with local organisations and community groups. Those at the symposium saw the student work as a resource for helping influence the kind of future that regeneration projects could help deliver for Stroud and its rural hinterland.

The project has now been exhibited in both Stroud and Bristol as part of a structured programme of dissemination of findings to the general public and practising architectural professionals. By the outcomes from this residency, the intention is to facilitate similar approaches in other institutions and at UWE to extend it to other design studios and teaching in the department.