Audits-of-place provide valuable data that can bridge the divide between health determinants and the design of built environments. This report discusses the role of auditing in developing healthy and sustainable places. It begins with a case-study of the Healthy Built Environments Program (HBEP) audit tool as used in Higgins, ACT. The methodology of the audit is explained along with a short discussion of the results. The report will go on to analyse the strengths and weaknesses of the HBEP tool as compared with current international and local walkability audit tools. It will discuss the role of auditing in the context of Health Impact Assessment (HIA) and policy development. Peer-reviewed academic journals, United Nations and Australian Government Department documents have informed the recommendations made as a result of this research.
The Healthy Built Environments Program (HBEP) and audit toolkit was developed by Professor Susan Thompson, Dr Jennifer Kent and colleagues of the UNSW Faculty of Built Environment. The program focuses on research, education, workforce development and advocacy as a strategy for connecting health professionals with the built environment (Thompson, 2015).
The mini-audit was conducted on-foot. It involved observing the vicinity of Higgins Place. Data was collected through written notes, photographs and Google Maps.
Six factors were considered in assessing the health-supporting capacity of the environment:
- Access and Circulation (ease of access via. paved and grass areas, including for mobility-disabled)
- Shade (sun exposure protection in walking and gathering areas)
- Safety (perceptions of safety regarding times of day, presence of others, vehicles and cyclists)
- Transport (availability and useability of active transport)
- Food Facilities (availability, affordability and quality of food available)
- Places to Meet and Socialise (availability and quality of public outdoor facilities, including green space)
The HBEP tool encourages users to analyse aspects of the environment regarding each of these factors, with the primary users of the area in mind. Guided questions require the auditor to give examples (direct observations) and use rating scales (perceptual observations) (see Appendix 1). In collating the data, qualitative (comments) and quantitative (ratings) data were analysed as either positive or negative. Higher levels of positive feedback correlate with more health-promoting areas.
See Appendix 2 for a data summary of the HBEP audit conducted for Higgins Place in June 2019. Table 1 outlines the major findings. Further discussion of this exercise is presented as an online presentation (accessible via https://youtu.be/OLugkReDH6I).
The HBEP tool assisted a Public Health student with little prior auditing experience to explore the associations between design and health outcomes for a specific environment. In conducting the audit of Higgins Place, it was important to consider the main users – families (many with young children) and older adults (often living with mobility disabilities). Many aspects of the environment did well to promote health (such as the large weather shelter, ample disabled parking and provision of bike racks). Other aspects, through poor design and maintenance or changes in user needs, could pose a risk to health (such as the lack of food facilities and damaged footpaths).
AN ANALYSIS OF THE AUDIT INSTRUMENT
OTHER AUDITING TOOLS
The HBEP audit is one of numerous ‘health of place’ auditing tools that have been developed in the last decade. These tools are designed by various stakeholders with differing objectives in mind. The objective of the developer impacts the methodology of the audit (including geographic scale, data collection techniques and degree of detail) (Dannenberg & Wendel, 2011). The HBEP tool was designed to introduce students to the user-perspective based concept of auditing for health (UNSW Faculty of Built Environment, 2013). It is broad in its scope of health-related factors and relies primarily on perceptual data collection.
It is valuable to compare this tool to those used in research and practice. For example, the Heart Foundation Neighborhood Walkability Checklist (HFNWC) was developed as an advocacy tool to facilitate community-led policy change (National Heart Foundation of Australia, 2011). The tool uses quantitative input, providing an overall ‘walkability score’ (see Appendix 3). The Walking Route Audit Tool for Seniors (WRATS) assesses walkability for ageing communities. WRATS was developed based on literature review and focus groups. It ranks 59 items (addressing safety, functionality, aesthetics and destinations) on a 3-point scale (see Appendix 4) (Kerr, Carlson, Rosenberg & Withers, 2012). Strengths and weaknesses of the HBEP audit compared to these quantitative, walkability-specific tools are outlined below.
- Range of healthy behaviour determinants covered (food, socialisation etc.), not solely walkability
- Emphasis on perceptual and qualitative data, valuable in latter design stages and assessing impact on healthy behaviours (especially in population groups) (Watkins, 2012)
- Guiding questions encourage critical thinking (e.g. WHY do you feel safe here?)
- Potential auditor-bias. Results are dependent on the auditor’s area of expertiese, prior perceptions of health and/or design, knowledge of area and community). Quantitative, scale-rated audits could minimize this.
- Focus on visual and perceptual observations, lacking geographic or quantitative data. Such data is often required to validify policy change and to evaluate change over time and/or location. For example, a retrospective audit with the HFNWC would indicate if the area’s walkability has changed through a change in score.
THE ROLE OF AUDITING IN THE CONTEXT OF HEALTH IMPACT ASSESSMENT
HEALTH IMPACT ASSESSMENT
Health Impact Assessment (HIA) is a public policy intervention tool. Since its development in the late 1990s, the collection of instruments has been used to ‘judge the potential effects of a policy, program or project on the health of a population, and the distribution of those effects within the population’ (WHO European Centre for Health Policy as cited in in Harris, Kemp & Sainsbury, 2012). Figure 1 outlines the HIA process. In Australia, public health and policy researchers are calling for an emphasis on HIA in Environmental Impact Assessment (EIA). EIA is mandatory for any policy or action that is likely to impact environment, history or biodiversity under the Environment Protection and Biodiversity Conservation Act, 1999 (Australian Government Department of the Environment and Energy, 2019). HIA is fundamental in health and urban design policy-making as it provides a linear process to assess a project’s effects on the wider determinants of health (Harris et al., 2012).
The enCouncil framework identifies ‘monitoring, environmental and health auditing’ as the final stage of the HIA process. Audits can measure a project’s compliance with conditions outlined in the HIA. They can also evaluate the longitudinal success of the HIA process in promoting health (Western Australia Department of Health, 2007, p. 16). A literature review highlighted some recommendations for the incorporation of auditing in HIA.
- Ahammed (2007) critiqued this ’Australian approach’ of retrospective auditing in EIA (of which HIA is often a component of). He suggests that using audit tools throughout the assessment process would increase compliance and reporting between the numerous agencies involved.
- Quigley & Taylor (2003) caution against using the results of audits to establish cause-effect relationships between determinants of health and health outcomes. A successful HIA intervention can make it impossible to test the accuracy of detrimental health outcomes predicated in the earlier stages of the process. For example, if a mitigation measure such the installation of temporary walking paths during construction work is implemented, there should be no associated behaviour change (it is unlikely people will begin to walk more, but they should walk less). They suggest audit tools should be used to assess the HIA process in itself.
The concept of HIA (and the role of auditing throughout the process) will continue to emerge as policy-makers, health professionals and urban designers acknowledge the unmistakable connection between health and place. Auditing tools are essential in monitoring the HIA process as well as assessing the success and adherence to resulting plans.
The results of the mini-audit in Higgins show a clear relationship between the aesthetics and functionality of the environment and users’ likelihood to participate in health-promoting behaviours. The HBEP tool allowed the auditor to identify some areas for improvement and make some practical recommendations. An analysis of the audit tool presented some issues with user bias and a lack of quantitative evidence. It is important to contextualize audit methods, timeframes and objectives. Auditing and monitoring tools are an integral part of conducting and evaluating HIA processes. The literature suggests that more research and real-world experience will be valuable in clearly defining the role of audits in impact assessment.
- Ahammed, A. K. M. Rafique. (2007). The Role of Monitoring and Auditing in the Environmental Impact Assessment (EIA) Process in Australia (Research Thesis). The University of Adelaide – School of Social Sciences, Australia.
- Australian Government Department of the Environment and Energy. (2019). Environmental Assessment and Approval Process. Retrieved from environment.gov.au: https://www.environment.gov.au/protection/environment-assessments/assessment-and-approval-process
- Dannenberg, A. L., Wendel, A. M. (2011). Chapter 20: Measuring, Assessing and Certifying Healthy Places. In A. Dannenberg, H. Frumkin & R. J. Jackson (Eds), Making Healthy Places: designing and building for health, well-being, and sustainability (pp. 303-318). Washington, DC: Island Press.
- Harris, P., Kemp, L., & Sainsbury, P. (2012). The essential elements of health impact assessment and healthy public policy: a qualitative study of practitioner perspectives. BMJ Open, 2(6). https://doi.org/10.1136/bmjopen-2012-001245
- Kerr, J., Carlson, J. A., Rosenberg, D. E. (2009). Walking Route Audit Tool for Seniors (WRATS). Retrieved from Active Living Research: https://activelivingresearch.org/walking-route-audit-tool-seniors-wrats
- Kerr, J., Carlson, J. A., Rosenberg, D. E., & Withers, A. (2012). Identifying and Promoting Safe Walking Routes in Older Adults. Health, 4(Special Issue I), 720-724. https://doi.org/10.4236/health.2012.429112
- National Heart Foundation of Australia. (2011). Neighbourhood Walkability Checklist [Pamphlet]. Retrieved from https://www.heartfoundation.org.au/images/uploads/main/Active_living/Neighbourhood-walkability-checklist.pdf
- Quigley, R., & Taylor, L. (2003). Evaluation as a key part of health impact assessment: the English experience. (Policy and Practice). Bulletin of the World Health Organization, 81(6), 415–419. https://doi.org/10.1590/S0042-96862003000600010
- Thompson, S. M. (2015). NSW Research and Workforce Development Program on Healthy Built Environments. Retrieved from City Futures Research Centre: https://cityfutures.be.unsw.edu.au/research/projects/nsw-research-and-workforce-development-program-on-healthy-built-environments/
- UNSW Faculty of Built Environment. (2010). Healthy Planning Mini Audit. Australia: UNSW
- UNSW Faculty of Built Environment. (2013). Healthy Built Environments Program Annual Report 2013. Sydney, NSW: City Futures Research Centre.
- Watkins, D. (2012). Qualitative Research: The Importance of Conducting Research That Doesn’t “Count.” Health Promotion Practice, 13(2), 153–158. https://doi.org/10.1177/1524839912437370
- Western Australia Department of Health. (2007). Health Impact Assessment in Western Australia Discussion Paper. Retrieved from http://hiaconnect.edu.au/old/files/HIA_in_WA_Discussion_Paper.pdf