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The intricate interplay between urban design, health, and equity has emerged as a critical focal point in pursuit of the United Nations Sustainable Development Goal 11, which seeks to make cities inclusive, safe, resilient, and sustainable. It reflects an increasing awareness of the social determinants of health – a term encapsulating the socioeconomic variables that shape an individual’s living and working conditions (Raphael et al., 2020). In other words, a person’s-built environment (the human-made surroundings within which people live and work) can either support or detract from their health. This relationship is underscored by the impact of urban design on equity.

Urban design plays a pivotal role in shaping the health and wellbeing of communities through its influence on various dimensions of human life. For example, facilitating active transportation options, such as walking and cycling through well-designed streets and bike lanes, urban design can promote physical activity, thereby reducing the risk of obesity and chronic diseases associated with sedentary lifestyles (Collins et al., 2018). Interventions such as speed limits and pedestrian safety measures directly impact public health by reducing the frequency and severity of crashes (Vecino-Ortiz et al., 2018). The layout of urban areas significantly influences access to healthy foods, with inadequate access linked to higher rates of diet-related health issues (Giles-Corti et al., 2016). Green spaces and community gathering areas contribute to a sense of safety and belonging, while well-designed public spaces foster social interaction and support networks, all of which positively contributes to citizens’ mental wellbeing (Thompson & Kent, 2014). Urban design decisions can create car-dependent suburbs, which are associated with more air pollution than less car-dependent areas (Walker, 2016; Richards, 2020), and social isolation especially among older adults and disabled persons (Jakubec et al., 2019).

There are several current-day examples where urban design and built environment positively contributed to a population’s overall wellbeing. In England, the National Health Service launched the Healthy New Towns programme that aimed to develop innovative approaches to shaping new towns and communities to promote health and wellbeing (Bowkett & Norman, 2018). One notable project, Barton Park in Oxford, addressed health inequalities by appointing a Community Health Development Officer, refurbishing the Neighbourhood Centre, and enhancing infrastructure. This included building 885 sustainable homes, improving walkability and cycling, promoting local food access, and offering community services. The project prioritized affordability, generating jobs, and fostering social connections. Social prescribing was implemented for 332 participating patients, yielding health benefits and cost savings in primary and secondary care. Barton Park exemplifies how focusing on built environment can enhance health and equity (Pineo, 2022).

With Canada now 80% urbanized, it is not surprising that cities and urban centers have emerged as a primary arena for addressing current health challenges and safeguarding the wellbeing of residents. Therefore, by recognizing the relationship between urban design and health provides an opportunity to address gaps that contribute to health inequities. However, not all municipal actors and urban design professionals readily acknowledge their pivotal role in improving population health. To understand how key municipal policy- and decision-makers view the relationship between health and urban design, our team used the City of Regina as a case study.

We interviewed 30 municipal actors from various roles and educational backgrounds within Regina’s municipal government. These interviews were analyzed using qualitative research methods and the findings were used to inform this policy paper.

In this study, the term ‘decision-maker’ refers to elected officials responsible for choosing policy directions and priorities, and for deciding which policies will be translated into tangible action by the municipal government. This responsibility primarily falls to the Mayor and City Council. In contrast, the term ‘policy-maker’ refers to public servants responsible for developing and implementing policies in accordance with the mandate chosen by decision-makers. In Regina, this work falls onto the City Administration. The terms ‘stakeholder’ and ‘actor’ are used interchangeably in reference to both policy- and decision-makers.

Our objective is to demonstrate policy- and decision-makers’ current understanding of health and equity in urban design, and explore what barriers prevent the integration of health into urban design policies. It should be noted that much of the current literature focuses on larger, international cities. Conversely, our findings from Regina are uniquely applicable to medium-sized cities across Canada, and beyond.

Regina, the capital of Saskatchewan, is Canada’s 16^th largest city, boasts a population of approximately 230,000 and is located on the traditional lands of the Treaty 4 Territory, original lands of the Cree, Saulteaux, Dakota, Nakota, Lakota, and Métis peoples (Statistics Canada, 2017). Approximately 80% of the population identifies as white, while around 10% identify as Indigenous, placing Regina 7^th in Canada for its Indigenous population. Additionally, the city is home to a mix of Southeast Asian, South Asian, East Asian, West Asian, Black, Latin American, and Arab communities (Canadian Municipal Network on Crime Prevention, 2021).

The City is comprised of auto-dependent and low-density suburbs with the majority of residents commuting by car rather than by active mode or public transport (Allen, 2019). According to the 2021 census, 90.2% of people in Regina commuted to work mainly by driving a private vehicle. A recent study examined access to public libraries in Regina and found that people reliant on public transport or walking have significantly less access to public libraries than those with a private car (Allen, 2019). A city that continues to grow with car-dependent suburbs could be an example of urban design policy that is inconsistent with public health evidence.

In line with their provincial and national counterparts, the City of Regina has adopted a number of health-supportive urban policies and plans. These include: Regina’s first two-way protected bike lane in October 2019; Vision Zero road safety framework in 2019; Age-Friendly checklist in September 2020; and Community Safety and Well-being (CSWB) plan in November 2021. The CSWB plan includes six key priorities: domestic violence, food insecurity, substance use, racism and discrimination, safety, and service systems (Canadian Municipal Network on Crime Prevention, 2021). The City has further developed a Community Well-being Impact Assessment Toolkit in August 2022 to evaluate the impact of urban policies on wellbeing, and to assess alignment of city/urban policies with the foundational principles outlined in the CSWB plan.

The barriers identified in our findings (Mahani et al., 2024) can be classified into three categories: constrained policy-making environment, societal and cultural factors, and competing interests of stakeholders.

1. Constrained Policy-Making Environment

Our research findings underscore the pivotal influence of the policy-making environment on the actions of policy- and decision-makers, revealing significant challenges to the development and implementation of healthy urban design policies.

Lack of Shared Understanding of Health

There were notable discrepancies in how interviewees conceptualized health, with many preferring the term “wellbeing” over “health” or “wellness” and no consensus on the essential traits integral to an individual’s health. While physical health received considerable attention, and mental health emerged as an increasingly recognized dimension, the social dimension of health was less commonly acknowledged unless explicitly prompted. This inconsistent understanding among stakeholders poses a significant obstacle to the meaningful integration of health into urban planning. Furthermore, the absence of shared motivation, knowledge, or interest hampers proactive policy-making, rendering the current municipal stance on public health predominantly reactive.

Inaccessibility of Evidence

While interviewees acknowledged the importance of evidence-informed policy-making, they reported substantial obstacles in accessing relevant evidence. For instance, it was noted that administrative hurdles, including a lack of coordination between provincial and municipal governments, limited access to timely and necessary data for policy-making. Similarly, scientific evidence was often found to be rendered inaccessible by paywalls with high financial costs. Even when scientific evidence is accessible, the frequent use of academic jargons and technical language can limit the ability of policy- and decision-makers to understand and interpret studies.

Participants also highlighted the limited capacity within the municipal government to effectively integrate evidence into policy- and decision-making. Several interviewees expressed concerns about a lack of understanding within the municipal government at both political and bureaucratic levels of the value of using data and evidence to inform decisions and policies. For example, one participant highlighted the challenge of navigating issues, such as vaccines, fluoridation, and climate change, that are heavily supported by scientific evidence but have become politicized. The participant expressed frustration over the unnecessary politicization of topics that, in essence, should be approached from a scientific and evidence-based standpoint. To bridge this gap, participants noted the importance of knowledge translation, which is the process of translating research recommendations into accessible formats aligned with the goals of policy- and decision-makers.

Insufficient Resourcing

Research participants pointed to resource limitations as another barrier to effecting change. Because municipalities heavily rely on property taxes as their primary revenue source, municipal stakeholders face challenges in allocating scarce funds for local services and projects. It should be noted that the provincial government often imposes constraints on the property tax income of municipalities, limiting the autonomy of municipalities in setting tax rates and responding to local needs. This constraint not only impacts the fiscal flexibility of local governments but also hinders their ability to address community-specific challenges and invest in crucial initiatives. Time constraints and staffing shortages further limit policy development. To address these gaps, research participants suggested exploring alternate revenue streams for municipalities beyond property taxes and spoke of the need for increased funding and operational capacity.

Siloed or Fragmented Governance Structure

The research findings highlight a substantial challenge posed by a fragmented governance structure in urban design. The lack of an integrated approach hinders meaningful collaboration and coordination among policy-makers within different branches and divisions of the municipality, a phenomenon commonly referred to as 'siloing'. This organizational structure creates a scenario where stakeholders are confined within their own professional domains, struggling to tap into resources from other areas. The consequences of siloing are profound, leading to missed opportunities for the comprehensive and multi-disciplinary collaboration essential for promoting healthy urban design. In fact, the challenge of silos is not exclusive to specific bureaucracies but is inherent in the structure of large organizations as a whole. Silos, which represent isolated and compartmentalized units within an organization, are identified as a systemic issue cutting across various types of large bureaucratic structures.

The interviews shed light on how language disparities contribute to siloing, with municipal actors using terminology differently across professions. One interviewee noted: “When I was working with architects, they used the word program very differently than I do as a planner”. This linguistic misalignment can lead to misunderstandings and hinder effective cross-sectoral collaboration. Moreover, the findings underscore how siloing can result in conflicts between the objectives of different branches and divisions. One interviewee cited an example of conflicting priorities between active transportation planners, urban designers, landscape architects, and traffic engineers. When professionals are torn between promoting the movement of people or prioritizing the movement of vehicles, the discrepancy can lead to conflicts in policy implementation.

Limited Legal Power of Local Governments  

The research findings highlight a significant challenge at the forefront of the Canadian political context—the limited legal powers of municipalities. Municipalities are often referred to as “creatures of the province”, highlighting the asymmetric nature of the municipal-provincial relationship. This characterization emphasizes the substantial disparities in legal authority between municipalities and provinces. Unlike provinces, which derive legislative powers from the Constitution, ensuring the permanence of their legal powers, municipalities derive their powers from provincial law. This distinction means that municipalities can only exercise powers explicitly delegated to them by the provincial government. The impact of this dynamic is far-reaching, as it grants provincial governments the authority to modify or revoke delegated powers at any time, contingent upon support from the provincial legislature. The findings reveal that this relationship has profound implications for municipal policy choices and financial decisions. The province’s influence is evident not only in policy choices but also in determining the financial resources available to municipalities. The interviews indicate disagreement and uncertainty about how municipalities should interact with the province. The ambiguity surrounding responsibilities can lead to cycles of uncertainty, impacting policy decisions, and financial commitments.

City Council as the Ultimate Decision-Making Authority in Municipal Governance

The research findings highlight the pivotal role played by City Council as the primary decision-making body in the City of Regina. City Council members, including the Mayor and 10 City Councillors, wield significant influence in determining the fate of major policies through their voting. This centralized decision-making structure positions City Council as the ultimate arbiter in the policy- and decision-making processes, creating a bottleneck through which policy proposals must pass before being adopted or rejected. Interviewees emphasized the Council’s authority, underscoring how, despite the role of policy-makers in conducting research, providing data, and making recommendations, the ultimate decision rests with the City Council. This recognition of the Council’s supremacy in decision-making is essential for understanding the dynamics of policy implementation around urban design in Regina.

The interviews reveal a strategic approach employed by policy-makers in presenting policy proposals to the City Council. Recognizing the Council’s receptiveness to emotional appeals, including personal narratives and stories from the public, interviewees adjusted their tactics. They shifted from fact- and statistic-based proposals to emphasizing the human perspective, reflecting an understanding of the Council’s decision-making preferences. The use of emotional appeals, particularly those from residents, was seen as a more effective way of swaying Council members towards a particular cause. However, this change in approach was not universally embraced, as some interviewees expressed their frustration with the evolving decision-making landscape. They noted Council’s perceived shift away from relying on City Administration’s recommendations to a more subjective and unpredictable decision-making process. This unpredictability was seen as a departure from past practices, creating challenges for policy-makers in anticipating and influencing Council decisions.

2. Societal and Cultural Factors

Alongside the policy-making environment, municipal stakeholders are also bound by societal and cultural factors. These factors influence policy development and which policies are ultimately implemented.

Dominant Culture of Individualism and Libertarian Ideology

The research findings illuminate the complex interplay between individualistic and collectivist ideologies in shaping urban policies in Canada, particularly in the context of health and urban design. The tension between individual- versus community-benefitting policies is underscored, with interviewees highlighting how deeply ingrained individualistic attitudes influence urban design, as seen in the prevalence of car-centric road networks. The ownership of cars is considered a symbol of libertarian individualism, reflecting personal mobility. Moreover, interviewees observed that individualistic attitudes impact how policy issues are framed and perceived by the public.

Policies seen as encroaching on individual liberties, even for the collective good, often face more resistance. This is exemplified by the public backlash against restricting pesticide use, where the perceived impact on individual property rights took precedence over collective environmental concerns. Similarly, policy-makers encountered challenges when advocating for policies benefiting minority groups, even when the personal drawbacks were minor compared to the substantial benefits for others, as seen in the resistance to policies supporting safer conditions for sex workers. It should be acknowledged that the tension between individual and collective rights is the defining feature of politics at all levels. The crux of the challenge lies in navigating the delicate balance reconciling between these two perspectives within policy frameworks.

Maintaining Status Quo vs Enacting Change          

Research participants highlighted the challenges faced by City Administration in implementing policy changes, emphasizing the prevalence of a status quo bias among key stakeholders. For example, one interviewee explained the difficulty of altering long-standing policies, highlighting the challenges inherent to navigating change, particularly when faced with outdated regulations. Interviewees highlighted the case of the City Council’s delay in fluoridating Regina’s drinking water. This example shows how a strong public preference for the status quo can influence decision-makers to choose the path of least resistance, even when presented with alternatives offering greater public health benefits. This highlights a tension between maintaining political palatability and pursuing higher quality, but potentially contentious alternatives. The findings also suggests that increasing polarization and sectarianism could hinder efforts to address the needs of marginalized populations and equity-deserving communities, as any deviation from the status quo may be perceived as a loss for the majority, limiting the ability of stakeholders to allocate resources and political will to address the concerns of minority groups.

3. Competing Interests of Stakeholders

The process of developing and implementing policies, especially in the realm of urban design, is highly collaborative and involves numerous stakeholders. It is imperative for policy- and decision-makers to carefully assess the interests of the various stakeholders they are collaborating with.

Navigating the Public-Private Nexus in Urban Design Policy

Many interviewees highlighted the relationship between the public and private sectors in the development and implementation of urban policies, particularly in the context of urban design. While most policy development occurs in the public sector, the implementation often involves private sector actors, primarily developers, who significantly influence the built environment.

The distinction between the public and private sectors becomes pronounced when developers, driven by profit motives, pursue projects that do not always align with the long-term goals of the city. Despite these mismatches in motivations, interviewees recognized the indispensable role of developers in translating urban planning policies into reality and acknowledged the need for cooperation. The findings necessitate a delicate balancing act from policymakers, requiring them to consider the profit-driven goals of developers while ensuring that the resulting projects align with their broader objectives of creating complete, sustainable communities. The complexity arises as developers, with less direct government oversight, may prioritize short-to-medium-term profits, potentially impacting housing affordability and other factors.

Lack of Representation in Policy-Making Process  

The research findings shed light on disparities in representation and influence within municipal policy- and decision-making processes in Regina. Despite its diversity, the City faces challenges in ensuring equitable participation, with certain communities experiencing greater barriers to engagement. These barriers typically mirror the distribution of socioeconomic disadvantages in Regina.

Interviewees pointed out that the policy-making landscape tends to be influenced by a minority of voices, typically from individuals with higher socioeconomic status, thus potentially neglecting the needs of marginalized communities. The underrepresentation of marginalized communities suggests a systemic issue that risks neglecting the interests of those who may already face various challenges. Concerns were also raised about the overrepresentation of certain communities, particularly white men, in decision-making roles, potentially neglecting perspectives from other excluded groups, like women. One interviewee noted the inaccessibility of public consultation processes: “…well you have a [public consultation] session and you have 15 people show up…what about the other 1000 that didn't come out”. While some argue lack of engagement implies consent for the status quo, it is nonetheless crucial to address barriers to participation including language barriers and time constraints for low-income households. This underscores the need for more inclusive and accessible mechanisms to ensure equitable representation in policy-making.

Navigating Constituent Voices in Decision-Making     

The research findings underscore the intricate relationship between City Councillors, their constituents, and the broader political landscape, highlighting how the agendas of elected officials are intricately tied to their political environments. The duty of City Councillors to represent the interests of their constituents is evident, with some feeling beholden to the views of the communities they serve. The imperative to maintain the support of their constituents for re-election often leads Councillors to advocate for positions that may not align with their personal beliefs. This discrepancy is exemplified by instances where Councillors support exclusive neighborhoods despite personal reservations, emphasizing the tension between individual convictions and political mandates.

Interviewees also noted that the accountability felt by Councillors tends to be more localized, with a focus on the interests of their specific wards, potentially at the expense of the broader needs of the entire City. Furthermore, the fluid nature of political agendas becomes apparent as Councillors adapt their positions over time to align with changing constituent attitudes as exemplified in this quote: “In June of 2022, they all unanimously passed a motion saying they want to explore what it could mean for the city to go forward and do some more funding. And then in December, almost all of Council was very strong and adamant in their decision around we will not levy more property taxes in support of social services for individuals who are homeless”. The shift in voting patterns related to the funding of homelessness interventions exemplifies how prevailing public sentiments can influence decision-making, highlighting the dynamic and responsive nature of local governance, which reflects majority opinion in a democracy.

Drawing from these barriers, we offer the following recommendations to policy-makers and decision-makers, with a primary focus on municipal government.

1. Create better collaboration with academic experts: Strengthening ties with academic experts entails fostering meaningful partnerships with researchers. This collaboration can involve joint projects, knowledge-sharing initiatives, and regular forums. In particular, academic professionals should improve knowledge translation of their research so that quality evidence is not lost amid complex language, while urban design professionals should routinely center expert knowledge to uphold the value of evidence-informed policy-making.
2. Improve intragovernmental collaboration to tackle siloing: In particular, this involves improving collaboration between different levels of government, different organizations at the same level of government, and across different departments within the municipality. This requires adequate resourcing and facilitative environments that promote effective communication and coordination. One notable example of successfully breaking down silos in government bureaucracies is the Whole-of-Government approach implemented by the Australian government. This strategy seeks to enhance collaboration and coordination across various departments and agencies to address complex issues such as national security, health, and environmental challenges. This approach fosters a more integrated and holistic perspective, promoting effective information sharing and resource allocation to achieve comprehensive policy outcomes (Aoki et al., 2023).
3. Integrating health equity in municipal funding models: Urging higher levels of government, particularly the provincial level, to incorporate health equity considerations into their funding models for municipalities. This highlights the importance of aligning funding mechanisms with health and equity objectives, emphasizing the need for a more comprehensive and inclusive approach to resource allocation. In Ontario, the unique approach of assigning public health as the mandate of municipalities sets it apart from other provinces in Canada. This distinctive mandate places the responsibility for public health within the local government's purview.
4. Educate decision-makers about the importance of integrating health into urban design: Beyond policy-makers, decision-makers need education on the significance of integrating health and equity into urban design because they make the final decisions on policy proposals. This education includes capacity building, which involves equipping decision-makers with tools, such as health impact assessments used in Quebec, to enable them to make informed choices that prioritize community wellbeing.
5. Ensure policy- and decision-makers are responding to community needs without allowing the loudest voices to dominate the process: Implementing effective inclusive engagement strategies is crucial for municipal actors to address community needs while avoiding undue influence. This entails actively involving diverse perspectives in policy-making processes and creating accessible platforms for participation. Methods such as multilingual outreach and flexible consultation options can enhance inclusivity and ensure all voices are heard.
6. Improve representation in the policy-making process: Addressing representation gaps requires intentional efforts to include diverse voices in the policy-making process. This includes outreach to underrepresented communities, creating platforms for inclusive participation, and implementing policies that promote equity and social justice.
7. Ensure policies are regularly reviewed and updated based on evidence and feedback from the community: Regular policy reviews are essential, involving systematic evaluations based on both evidence and community feedback. This iterative process ensures that policies remain relevant, effective, and aligned with the evolving needs and priorities of the community. This is also necessary to ensure that policies are being properly implemented.

This policy paper presented the findings of our recent study investigating the barriers preventing urban design professionals from integrating health and equity into urban policies. The recommendations from this study hold relevance for both urban planners and public health professionals. Implementing these recommendations will contribute to overcoming the entrenched challenges and fostering a collective commitment to prioritizing public health in urban design. As a greater proportion of the global population moves into urban settings, it becomes crucial to enhance our comprehension of how municipal governments can serve as catalysts in cultivating environments that enhance the wellbeing of their residents.

The research presented in this policy paper is supported by funding from the Saskatchewan Health Research Foundation (SHRF). The views expressed in this paper are those of the authors and do not necessarily reflect the views of SHRF.

Akram Mahani, Assistant Professor, Johnson Shoyama Graduate School of Public Policy, University of Regina

Joonsoo Sean Lyeo, Research Associate, Johnson Shoyama Graduate School of Public Policy (JSGS), University of Regina

Agnes Fung, Master of Public Health Student, Dalla Lana School of Public Health, University of Toronto

Shanzey Ali, Undergraduate Student, Bachelors of Health Sciences (Honours), McMaster University

Kelly Husack, Director, Community Initiatives, REACH Edmonton Council for Safe Communities

Nazeem Muhajarine, Professor, Department of Community Health and Epidemiology, University of Saskatchewan

Tania Diener, Area Department Lead Medical Health Officer Regina, Saskatchewan Health Authority

Chelsea Brown, Senior Population Health Promotion Practitioner, Saskatchewan Health Authority

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