The following is an excerpt of the paper Unhealthy Neighbourhood "Syndrome": A Useful Label for Analysing and Providing Advice on Urban Design Decision-Making? (Al-Waer H., Speedie, J. & Cooper, I.) in a special issue "Happiness and Quality of Life in a Sustainable Built Environment" in the academic journal Sustainability. Sustainability is an international, cross-disciplinary, scholarly, peer-reviewed and open access journal of environmental, cultural, economic, and social sustainability of human beings.
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Health and Wellbeing at the Neighbourhood Scale
In response to the recent COVID-19 pandemic, there has been an explicit recommendation to “further understand the links between neighbourhood design and health”  (p. 9). Yet, even before the recent pandemic there was growing interest in designing healthier neighbourhoods. Clear evidence that makes the connection between the built environment (within the discourses of planning and urban design) and health/ill health has been identified as being required to guide built environment professionals and policy makers towards positive change [2-4]. However, considerably less attention has been paid to how to alleviate such conditions through integrated interventions designed to operate specifically at the neighbourhood scale.
Unless there is explicit articulation of what contributes to the healthiness of neighbourhoods and of urban design strategies for its promotion, there is a risk of creating misunderstanding and barriers to communication across different organizations, stakeholder groups and actors involved. A lack of clarity can also undermine trust and confidence, leading ultimately to opposition to both the urban design process and to its outcomes. However, the number of studies directly focused on attempting to identify the unhealthy characteristics (symptoms) of neighbourhoods is limited and fragmented.
To address this gap, this paper introduces the term “unhealthy neighbourhood syndrome” (UNS). Adopting this perspective brings attention to how conditions in neighbourhoods (directly and indirectly) affect their inhabitants’ physical health and mental wellbeing. This paper cautiously promotes the terms healthy (and unhealthy) neighbourhoods. It does so not as a means of approving or stigmatising one location over another, but rather as offering a lens for paying explicit attention to how urban design may be able to contribute to the alleviation (or reinforcement) of the conditions leading to the health and wellbeing of people in particular locations.
How the Built Environment Is Held to Affect Physical Health and Wellbeing at the Neighbourhood Scale
The sheer length of potential physical and perceived neighbourhood factors that contribute to physical health and wellbeing, and their claimed effects and outcomes, creates an impression that, taken together, they encompass almost everything (to see a detailed list of the reported effects and outcomes of physical and social environment factors see the full article. This, understandably, leads not just to a loss of specificity and clarity, but to misgivings about how the situations so described can possibly be tackled in practice.
It is possible to derive a framework to show the elements that urban designers have been advised can contribute to poor physical health and mental wellbeing in neighbourhoods. The mechanisms through which these contributions are held to occur are manifold: physical and social environment and perceived and objective environment, as shown in Figure 1.
This framework is useful because it recognizes that the built environment is composed of interconnected physical and social elements which are mediated by how these are perceived. Perceptions of built and social environments influence how neighbourhoods are experienced: this, in turn affects physical and mental health Hajrasouliha et al.’s . As Sim  suggested, a neighbourhood is thus more than just its physical parts: it also gives rise to feelings, and so can produce a state of mind in those who experience it. However, this framework conceals as well as reveals, because it ignores the power dynamic which underlies and differentiates between the lived experience of groups of people who live in neighbourhoods.
Manipulating Urban Design to Affect Physical Health and Mental Wellbeing at the Neighbourhood Scale
London  synthesized material presented in the literature to suggest that there are eight key areas of decision making for urban design which are presented as having far-reaching effects on mental wellbeing in neighbourhoods. These eight areas focus on decisions about: limiting emissions and enhancing air quality, greenspace, participation in public life, feeling safe and comfortable, access to peaceful spaces, quality public space, and flexible urban space (see Figure 2).
As aspects of the built environment are held to affect people’s physical health and mental wellbeing, manipulation of these aspects by urban designers is seen as offering opportunities to improve their health and wellbeing. Accordingly, mitigating UNS means not only reducing and eliminating aspects of neighbourhood urban design that contribute to poor physical health and mental wellbeing, but also enhancing those that give people options for making choices that positively affect their health and wellbeing (see Figure 2).
London  suggests none of the urban design criteria required to mitigate “unhealthiness” can deliver quick transformations. However, when harnessed together into an integrated strategy, he pointed to them as making a combined effect that will lead to substantial improvements to people’s mental wellbeing and so to their quality of life. Their level of interconnectivity should not be overlooked. The linkages between them speak to the complexity, and the highly integrated nature, of the approach required for attempting to tackle UNS. They must be tackled in an integrated manner when attempting to promote both physical health and mental wellbeing in neighbourhoods.
Lessons for Urban Design Practitioners
From a design perspective, a priority in the paper is what designers can and should do on the basis of the available evidence. Here, the paper has signaled a need for humility and caution, to avoid over-claiming what urban designers, operating alone, can deliver. Instead, the aspirations and concerns described above present an enormous challenge, not just to individuals as practitioners, but to their professional bodies as well—how should they act to discharge their responsibility by becoming accountable for their personal and collective roles in delivering healthier outcomes? For urban designers, this means moving beyond simplistic physically led approaches to planning, to embrace the complexity of the interactions between people’s health and wellbeing and the built environment in which they live and work. This will require more strategic and holistic methods for making effective decisions. The search for new ways for thinking about, and for delivering, healthier neighbourhoods requires acting on the understanding that they are complex systems. Tackling this complexity, as Gatzweiler et al.  advised, requires a coordinated approach, capable of meeting the challenges of the multi-level, multi-sectorial, policymaking that is required to improve urban sustainability and healthier outcomes.
The Need for an Integrated Approach
The innovative contribution of this paper lies in identification of the wide cluster symptoms used to describe unhealthy neighbourhoods in the literature as being a “syndrome” which needs to be tackled through integrated streams of remedial action. Its significance resides in its acknowledgement that such action needs to draw on experience and expertise that lie beyond that contained by traditional membership of urban design teams. If harnessed and deployed sensitively, and with due regard to the caveats we set out, the use of the term unhealthy neighbourhood “syndrome” could help establish both the more broadly based interventions and the wider skill sets demanded of the teams required to tackle it.
The call for a more integrated attack on unhealthy neighbourhoods indicates the need for team-based decision-making involving not just urban designers but also all those middling out actors responsible for an area’s economic and social development, as well as for the physical and mental health of its population (see Figure 3). This horizontal and vertical span of collaborative, interdisciplinary engagement is difficult to achieve, let alone sustain, but it will be required to discharge the heavy aspirations that are being placed on interventions in the built environment, particularly once the wider social, economic, environmental, and political changes occurring in cities, towns, and neighbourhoods are taken into account.
The methods employed for making decisions will need to align not just the contributions of “middling out” professionals but reconcile these with those of “top down” political actors (who hold the purse strings) and with the “bottom up” aspirations and concerns of those affected when interventions in the built environment are being planned. Achieving the desired outcomes of healthy neighbourhoods cannot rest with a “single set of hands”—however “responsible” or “benign” these may appear. A more inclusive network of shapers and framers, and of affected stakeholders, is required.
Framing unhealthy neighbourhoods as a “syndrome” helps to identify three steps necessary for tackling it:
1. recognising that such neighbourhoods display an array of symptoms affecting both physical health and mental wellbeing
2. assembling broadly based multi-disciplinary teams with the wide-ranging skills and expertise necessary to address this broad array of symptoms, and
3. deploying these skills through longitudinal programmes of parallel workstreams capable of tackling the particular symptoms presented.
The term “unhealthy neighbourhood syndrome” is useful because the term illustrates how seemingly separate issues operate in urban design, promoted for tackling specific symptoms of ill health, need to be addressed jointly through an integrated programme of parallel work streams operating at the neighbourhood scale. The paper is innovative in identifying the wide cluster of symptoms used to describe unhealthy neighbourhoods in the literature as being a “syndrome”. Its significance lies in its injunction that this syndrome needs to be tackled through integrated streams of remedial action drawing on experience and expertise that lie beyond those offered by the traditional membership of urban design teams.
None of the urban design criteria identified above for mitigating UNS can deliver quick transformations. However, harnessed together, integrated strategies for tackling them may be able to make a combined effect that could lead to substantial improvements in health, wellbeing, and so quality of life. The simple act of applying the label “unhealthy neighbour syndrome” is no panacea. However, its use could:
• present a more holistic and inclusive definition of what constitutes unhealthy neighbourhoods, whilst acknowledging the direct and indirect effects of broader economic, environmental forces on desired outcomes in terms of physical health and mental wellbeing;
• expand the evidence bases called upon by urban designers and associated professionals when deciding what contributes to poor physical and mental health, thereby demonstrating critical obstacles as well as signposting future directions;
• help to further demonstrate the economic, social and environmental costs of inadequate neighbourhood urban design and their contribution to poor physical health and mental wellbeing;
• increase both professional and public awareness of the effects of neighbourhood urban design on health and wellbeing;
• lead to developments of incentivized programmes and policies for encouraging politicians, professionals, as well as building owners, to adopt the actions required to move towards healthier neighbourhoods; and
• aid the identification of who are the principal actors, the prime movers, for putting this agenda into practice.
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