Skip to main content

Walkability and urban built environments—a systematic review of health impact assessments (HIA)



Urban environments are important determinants of human health. The term walkability summarizes features of the urban built environment that promote walking and other types of physical activity. While the beneficial effects of active and public transport have been well established, the health impact of other features of walkability are less well documented.


We conducted a systematic review of health impact assessments (HIAs) of walkability. Studies were identified through PUBMED and Science Direct, from two German websites related to urban health and reference tracking. Finally, 40 studies were included in the present review. We applied qualitative thematic analysis to summarize the major results from these studies.


Most of the HIAs (n = 31) reported the improvement of health or health behaviour resulting from an investigated project or policy. However, three HIAs reported a lack of improvement or even a decrease of health status. In parallel, 13 HIAs reported a gain in economic value, whereas one reported a lack or loss of economic effects. Moreover, three HIAs reported on social effects and six HIAs gave additional recommendations for policies or the implementation of projects or HIAs.


Most HIAs investigate the impact of increasing active or public transport. Other features of walkability are less well studied. With few exceptions, HIAs document beneficial impacts of improving walkability on a variety of health outcomes, including reductions of mortality and non-communicable diseases.

Peer Review reports


Human health is influenced by a variety of determinants including factors related to the environment where people live [1]. Urbanization has become one of the global megatrends that characterize the current development of mankind. At the beginning of the 20th century, only about 10 percent of the world’s population were living in urban areas. In 2015, this percentage increased to about 54%, and is predicted to reach 60% in 2030 and 66% by 2050 [2].

Urbanization more often offers health advantages in comparison with rural areas, as the basic infrastructure relevant for health such as water, sanitation and housing are generally more developed. In addition, health services and facilities appear to be more available in cities than in rural areas. However, cities may also cause relative disadvantages for health, e.g. crowded living and stressing working conditions, higher rates of crime and violence, sedentary life styles, reduced physical activity, and, additionally, the urban food environment may contribute to the rise of non-communicable diseases [2].

However, many decisions that impact human health are made outside the health sector [3, 4]. For example, environmental changes resulting from the intensification of agriculture, industrialization and increasing energy use are considered as important sources of health problems [5]. Decisions about the quality of social services, housing, employment opportunities or public transport are among many others key influences on health [6], and are again usually made outside the health sector. This has led the WHO to extend the ideas of healthy public policy, already formulated in the Ottawa Charta of Health Promotion to the principle of “Health in All Policies” [7]. Yet, considering not only reduction of health risks, but also enhancing health promoting potentials in urban development and urban planning seems not to be implemented systematically on a large scale [6].

Health Impact Assessment (HIA) is an approach to bring health considerations into urban development and urban planning. HIA has been defined as “… a combination of procedures, methods and tools by which a policy, program or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population” [4]. One aim is to produce recommendations for decision makers and stakeholders for “… maximizing the proposal’s positive health effects and minimizing its negative health effects” [8]. HIAs have been conducted in all regions of the world, and the majority of HIA practitioners expect an increased use in Australia, East Asia and Pacific, Europe and North America [9].

The impact of urban environment on physical activity has received some consideration during the last decades. Globally, physical inactivity has been accounted for the fourth leading cause of mortality, after high blood pressure, tobacco use and high blood glucose, contributing to 6 percent of worldwide deaths [10]. The Global Burden of Disease study is using a sophisticated hierarchical model of risk factors including physical inactivity as a level 2 risk factor [11]. Recently, results from this study indicated that, globally seen, close to 1 million deaths in 2019 were attributable to physical inactivity [11]. In addition, physical inactivity is considered as a major risk factor for non-communicable disease, particularly cardio-vascular diseases, diabetes mellitus type 2, and several types of cancer [12]. Moreover, physical activity contributes to the maintenance of healthy weight and to the prevention of overweight and obesity [12] which in turn is a major risk factor for the mentioned NCDs [13]. On the other hand, the beneficial effects of physical activity on all-cause mortality [14,15,16], the incidence of cardiovascular health, diabetes, several types of cancer [17], and mental health [18, 19] have been well documented.

In relation to physical activity two concepts for the urban environment have received considerable attention and generated some research: active transport and walkability. Active transport comprises walking or cycling for the purpose of reaching a destination such as school, workplace, or a shop [20]. Walkability summarizes attributes of the urban built environment that encourage and/or enable more walking [21,22,23]. The original concept of walkability was developed in the 1990s in US transportation research and has focused on walking for transportation [24]. As this concept was adopted by physical activity and public health researchers and practitioners, it was extended to include walking for transportation and recreational purposes as well as other types of physical activity, e.g. biking [24]. Hence, walkability has extended beyond walking to generally promoting physical activity in communities, urban neighbourhoods and larger urban areas [25]. A review [23] concludes that there is sufficient evidence that the proximity to potential destinations, aesthetic qualities – the attractiveness of the environment -, mixed land use, residential density within neighbourhoods, sidewalks and connectivity are attributes of the built environment that correlate with increased walking. Recently, a more comprehensive framework of walkability has been suggested [26, 27] that incorporates nine dimensions of the built environment, namely connectivity, diversity of land-use, residential density, traffic safety, surveillance (how well traveling in the street can be seen from surrounding houses and businesses), parking (less parking encourages more walking), experience (including e.g. aesthetics), greenspace and community (social interaction and participation).

The health impacts of active transport have been intensively studied and a systematic review provides strong evidence that active transport provides substantial net health benefits even if negative health impacts like accidents and exposure to air pollution are taken into account [14, 20].

To the best of our knowledge up to now no systematic review is available to summarize the evidence on the health impacts of walkability conceptualized as detailed above as characteristics of the urban built environment. We hypothesize that the walkability of urban environments may affect health outcomes via several pathways (see Fig. 1): walkability may result in more physical activity either by improving active transport or by encouraging recreational activities including deliberate exercising. In addition, green space improves health by encouraging more physical activity and by other effects, e.g. lower distress and better mental health [28] and the better walkability of the built environment could promote and result in improved social relationships [29] that in turn impact human health.

Fig. 1
figure 1

Potential major pathways of the health impact of walkability, own presentation

The objective of this paper is to conduct and report on a systematic review of health impact assessments (HIAs) of projects, policies or programmes that aim to improve the walkability of urban built environments.

Particularly, we aim at answering the following research questions related to such HIAs:

  • Which types of projects, policies or programmes related to walkability in urban development have been investigated in HIAs?

  • Which methods were used to assess the health impacts? Which data sources were used, and which analytical models were applied to assess health impacts?

  • Which health impacts (e.g. changes in mortality, incidence or prevalence of diseases, quality of life) have been identified related to improvements of walkability?

  • How and by whom are HIAs of walkability implemented in practice?


This systematic review was designed based on the PRISMA 2020 guidelines [30]. We considered the following definition of walkability as the dividing line for identification of eligible articles in the current systematic review: Walkability summarizes attributes of the urban built environment that encourage and/or enable more walking or other types of physical activity in communities, urban neighbourhoods and larger urban areas.

In order to include a wide range of studies, no specific preference for a definition of Health Impact Assessment was considered.

Data sources and search strategy

We searched PubMed and ScienceDirect databases with the purpose of incorporating international studies as well as the websites of two German associations “Stadt-und-Gesundheit” (City and Health; and “Akademie für Raumentwicklung in der Leibniz-Gemeinschaft” (ARL – Academy for Territorial Development in the Leibniz Association; to identify research reports focusing on spatial planning particularly in the German context. The databases were searched thoroughly in November 2020, and an additional search of PubMed and Science Direct was also conducted in the end of 2021 to update the study pool. We operated the advanced search in PubMed and ScienceDirect using the search terms in Table 1. The two German databases did not offer an advanced search tool. Therefore, an adoption of the strategy for these two sources was necessary. This involved a title screening of all listed papers and reports. We included all papers that mentioned “Health Impact Assessment” (the German equivalent term “Gesundheitsfolgenabschätzung” respectively) or “Walkability” in the title. As the term Walkability was rarely used in the titles of the reports on the two German databases, we accepted the German terms for mobility/mobile, physical activity, walking (distance), transport (ation), walkable, and pedestrian as potential equivalents. For the same reason, we accepted papers with a title suggesting a health outcome related to walkability (e.g. increased walking). The details of identified articles and search terms for each of databases are provided in the Table 1. In addition, reference lists of papers included during the selection process were screened for additional papers that might be relevant.

Table 1 Search strategy and identified articles in each database

Inclusion and exclusion criteria

Regarding selection criteria, any peer-reviewed publications evaluating a real or projected (modelled) health impact or health outcomes of a policy, programme or project that intended to change an aspect of walkability in an urban environment were eligible for the review, with the exception of short communications, published abstracts and conference contributions. Furthermore, the eligible articles were published in English or German and after the year 2010. We decided not to include grey literature because we believe that the peer-review process provides an important quality assurance and therefor enhances the credibility of the research findings. In addition, identification of relevant articles via databases of the peer-reviewed scientific literature seems more transparent and replicable than a comprehensive open search using a wide variety of search engines. Details of inclusion and exclusion criteria are available in Table 2.

Table 2 Inclusion and exclusion criteria for article selection

Screening, data extraction and analysis

Title screening was done by one reviewer. In case of any uncertainty, the decision was made after discussion with another author. For the remaining records, abstract screening was done independently by two reviewers. Any disagreement between the reviewers was resolved by discussion, in some rare cases by including additional authors of the present paper.

The final selection step was the review of the full text of remaining articles by two authors. Every step of the review process was discussed during regular meetings in order to clarify uncertainties and challenges related to selection process. In case of disagreement of authors on the eligibility of articles, a third reviewer conducted an additional review, and the final selection was approved by discussion.

During data extraction stage, two authors independently reviewed the full text and tabulated the extracted data. The third reviewer extracted the data of articles that were the subject of disagreement of the first two reviewers. Extracted data included author, year of publication, HIA definition and method that was used, operationalization of walkability (if any), which NCDs were considered in HIA, aim, setting, study population of the project, policy or program, dependent and independent variables, measuring instruments, statistical/analytical methods applied, and results. In addition, conductive conditions and resources, barriers and challenges, and recommendations were extracted, if mentioned. Regarding the HIA itself, we extracted, if mentioned, who initiated the HIA, who conducted the HIA, other actors involved in the HIA, and how HIA was integrated into existing planning instruments or processes. The extracted data were captured in an Excel-Sheet that is available as supplemental material.

We conducted a qualitative analysis and summary of the extracted data to answer our research questions. The development of categories and classification of study reports was done following the principles of inductive thematic analysis [31, 32], and was done in consensus of three authors (JW, JB, EN).


Identification and selection of relevant studies

As shown in Fig. 2, a total of 946 records was identified. Database search resulted in 817 records. Additional 129 records were identified through reference tracking. 21 duplicate records were removed before title and abstract screening. Title screening excluded 682 records; abstract screening excluded additional 133 records. Since 8 reports could not be retrieved, the full text of 102 reports were assessed according to inclusion and exclusion criteria. 62 reports were excluded, most often because they did not address the effect of a policy, programme, or project on walkability (see Fig. 2). Finally, 40 study reports were included in the present review.

Fig. 2
figure 2

Prisma flow chart of study identification and selection

An overview of the included HIA reports is presented in Table 3. The complete data extraction sheet is available as supplementary material (Additional File 2).

Table 3 Source, place, aim of project, main results of included HIAs

Location, type of projects, and type of HIAs

Most of the identified published HIAs addressed projects or policies in the USA (n = 18), followed by Australia (n = 6), UK (n = 5), and Canada (n = 3). Moreover, there were two reports from India, one from New Zealand, one that covered several European countries, one that covered several European and Non-European Countries, and another three reports each covering one European country. Particularly, Germany was only addressed in one HIA as one of several European countries (see Additional file 1: supplementary table S1 for details).

Most of the HIAs investigated the impact of improving or extending the infrastructure to facilitate active transport or public transport (n = 13). This refers to more concrete projects like extending cycling networks or better sidewalks. Among them, five HIAs were about improving bicycle and pedestrian infrastructure, and another five addressed bicycle infrastructure alone. Respectively one HIA studied improving public transport infrastructure alone, non-motorized transport plus public transport infrastructure, or extending sidewalks. Additional 11 HIAs assessed the impact of more general scenarios or policies to support active transport (see Additional file 1: suppl. table S2 for details).

Six HIAs examined the development of new suburbs; the redevelopment, revitalisation, or regeneration of a city or abandoned areas: Another five HIAs examined the redesign of urban neighbourhoods.

33 HIAs were clearly quantitative HIAs, that aimed at quantifying at least one primary health outcome, four HIAs were clearly qualitative HIAs and three reports included quantitative and qualitative reports (see Additional file 1: suppl. table S3 for details).

Data sources and analysis

A variety of data sources was used as basis for HIAs, this included primary data collection, secondary use of existing data, measurement of built environment variables via geographic information systems (GIS), and analysis of existing reports, inventories, or other similar data (see Addirional file 1: suppl. table S5 for details). Primary data collection through surveys or questionnaires was used in eight HIAs, interviews and/or focus groups and group discussions in seven HIAs, structured observations and audits in three HIAs, and accelerometer measurement in one HIA.

The secondary use of existing surveys was applied in 14 HIAs. The secondary use of data from group discussions, interviews and travel diaries was each mentioned in one HIA respectively.

Literature reviews as basic data source were used in five HIAs, the measurement of built environment variables by GIS was applied in seven HIAs, and the analysis of existing reports, inventories or other types of data was applied in seven HIAs.

Health impacts

Cardiovascular diseases were the health endpoint that was investigated most often, in 16 HIAs. This was followed by diabetes in 12 HIAs, Cancer (8 HIAs), mental illness (6 HIAs), premature death (5 HIAs), all-cause mortality (5 HIAs), respiratory diseases (5 HIAs), traffic accidents (4 HIAs) and obesity (4 HIAs) (see Additional file 1: suppl. table S4).

Most of the HIAs (n = 31) reported the improvement of health or health behaviour resulting from the investigated project or policy. However, three HIAs reported a lack of improvement or even a decrease of health status. In parallel, 13 HIAs reported a gain in economic value, whereas one reported a lack or loss of economic effects. Moreover, three HIAs reported on social effects and six HIAs gave additional recommendations for policies or the implementation of projects or HIAs (see Additional file 1: suppl. table S6 for details).

A closer look at those HIAs that reported negative health impacts or failed to find a positive impact yields the following results. One HIA that reported negative health impacts was on a comprehensive transit-oriented district redevelopment plan, that would result in increased exposure to air pollution and increased rate of asthma in children on one hand, but increased physical activity from walking and reductions in type 2 diabetes and high blood pressure on the other hand [43]. A HIA of different scenarios of urban development on air quality concluded that compact development increases particulate matter PM2.5 concentrations and PM2.5 attributable mortality [55]. Finally, a qualitative HIA using focus groups of a neighbourhood transformation project failed to find noticeable increases of physical activity [41].

Among the social effects reported, there was the potential for more alcohol outlets in mixed-use developments of a rezoning project in Baltimore, and associated increasing violent crime [65]. In contrast, greening of a vacant urban space was associated with reductions in gun assaults, vandalism and stress, and more safety [37]. Finally, in a newly developed neighbourhood that was designed to improve walkability, residents reported safety, aesthetics, and sense of community as factors that facilitated walking [49].

Implementation of HIAs

Regarding the implementation of the HIAs, none of the reports mentioned explicitly who was doing the work, but it reasonable to assume that this was done by the listed authors.

Most of the studies (32 of 40) reported external funding of the HIA and few studies explicitly mentioned that the HIA was initiated by a particular institution.

Only two study reports mentioned other institutions or stakeholders that were actively involved in the HIA: the city where the project was located, the respective Metro company and the NIH in one study, a number of local organizations, the police department, the church priest and local farmers and ranchers in the other study.

None of the study reports mentioned whether or how the HIA was integrated or associated with other planning instruments or procedures.


The present review aims at summarizing the peer-reviewed literature on health impact assessments of walkability in urban development. The vast majority of studies reported beneficial health impacts particularly reductions of non-communicable diseases like cardiovascular diseases, diabetes, cancer, and mortality. As most HIAs examined the impact of projects, plans or scenarios that aimed at increasing active transport and/or public transport these results are in line with prior findings, because the beneficial consequences of active transport, walking and cycling have been well established [14, 20]. Negative health impacts were only reported in two HIAs and were related to increased exposure to air pollution that may result from more walking and cycling [43, 55]. However, it has been shown that beneficial impacts of walking and cycling clearly outweigh the potential negative impacts from air pollution and traffic accidents.

Walkability in a wider sense was studied in eleven HIAs, by either investigating the redevelopment of cities or abandoned areas, the development of new suburbs or the redesign of urban neighbourhoods. With one exception these HIAs reported beneficial health impacts. Social effects were rarely addressed in the included HIAs and differed fundamentally among the examined projects or plans. Mixed-use neighbourhoods could result in more alcohol outlets and more violent crime [65], whereas greening of vacant urban space could result in reduced violence and vandalism and increased perceived safety of the residents [37]. A newly developed neighbourhood designed to improve walkability was associated with improved perceived safety, aesthetics and sense of community [49].

In summary, the present review clearly shows that improving the walkability of neighbourhoods or cities yields positive health impacts and has only limited negative effects, depending on the project or policy. Moreover, improving infrastructure and opportunities for active transport and public transport play a major role for the beneficial effects. However, the research reports included in this review did not address aspects of inequality and equity, i.e. whether beneficial or harmful effects of projects, policies or programmes are equally distributed among different population groups. There is a need for future research to address the social inequalities of health impacts as well. Otherwise, it could happen that walkability is primarily improved in more affluent neighbourhoods, whereas more deprived neighbourhoods are even more neglected.

This review has some limitations that have to be considered when drawing conclusions. Most importantly, due to our search and selection strategy we may have missed several relevant HIA reports. First, we limited our search on peer-reviewed papers that were identified through two databases and two websites of German organizations and follow-up reference tracking. Thus, HIA reports in the grey literature were not included. It is likely that several HIA reports exist either unpublished or available only on local or regional websites. Indeed, this has been confirmed by a UK expert in health impact assessment (personal communication Dr. Fischer, Liverpool).

Secondly, we explicitly included walkability in our search terms which may cause restriction of the identified results. For example, the article by Mueller et al. [58] examines the health impacts of the superblock design in Barcelona, Spain. The superblock design is clearly improving the walkability of neighbourhood blocks as it “… aims to reclaim space for people, reduce motorized transport, promote sustainable mobility and active lifestyles, provide urban greening …” [58]. However, the whole article does not even mention the term “walkability”. Nevertheless, we hope that we have covered the most important HIAs related to walkability through our reference tracking which identified the mentioned article on the Barcelona superblocks.

Having the limitations in mind, the following conclusions seem justified. Health impact assessments related to the walkability of urban environments are more established in English speaking countries, including US, UK, Canada, Australia, and New Zealand. Other European countries, particularly Germany, clearly lack behind. Despite the 40 HIA reports that were included in our review, there is a need for more HIAs published in peer-reviewed journals, given the important role urban environments play in determining human health. Peer-reviewed publication would provide some basic quality assurance and hence increase the credibility of the findings, and in addition would help to identify relevant reports more easily through standard scientific literature data bases. This in turn could motivate more research on the health impacts of walkability and underline the importance of considering and improving walkability in urban planning processes. If not considerably more unpublished HIAs exist, we have to conclude that health impacts of urban planning and urban development need a considerable push in local administrations and planning agencies.

A major strength of this review is going beyond active and public transport; it also includes more general characteristics of the urban built environment which are subsumed under the concept of walkability.


While the beneficial effects of active transport and public transport which are important components of walkability are well documented and established, the contribution of other features or components of walkability to health are less well understood. Particularly, there is a need to establish more quantitative associations of the different dimensions of walkability as suggested in the walkability framework [27] to increased physical activity, social interaction and perceived safety and stress. Such quantitative associations would allow to predict the health impact of urban design features more accurately.

Future research would benefit from explicitly mentioning the key terms like “health impact” or “walkability” in the title of their publications, and from providing more clear definitions of such constructs in their report. With regard to public health practice, reports should provide more detail about who initiated HIAs, who conducted them, who participated and how they were implemented in the planning processes. Finally, it is desirable, that access to existing HIAs is facilitated by publishing them in peer-review, preferably open access scientific journals. This could promote the consideration of health impacts in urban planning, particularly in countries and regions were this is not well-established practice.

Availability of data and materials

The data extraction sheet produced for the literature review is available as Additional file 2 (Excel File).


  1. Dahlgren G, Whitehead M. Policies and strategies to promote social equity in health. 1991. Verfügbar unter: Accessed 5 Apr 2016.

  2. World Health Organization, UN Habitat. Global report on urban health: equitable, healthier cities for sustainable development. World Health Organization; 2016. Accessed 15 Jul 2019.

  3. Fehr R, Viliani F, Nowacki J, Martuzzi M. Health in Impact Assessments: Opportunities not to be missed. Copenhagen: WHO Regional Office for Europe; 2014. Accessed 16 Apr 2021.

    Google Scholar 

  4. WHO Regional Office for Europe, European Centre for Health Policy. Health Impact Assessment. Main concepts and suggested appraoch. 1999. Accessed 25 Mar 2019.

  5. Remoundou K, Koundouri P. Environmental Effects on Public Health: An Economic Perspective. IJERPH. 2009;6(8):2160–78.

    Article  PubMed  PubMed Central  Google Scholar 

  6. World Health Organization. Health Impact Assessment Toolkit for Cities. 2005. Accessed 17 Jan 2022.

  7. World Health Organization. The Helsinki Statement on Health in All Policies. 2013. Accessed 17 Feb 2022

  8. World Health Organization. Health impact assessments. Accessed 17 Jan 2022.

  9. Winkler MS, Furu P, Viliani F, Cave B, Divall M, Ramesh G. Current Global Health Impact Assessment Practice. Int J Environ Res Public Health. 2020;17(9):E2988.

    Article  Google Scholar 

  10. World Health Organization. Global recommendations on physical activity for health. Geneve: WHO; 2010.

    Google Scholar 

  11. GBD 2019 Risk Factors Collaborators. Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396(10258):1223–49.

    Article  Google Scholar 

  12. World Health Organization. WHO guidelines on physical activity and sedentary behaviour. Geneva: World Health Organization; 2020. Accessed 4 Feb 2022.

  13. Hruby A, Manson JE, Qi L, Malik VS, Rimm EB, Sun Q. Determinants and Consequences of Obesity. Am J Public Health. 2016;106(9):1656–62.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Kahlmeier S, World Health Organization, Regional Office for Europe. Health economic assessment tools (HEAT) for walking and for cycling: methodology and user guide : economic assessment of transport infrastructure and policies. Copenhagen: World Health Organisation, Regional Office for Europe; 2013.

    Google Scholar 

  15. Kelly P, Kahlmeier S, Götschi T, Orsini N, Richards J, Roberts N. Systematic review and meta-analysis of reduction in all-cause mortality from walking and cycling and shape of dose response relationship. Int J Behav Nutr Phys Act. 2014;11:132.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Wen CP, Wai JPM, Tsai MK, Yang YC, Cheng TYD, Lee MC. Minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort study. Lancet. 2011;378(9798):1244–53.

    Article  PubMed  Google Scholar 

  17. Kyu HH, Bachman VF, Alexander LT, Mumford JE, Afshin A, Estep K. Physical activity and risk of breast cancer, colon cancer, diabetes, ischemic heart disease, and ischemic stroke events: systematic review and dose-response meta-analysis for the Global Burden of Disease Study 2013. BMJ. 2016;354:i3857.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Sieverdes JC, Ray BM, Sui X, Lee DC, Hand GA, Baruth M. Association between leisure time physical activity and depressive symptoms in men. Med Sci Sports Exerc. 2012;44(2):260–5.

    Article  PubMed  Google Scholar 

  19. Sofi F, Valecchi D, Bacci D, Abbate R, Gensini GF, Casini A. Physical activity and risk of cognitive decline: a meta-analysis of prospective studies. J Intern Med. 2011;269(1):107–17.

    Article  CAS  PubMed  Google Scholar 

  20. Mueller N, Rojas-Rueda D, Cole-Hunter T, de Nazelle A, Dons E, Gerike R. Health impact assessment of active transportation: A systematic review. Prev Med. 2015;76:103–14.

    Article  PubMed  Google Scholar 

  21. Saelens BE, Sallis JF, Black JB, Chen D. Neighborhood-based differences in physical activity: an environment scale evaluation. Am J Public Health. 2003;93(9):1552–8.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Saelens BE, Sallis JF, Frank LD. Environmental correlates of walking and cycling: findings from the transportation, urban design, and planning literatures. Ann Behav Med. 2003;25(2):80–91.

    Article  PubMed  Google Scholar 

  23. Saelens BE, Handy SL. Built environment correlates of walking: a review. Med Sci Sports Exerc Juli. 2008;40(7 Suppl):S550-566.

    Article  Google Scholar 

  24. Kerr J. Definitions and Dimensions of Walkability. In: Bucksch J, Schneider S, Herausgeber. Walkability: das Handbuch zur Bewegungsförderung in der Kommune. 1. Auflage. Bern: Verlag Hans Huber; 2014. S. 143–51. (Verlag Hans Huber Programmbereich Gesundheit).

  25. Bucksch J, Schneider S. Vorwort. In: Bucksch J, Schneider S, Herausgeber. Walkability: das Handbuch zur Bewegungsförderung in der Kommune. 1. Auflage. Bern: Verlag Hans Huber; 2014. S. 9–11. (Verlag Hans Huber Programmbereich Gesundheit).

  26. Zuniga-Teran AA. From Neighborhoods to Wellbeing and Conservation: Enhancing the use of Greenspace Through Walkability [Internet]. University of Arizona; 2015. Accessed 11 May 2021.

  27. Zuniga-Teran AA, Orr BJ, Gimblett RH, Chalfoun NV, Marsh SE, Guertin DP. Designing healthy communities: Testing the walkability model. Front Arch Res. 2017;6(1):63–73.

    Article  Google Scholar 

  28. White MP, Alcock I, Wheeler BW, Depledge MH. Would you be happier living in a greener urban area? A fixed-effects analysis of panel data. Psychol Sci Juni. 2013;24(6):920–8.

    Article  Google Scholar 

  29. Hua J, Mendoza-Vasconez AS, Chrisinger BW, Conway TL, Todd M, Adams MA. Associations of social cohesion and quality of life with objective and perceived built environments: a latent profile analysis among seniors. J Public Health (Oxf). 2022;44(1):138–47.

    Article  CAS  PubMed  Google Scholar 

  30. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Mayring P. Qualitiative Inhaltsanalyse: Grundlagen und Techniken. 12. Auflage. Weinheim, Basel: Beltz; 2015.

  32. Pope C, Ziebland S, Mays N. Qualitative research in health care. Analysing qualitative data. BMJ. 2000;320(7227):114–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Agarwal A. Quantifying Health & Economic Benefits of Bicycle Superhighway: Evidence from Patna. Procedia Comput Sci. 2021;184:692–7.

    Article  Google Scholar 

  34. Andersen HB, Christiansen LB, Klinker CD, Ersbøll AK, Troelsen J, Kerr J. Increases in Use and Activity Due to Urban Renewal: Effect of a Natural Experiment. Am J Prev Med. 2017;53(3):e81–7.

    Article  PubMed  Google Scholar 

  35. Badland H, Mavoa S, Boulangé C, Eagleson S, Gunn L, Stewart J. Identifying, creating, and testing urban planning measures for transport walking: Findings from the Australian national liveability study. JTH. 2017;5:151–62.

    Article  Google Scholar 

  36. Bias TK, Abildso CG. Measuring policy and related effects of a health impact assessment related to connectivity. Prev Med. 2017;95:S92-4.

    Article  Google Scholar 

  37. Branas CC, Cheney RA, MacDonald JM, Tam VW, Jackson TD, Ten Have TR. A Difference-in-Differences Analysis of Health, Safety, and Greening Vacant Urban Space. Am J Epidemiol. 2011;174(11):1296–306.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Buekers J, Dons E, Elen B, Int Panis L. Health impact model for modal shift from car use to cycling or walking in Flanders: application to two bicycle highways. J Trans Health. 2015;2(4):549–62.

    Article  Google Scholar 

  39. Buregeya JM, Loignon C, Brousselle A. Contribution analysis to analyze the effects of the health impact assessment at the local level: A case of urban revitalization. Eval Program Plann. 2020;79:101746.

    Article  PubMed  Google Scholar 

  40. Chapman R, Keall M, Howden-Chapman P, Grams M, Witten K, Randal E. A Cost Benefit Analysis of an Active Travel Intervention with Health and Carbon Emission Reduction Benefits. Int J Environ Res Public Health. 2018;15(5):962.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Coulson JC, Fox KR, Lawlor DA, Trayers T. Residents’ diverse perspectives of the impact of neighbourhood renewal on quality of life and physical activity engagement: Improvements but unresolved issues. Health Place. 2011;17(1):300–10.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  42. Frank LD, Hong A, Ngo VD. Causal evaluation of urban greenway retrofit: A longitudinal study on physical activity and sedentary behavior. Prev Med. 2019;123:109–16.

    Article  PubMed  Google Scholar 

  43. Frank LD, Fox EH, Ulmer JM, Chapman JE, Braun LM. Quantifying the health benefits of transit-oriented development: Creation and application of the San Diego Public Health Assessment Model (SD-PHAM). Transport Policy. 2022;115:14–26.

    Article  Google Scholar 

  44. Goodman A, Sahlqvist S, Ogilvie D. New Walking and Cycling Routes and Increased Physical Activity: One- and 2-Year Findings From the UK iConnect Study. Am J Public Health. 2014;104(9):e38-46.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Gotschi T. Costs and Benefits of Bicycling Investments in Portland. Oregon J Phys Act Health. 2011;8(s1):S49-58.

    Article  PubMed  Google Scholar 

  46. Gu J, Mohit B, Muennig PA. The cost-effectiveness of bike lanes in New York City. Inj Prev. 2017;23(4):239–43.

    Article  PubMed  Google Scholar 

  47. Guo JY, Gandavarapu S. An economic evaluation of health-promotive built environment changes. Prev Med. 2010;50:S44-9.

    Article  PubMed  Google Scholar 

  48. Hoehner CM, Rios J, Garmendia C, Baldwin S, Kelly CM, Knights DM. Page Avenue health impact assessment: Building on diverse partnerships and evidence to promote a healthy community. Health Place. 2012;18(1):85–95.

    Article  PubMed  Google Scholar 

  49. Kaczynski AT, Sharratt MT. Deconstructing Williamsburg: Using focus groups to examine residents’ perceptions of the building of a walkable community. Int J Behav Nutr Phys Act. 2010;7(1):50.

    Article  PubMed  PubMed Central  Google Scholar 

  50. King DK, Glasgow RE, Leeman-Castillo B. Reaiming RE-AIM: Using the Model to Plan, Implement, and Evaluate the Effects of Environmental Change Approaches to Enhancing Population Health. Am J Public Health. 2010;100(11):2076–84.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Knuiman MW, Christian HE, Divitini ML, Foster SA, Bull FC, Badland HM. A Longitudinal Analysis of the Influence of the Neighborhood Built Environment on Walking for Transportation: The RESIDE Study. Am J Epidemiol. 2014;180(5):453–61.

    Article  PubMed  Google Scholar 

  52. MacDonald JM, Stokes RJ, Cohen DA, Kofner A, Ridgeway GK. The Effect of Light Rail Transit on Body Mass Index and Physical Activity. Am J Prev Med. 2010;39(2):105–12.

    Article  PubMed  PubMed Central  Google Scholar 

  53. MacDonald Gibson J, Rodriguez D, Dennerlein T, Mead J, Hasch T, Meacci G. Predicting urban design effects on physical activity and public health: A case study. Health Place. 2015;35:79–84.

    Article  PubMed  Google Scholar 

  54. Mansfield TJ, Gibson JM. Estimating Active Transportation Behaviors to Support Health Impact Assessment in the United States. Front Public Health. 2016;4:63.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Mansfield TJ, Gibson JM. Health Impacts of Increased Physical Activity from Changes in Transportation Infrastructure: Quantitative Estimates for Three Communities. BioMed Res Int. 2015;2015:812325.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Mansfield TJ, Rodriguez DA, Huegy J, MacDonald GJ. The Effects of Urban Form on Ambient Air Pollution and Public Health Risk: A Case Study in Raleigh. North Carolina Risk Analysis. 2015;35(5):901–18.

    Article  PubMed  Google Scholar 

  57. Mueller N, Rojas-Rueda D, Salmon M, Martinez D, Ambros A, Brand C. Health impact assessment of cycling network expansions in European cities. Prev Med. 2018;109:62–70.

    Article  PubMed  Google Scholar 

  58. Mueller N, Rojas-Rueda D, Khreis H, Cirach M, Andrés D, Ballester J. Changing the urban design of cities for health: The superblock model. Environ Int. 2020;134:105132.

    Article  CAS  PubMed  Google Scholar 

  59. Nicholas W, Vidyanti I, Caesar E, Maizlish N. Routine Assessment of Health Impacts of Local Transportation Plans: A Case Study From the City of Los Angeles. Am J Public Health März. 2019;109(3):490–6.

    Article  Google Scholar 

  60. Panter J, Heinen E, Mackett R, Ogilvie D. Impact of New Transport Infrastructure on Walking, Cycling, and Physical Activity. Am J Prev Med. 2016;50(2):e45-53.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Payton Foh E, Brown RR, Denzongpa K, Echeverria S. Legacies of Environmental Injustice on Neighborhood Violence, Poverty and Active Living in an African American Community. Ethn Dis. 2021;31(3):425–32.

    Article  PubMed  PubMed Central  Google Scholar 

  62. Perdue LA, Michael YL, Harris C, Heller J, Livingston C, Rader M, Goff NM. Rapid health impact assessment of policies to reduce vehicle miles traveled in Oregon. Public Health. 2012;126(12):1063–71.

  63. Ross CL, Leone de Nie K, Dannenberg AL, Beck LF, Marcus MJ, Barringer J. Health Impact Assessment of the Atlanta BeltLine. Am J Prev Med. 2012;42(3):203–13.

    Article  PubMed  Google Scholar 

  64. Stevenson M, Thompson J, de Sá TH, Ewing R, Mohan D, McClure R. Land use, transport, and population health: estimating the health benefits of compact cities. Lancet. 2016;388(10062):2925–35.

    Article  PubMed  PubMed Central  Google Scholar 

  65. Thornton RLJ, Greiner A, Fichtenberg CM, Feingold BJ, Ellen JM, Jennings JM. Achieving a Healthy Zoning Policy in Baltimore: Results of a Health Impact Assessment of the TransForm Baltimore Zoning Code Rewrite. Public Health Rep. 2013;128(6_suppl3):87–103.

    Article  Google Scholar 

  66. Tiwari G, Jain D, Ramachandra Rao K. Impact of public transport and non-motorized transport infrastructure on travel mode shares, energy, emissions and safety: Case of Indian cities. Transp Res D Transp Environ. 2016;44:277–91.

    Article  Google Scholar 

  67. Tully MA, Hunter RF, McAneney H, Cupples ME, Donnelly M, Ellis G. Physical activity and the rejuvenation of Connswater (PARC study): protocol for a natural experiment investigating the impact of urban regeneration on public health. BMC Public Health. 2013;13(1):774.

    Article  PubMed  PubMed Central  Google Scholar 

  68. Veerman JL, Zapata-Diomedi B, Gunn L, McCormack GR, Cobiac LJ, Mantilla Herrera AM. Cost-effectiveness of investing in sidewalks as a means of increasing physical activity: a RESIDE modelling study. BMJ Open. 2016;6(9):e011617.

    Article  PubMed  PubMed Central  Google Scholar 

  69. Woodcock J, Givoni M, Morgan AS. Health Impact Modelling of Active Travel Visions for England and Wales Using an Integrated Transport and Health Impact Modelling Tool (ITHIM). PLoS ONE. 2013;8(1):e51462.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  70. Zapata-Diomedi B, Herrera AMM, Veerman JL. The effects of built environment attributes on physical activity-related health and health care costs outcomes in Australia. Health Place. 2016;42:19–29.

    Article  PubMed  Google Scholar 

  71. Zapata-Diomedi B, Boulangé C, Giles-Corti B, Phelan K, Washington S, Veerman JL. Physical activity-related health and economic benefits of building walkable neighbourhoods: a modelled comparison between brownfield and greenfield developments. Int J Behav Nutr Phys Act. 2019;16(1):11.

    Article  PubMed  PubMed Central  Google Scholar 

  72. Zapata-Diomedi B, Gunn L, Giles-Corti B, Shiell A, Lennert Veerman J. A method for the inclusion of physical activity-related health benefits in cost-benefit analysis of built environment initiatives. Prev Med. 2018;106:224–30.

    Article  PubMed  Google Scholar 

Download references


Not applicable.


Open Access funding enabled and organized by Projekt DEAL. The study was supported by funding from the German Federal Ministry of Education and Research (Funding No. 13FH021SA8). The funding body had no role in the design of the study, collection, analysis and interpretation of data or in writing the manuscript.

Author information

Authors and Affiliations



JW made substantial contributions to the conception of the work, the analysis and interpretation of the data and drafted the manuscript. EN made substantial contributions to the acquisition, analysis and interpretation of the data, and contributed substantially to the revision of the manuscript. MLR and FS made substantial contributions to the acquisition and analysis of the data. JB made substantial contributions to the conception of the work, the analysis and interpretation of the data and contributed substantially to the revision of the manuscript. All authors have approved the submitted version of the manuscript.

Corresponding author

Correspondence to Joachim Westenhöfer.

Ethics declarations

Ethics approval and consent to participate

The study does not include human participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1: Table S1.

Geographic distribution of HIAs. Table S2. Types of projects, programs or policies that is evaluated using HIA. Table S3. Type of HIA. Table S4. Type of health endpoints. Table S5. Type of data source for the HIA. Table S6. Type of results.

Additional file 2:

Data extraction sheet.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Westenhöfer, J., Nouri, E., Reschke, M.L. et al. Walkability and urban built environments—a systematic review of health impact assessments (HIA). BMC Public Health 23, 518 (2023).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: