Health improvement and inequality in local authority green infrastructure strategies in England: a policy review.

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Learn more: PMC Disclaimer | PMC Copyright Notice J Public Health (Oxf) . 2026 Feb 7;48(2):543–551. doi: 10.1093/pubmed/fdag006 Health improvement and inequality in local authority green infrastructure strategies in England: a policy review Angela Hands 1, 2, 3 , Jennifer Israelsson 4, 5 , Nina Reynolds 6, 7, ✉ , Elozona Umeh 8, 9 , Peninah Murage 10, 11, ✉ , Grace Turner 12, 13 Author information Article notes Copyright and License information 1 NIHR Health Protection Research Unit on Environmental Change and Health, London School of Hygiene and Tropical Medicine, Keppel Street, Camden, London WC1E 7HT, UK 2 Department of Public Health, Environment and Society, London School of Hygiene and Tropical Medicine, Keppel Street, Camden, London WC1E 7HT, UK 3 Office of Health Improvement and Disparities, Victoria Street, Victoria, London SW1H 0EU, UK 4 NIHR Health Protection Research Unit on Environmental Change and Health, London School of Hygiene and Tropical Medicine, Keppel Street, Camden, London WC1E 7HT, UK 5 Centre for Climate and Health Security, UK Health Security Agency, South Colonnade, Canary Wharf, London E14 4PU, UK 6 NIHR Health Protection Research Unit on Environmental Change and Health, London School of Hygiene and Tropical Medicine, Keppel Street, Camden, London WC1E 7HT, UK 7 Office of Health Improvement and Disparities, Victoria Street, Victoria, London SW1H 0EU, UK 8 NIHR Health Protection Research Unit on Environmental Change and Health, London School of Hygiene and Tropical Medicine, Keppel Street, Camden, London WC1E 7HT, UK 9 Office of Health Improvement and Disparities, Victoria Street, Victoria, London SW1H 0EU, UK 10 NIHR Health Protection Research Unit on Environmental Change and Health, London School of Hygiene and Tropical Medicine, Keppel Street, Camden, London WC1E 7HT, UK 11 Department of Public Health, Environment and Society, London School of Hygiene and Tropical Medicine, Keppel Street, Camden, London WC1E 7HT, UK 12 NIHR Health Protection Research Unit on Environmental Change and Health, London School of Hygiene and Tropical Medicine, Keppel Street, Camden, London WC1E 7HT, UK 13 Department of Public Health, Environment and Society, London School of Hygiene and Tropical Medicine, Keppel Street, Camden, London WC1E 7HT, UK ✉ Corresponding author. Department of Health and Social Care, Quarry House, Leeds, LS2 7UA, UK. E-mail: nina.reynolds@dhsc.gov.uk ✉ Corresponding author. Received 2025 Jun 5; Revised 2025 Nov 5; Accepted 2026 Jan 2; Collection date 2026 Jun. © The Author(s) 2026. Published by Oxford University Press on behalf of the Faculty of Public Health. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License ( https://creativecommons.org/licenses/by-nc/4.0/ ), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com. PMC Copyright notice PMCID: PMC13223564  PMID: 41652877 Abstract Introduction Green spaces are increasingly recognized as critical to public health. This study examines English local planning authorities’ green infrastructure strategies, evaluating how health improvement and inequality reduction goals are integrated. Methods A quantitative content analysis was conducted on publicly accessible green infrastructure strategy documents. Of 305 potential authorities, 133 (44%) were included based on eligibility criteria. Only strategies published from 2012 onwards were included. Data were coded across themes: health policy and actors, health outcomes, demographics and inequalities, environmental change and health. A scoring system quantified consideration of health and inequality, with descriptive statistics summarizing thematic presence, frequency, regional variation, and temporal trends. Results The integration of health and inequality varied substantially. Most strategies referenced general health outcomes, but fewer detailed actions targeting health inequalities or specific demographic groups. Regional differences were observed, and methods for monitoring health impacts were limited. Conclusion Local green infrastructure strategies in England increasingly recognize their health improvement potential, but inconsistent integration of health and inequality may limit impact. Stronger collaboration between planning and public health is needed to create equitable, accessible, health-promoting environments. Future research should explore longitudinal health impacts and identify best practices for integrating health equity in spatial planning. Keywords: health promotion, management and policy, planning Introduction The environment has long been recognized as a key determinant of health. 1 , 2 Evidence suggests there is an association between access to greenspace and green infrastructure with both mental and physical health. 3 , 4 Green Infrastructure is defined as ‘ a network of multi-functional green and blue spaces and other natural features, urban and rural, which can deliver a wide range of environmental, economic, health and wellbeing benefits for nature, climate, local and wider communities and prosperity ’, 5 includes parks, allotments, and woodlands, all of which have significant positive impacts on human health. 6 An umbrella review of 40 systematic reviews and meta analyses found positive associations between health outcomes and greenspace, including physical activity, mental health, cardiometabolic factors, all cause and stroke specific mortality, and cardiovascular disease (CVD) morbidity. 7 While access to greenspace benefits public health broadly, its impact is unevenly distributed. 6 , 8 Low-income communities, ethnic minorities, and other vulnerable groups are more likely to live in areas with poorer quality or fewer greenspaces. 6 Health inequalities in England are widening, with those in more deprived areas experiencing worsening health outcomes. 9 Therefore, understanding how green infrastructure is planned and designed in England is crucial for creating healthier, more equitable environments. This matter sits within a wider national policy landscape. The 10-Year Health Plan for England (‘Fit for the Future’, 2025) 10 emphasizes prevention and tackling wider determinants of health, including access to green and blue spaces. In parallel, the Government’s 25 Year Environment Plan 11 and Environmental Improvement Plan 12 commit to enhancing access to nature, while Natural England’s Green Infrastructure Framework 13 provides practical guidance for local authorities and developers. Together, these policies underscore the importance of green infrastructure in advancing both health and equity. The local planning system plays a critical role in shaping the design and development of local areas including access to green infrastructure. The National Planning Policy Framework (NPPF), 5 provides national planning policy, with chapter 8 emphasizing the importance of enabling and supporting healthy lifestyles including access to green infrastructure for physical and mental wellbeing. However, implementation of the NPPF varies across local authorities and it is unclear how the physical and mental health objectives are being met. Recent research highlights the importance of governance, policy design, and quality in delivering green infrastructure that supports health. Effective planning and equitable distribution of resources can mitigate inequality in access to nature. 14 Furthermore, robust green infrastructure planning policies, assessed through structured tools or frameworks, can support multifunctional and inclusive green spaces, indirectly improving population health. 15 , 16 Management and community engagement enhance the long-term benefits of green infrastructure, including well-being outcomes. 17 Although not a statutory requirement, a Green Infrastructure Strategy serves as a key spatial planning tool to guide the development of natural environments while fostering sustainable communities ensuring equitable access to green infrastructure. Despite the well documented health benefits, there is limited understanding of how local planning authorities in England integrate health and inequality consideration into their green infrastructure strategies. Therefore, this study seeks to address the gap by conducting a content analysis of publicly available green infrastructure strategies assessing how health, well-being, health inequalities, and deprivation are considered providing valuable insights for policymakers, urban planners, and public health professionals. Method Study design A quantitative content analysis was conducted to examine all publicly accessible green infrastructure strategy documents from local planning authorities across England. Of 305 potential authorities, 133 met the inclusion criteria. Search strategy The initial sample comprised a list of all two-tier, unitary, and combined authorities in England only, provided by the Ministry of Housing, Communities and Local Government (previously the Department of Levelling Up, Housing and Communities). Publicly available ‘greenspace’ or ‘green/blue’ infrastructure strategies from the local authorities on this list were identified by the Office for Health Improvement and Disparities (OHID) regional teams (8 regions) in August 2023. Missing strategies, were located through local authority website searches, using the terms ‘green space’, ‘green infrastructure’ or ‘green and blue infrastructure’. A final search in January 2024, included Google searches using the local authority’s name combined with the same terms. The inclusion criteria were: A local authority green/blue infrastructure/greenspace strategy The most recent publicly available document, published 2012 or later Any tier of local planning authority, including combined authority Appendices were not reviewed unless these were action plans supporting their delivery. Data were extracted from supplementary planning documents (SPDs) ( n = 22) but excluded from the analysis as these were not considered comprehensive strategies providing action to deliver local green infrastructure. Data analysis Three strategies were review by all authors to generate a list of initial codes to represent the main themes in the data. A further six strategies were reviewed by all authors to test and refine the coding scheme, including developing clear definitions and guidelines to ensure consistent and reliable coding. The remaining strategies were then divided between the team to extract data. Data were analyzed under six themes, health policy and actors, health outcomes, demographics and inequalities, monitoring and evaluation, and wider determinants of health. This paper reports the health related findings, and a companion paper will address the climate and environmental change aspects. A scoring system was developed and applied to each strategy. The scoring system included 10 categories with scores ranging from 0 to 3 (see Supplementary Table S1 ). An inter-rater reliability assessment was conducted to assess the degree of agreement between authors. The Fig. 1 map below presents the English local authority scores by colour using this scoring system, with darker colours indicating higher score. Figure 1. Open in a new tab Maps of local authorities in England showing the integration of health considerations in green infrastructure strategies. Panels show the (a) overall strategy score, (b) health score, (c) mental health score, and (d) physical health score. Scores were calculated by summing the presence of relevant strategy elements within each local authority plan, with higher values indicating more comprehensive consideration of public health. Colours represent score ranges, with darker colours indicating higher scores. Grey areas indicate local authorities for which no strategy was identified. Descriptive statistics summarized the presence and distribution of themes. All statistical analyses and visualizations were performed in R (version 4.3.2). Regional analysis was conducted using the eight OHID regions, aligning with established governance structures within the public health system. The analysis allowed us to identify areas potentially requiring additional support. Ethics As this study comprised a document analysis, ethics approval was not required. Results About 133 local authority green infrastructure strategies meeting the inclusion criteria were reviewed in this study. A summary table of included strategies can be found in Supplementary Table S2 . The remaining 172 (56%) of local planning authorities either lacked a green infrastructure strategy or had not updated their strategy since before 2012. The highest number of strategies were published in 2022 ( n = 21), followed by 2018 ( n = 16). The lowest frequency of strategies published was in 2012 and 2016. Descriptive statistics are presented in Table 1 below, detailing the frequency and percentage of health and inequality considerations identified in included green infrastructure strategies. Inter-rater reliability was assessed using Fleiss’ Kappa, yielding a score of 0.54 indicating moderate agreement amongst coders. This suggests a reasonable level of consistency in scoring. Table 1. Public Health considerations in publicly available Green Infrastructure Strategies in England. Category Subcategory Yes (n) Yes (%) Health policy and actors Health considered 129 97% Health and wellbeing strategy 45 34% Joint strategic needs assessment 26 19.5% Physical health outcomes General physical health 125 94% Physical activity 109 82% Healthy weight 73 55% Cardiovascular health 56 42% Diabetes 29 22% Cancer 23 17% Musculoskeletal health 2 1.6% Mental health outcomes General mental health 102 77% Stress 45 34% Depression 30 23% Anxiety 25 19% Dementia 21 16% Cognitive development 16 12% Other mental health disorders 12 9% Health inequalities Access to green infrastructure 125 94% Quality of life 98 74% Deprivation 72 54% Mortality/life expectancy 40 30% Open in a new tab Of the 133 strategies analyzed, general health considerations are incorporated into most included strategies (97%, n = 129). However, only 34% ( n = 45) of strategies refer to a relevant Health and Wellbeing Strategy, and approximately one fifth included Joint Strategic Needs Assessments (19.5%, n = 26). General physical health was included in 94% ( n = 125) of strategies, with 82% acknowledging the importance of physical activity ( n = 109). However, more specific health outcomes were less frequently considered. Healthy weight was included in 55% ( n = 73) of strategies, while cardiovascular health (42%, n = 56), diabetes (22%, n = 29), and cancer (17%, n = 23) received less attention. Musculoskeletal health was addressed in only 1.5% of strategies ( n = 2). General mental health was addressed in 77% ( n = 102) of green infrastructure strategies, followed by stress (45%, n = 45), depression (23%, n = 30), and anxiety (19%, n = 25). However, more specific conditions such as dementia (16%, n = 21) and cognitive development (12%, n = 16) were less often included. About 94% ( n = 125) of strategies discussed access to green infrastructure. Deprivation was mentioned in just over half (54%, n = 72) of strategies and quality of life in 74% ( n = 98). However, mortality or life expectancy was considered in only 30% ( n = 40) of strategies. The London region had the highest proportion (61%) of local planning authorities with a current strategy, whereas Yorkshire and the Humber had the lowest (20%). The North-West (26%) and East (29%) also exhibited relatively low proportions. Conversely, 58% of local planning authorities in the Midlands region had a published strategy, with the North-East, 42%, South-West, 41%, and South-East, 37%. As shown in Fig. 2 below, analysis of local authority greenspace strategies over time shows noticeable trends in the incorporation of health considerations. While physical health scores show variability across the period 2012–2023, mental health scores demonstrate an upward trend in later years, suggesting an increasing emphasis on mental wellbeing within green infrastructure strategies over time. Similarly, health inequality scores exhibit a rise in higher category scores, indicating a growing recognition of health inequality in green infrastructure strategies over time. Figure 2. Open in a new tab Stacked bar charts showing the proportional distribution of (a) physical health, (b) mental health, and (c) health inequality scores in local authority green infrastructure strategies from 2012 to2023. Each bar represents the proportion of local authorities within different score categories for that year. The box and whisker plot presented in Fig. 3 illustrates the total policy score given for the integration of health and inequality considerations in green infrastructure strategies across different regions of England. Figure 3. Open in a new tab Box and whisker plot for each of the eight English regions. The mean is indicated by a red star, and the horizontal line in each box represents the median score. The boxes cover the 25 th (Q1) to 75 th (Q3) inter-quartile range (IQR) of the data, and whiskers extend to 1.5* inter-quartile range. The median policy scores show some regional variation, with London, North-East, North-West and Yorkshire & Humber having the highest median values, with the Midlands, East of England, South-East and South-West having the lowest. Interquartile ranges (IQRs) vary across regions, suggesting difference in score dispersion. The North-East and Yorkshire & Humber regions show more consistency as shown by smaller IQRs and shorter whiskers. In contrast, the East of England shows a relatively wider IQR and the North-West, longer whiskers, indicating greater variability in scores. The alignment between mean and median in the East of England, Midlands and South-East suggests a relatively symmetrical distribution of data. However, the mean score does not always align with the median, suggesting skewed distributions in some areas. In practice, this suggests that integration of health in green infrastructure strategies varies across local planning authorities. Discussion Main finding of this study To our knowledge this is the first study to undertake a content analysis of public health content of green infrastructure strategies which form part of local planning policy in England. Over half of local planning authorities in England lack a green infrastructure strategy. Of those available, 97% acknowledge the general health benefits of green infrastructure, but specific health outcomes such as musculoskeletal health, cancer, and mental health, remain limited. While some strategies mention health inequality, few outline actionable policies. However, growing recognition of health inequalities may reflect the influence of policies highlighting the role of the environment on health. 2 , 9 Our analysis found differences and similarities across regions. Regions such as London and the North-West have stronger but more inconsistent policy inclusion, whereas the Midlands and Yorkshire & Humber exhibit lower and more uniform scores, suggesting they may need further support in integrating health considerations into green infrastructure policies. Regions with lower scores may face challenges such as resource constraints or competing policy priorities, which could exacerbate existing health inequalities. What is already known on this topic The role of spatial planning in shaping health outcomes has been widely recognized with previous studies identifying that although greenspaces are beneficial to health, planning policies frequently lack specificity in implementation,. 2 , 9 , 18 A previous study identified gaps in embedding health priorities into local planning policies, noting that while general health is often acknowledged, specific health outcomes and inequalities receive less attention. 19 Similarly, there are inconsistencies in how planning policies incorporate health inequality, with significant variation in the extent to which social determinants, such as deprivation and access to greenspace, are addressed. 20 What this study adds This study provides the first systematic, quantitative assessment of how English Local Planning Authorities integrate health and inequality considerations into green infrastructure strategies. The findings show that while 94% of strategies referenced green infrastructure access, only 30% addressed mortality or life expectancy, suggesting a lack of comprehensive health impact considerations. Chang et al. further reinforce this issue, demonstrating through their local plan audit that many policies include aspirational language about health, without clear implementation mechanisms, a challenge also observed in our review of green infrastructure strategies, a challenge also identified in our review. Our findings align with existing research on the challenges of integrating health and equity considerations into spatial planning. Despite broad recognition of green infrastructure as a health-promoting asset, there is a lack of detailed policy measures to address key health disparities. Furthermore, urban planning documents frequently reference health inequalities but rarely provide actionable strategies to mitigate them, reinforcing the need for stronger policy frameworks that explicitly link planning with public health priorities. 1 The study also highlights regional variation, suggesting that governance structures, local capacity and policy priorities may influence the extent of health integration. Strengthening national guidance and fostering closer collaboration between planning and public health professionals may help ensure that green infrastructure strategies contribute to effectively reducing health inequalities. Limitations of this study A systematic approach was used to identify published green infrastructure strategies, ensuring inclusion of all possible local planning authorities in this study. By relying on publicly available strategies, the study reduced selection and publication bias and strengthened our findings by focusing on officially published documents only. A structured coding scheme was developed and refined through pilot testing, ensuring a reliable and consistent approach. Several measures were taken to reduce bias, including systematic inclusion criteria, and multiple researchers reviewing a proportion of strategies to check for coding consistency. However, there are some limitations. One key limitation is potential missing data due to gaps in publicly available strategies. Over half (55%) of local planning authorities lacked a published green infrastructure strategy, either because one had not been developed, or was not publicly available. This raises questions about whether the absence of a published strategy reflects simply an issue of accessibility. While SPDs were excluded from the main analysis, they may still play an important role in shaping green infrastructure at a local level. Their exclusion may have reduced the completeness of the dataset. Similarly, it is possible that some strategies developed by previous local authority structures may still be in use within new authorities but were not captured in our searches. For example, a newly formed unitary authority may continue to follow a strategy from a former county council. We expect that this is likely to affect only a small number of cases and is unlikely to substantially influence the overall findings. The inter-rater reliability of 0.54 indicates moderate agreement, suggesting a reasonable level of consistency between researchers, and that some shared understanding exists. Content analysis inherently involves some degree of subjective interpretation, which leads to lower agreement. Therefore, further training or clarification of criteria may improve agreement. England has a complex governance structure, with two-tier, unitary and combined authorities. Differences in planning responsibilities, funding and political priorities may influence how green infrastructure strategies are developed and implemented, making direct comparisons between local authorities difficult. Furthermore, whilst this study examines the content of strategies, it does not assess implementation. Mentioning health or inequality does not necessarily translate into measurable health outcomes. The additive scoring system was based on subjective judgement of document content, with equal weighting given across diverse concepts. As such, the overall score should be interpreted as a relative indication of how comprehensively different authorities consider health and inequality in green infrastructure strategies, rather than as a precise quantitative measure of policy quality. Recommendations To strengthen collaboration between local planning authorities and public health departments, insights could be gathered by consulting with planners and public health professionals, through qualitative methods such as focus groups or interviews. A theoretical framework like the Capability, Opportunity, Motivation and Behaviour (COM-B) model 21 could guide this process. Additionally, research could examine those local planning authorities who are yet to publish a green infrastructure strategy to understand opportunities for public health support. Longitudinal studies may be valuable, to assess the impact of new green infrastructure strategies on health outcomes to support our understanding of policy impact. To enhance the integration of public health and health inequality within green infrastructure strategies, a clearer and more explicit emphasis on public health could be developed within the NPPF and Local Plans. Policymakers should ensure green infrastructure strategies contribute effectively to improving health outcomes and reducing disparities. Developing standardized metrics for assessing health outcomes related to green infrastructure may ensure more consistent and comparable evaluations, ultimately guiding policy makers in refining green infrastructure strategies. The findings suggest a need to bridge the gap between recognizing the broad health benefits of green infrastructure and implementing detailed, health and equity focused strategies. Without a stronger emphasis on addressing health disparities, particularly those linked to socioeconomic determinants, the potential of green infrastructure to promote health and well-being may remain unfulfilled. A framework ensuring green infrastructure strategies are designed with public health as a priority, may be of benefit, thereby creating spaces that promote physical, mental and social wellbeing. Clear evidence based guidance should underpin collaboration between public health, planners, and communities. Conclusion This study provides the first nationwide analysis of green infrastructure strategies in England, revealing gaps in health and inequality considerations. While general health is widely acknowledged in green infrastructure strategies, specific health conditions and health inequalities receive less attention, with regional differences and limited integration of specific health strategies like Joint Strategic Needs Assessments. Encouragingly, recent years have seen greater inclusion of health considerations in green infrastructure strategies but stronger collaboration between local planning and public health teams is needed. Policymakers should prioritize public health in future planning for green infrastructure, to ensure equity in access to green infrastructure for all communities. Supplementary Material JPH250638_Supp_Material_fdag006 jph250638_supp_material_fdag006.docx (45KB, docx) Acknowledgements All authors acknowledge support from the NIHR Health Protection Research Unit in Environmental Change and Health. This study was funded by the National Institute for Health and Care Research (NIHR) Health Protection Research Unit in Environmental Change and Health (NIHR 200909), a partnership between UK Health Security Agency and the London School of Hygiene and Tropical Medicine (LSHTM), in collaboration with University College London, Office for Health Improvements and Disparities and the Met Office. Angela Hands , Honorary Associate Professor & Public Health Programme Manager Jennifer Israelsson , (PhD), Senior Climate Change Scientist Nina Reynolds , Policy Manager Elozona Umeh , Head of Health Improvement Peninah Murage , Associate Professor Grace Turner , MSc Contributor Information Angela Hands, NIHR Health Protection Research Unit on Environmental Change and Health, London School of Hygiene and Tropical Medicine, Keppel Street, Camden, London WC1E 7HT, UK; Department of Public Health, Environment and Society, London School of Hygiene and Tropical Medicine, Keppel Street, Camden, London WC1E 7HT, UK; Office of Health Improvement and Disparities, Victoria Street, Victoria, London SW1H 0EU, UK. Jennifer Israelsson, NIHR Health Protection Research Unit on Environmental Change and Health, London School of Hygiene and Tropical Medicine, Keppel Street, Camden, London WC1E 7HT, UK; Centre for Climate and Health Security, UK Health Security Agency, South Colonnade, Canary Wharf, London E14 4PU, UK. Nina Reynolds, NIHR Health Protection Research Unit on Environmental Change and Health, London School of Hygiene and Tropical Medicine, Keppel Street, Camden, London WC1E 7HT, UK; Office of Health Improvement and Disparities, Victoria Street, Victoria, London SW1H 0EU, UK. Elozona Umeh, NIHR Health Protection Research Unit on Environmental Change and Health, London School of Hygiene and Tropical Medicine, Keppel Street, Camden, London WC1E 7HT, UK; Office of Health Improvement and Disparities, Victoria Street, Victoria, London SW1H 0EU, UK. Peninah Murage, NIHR Health Protection Research Unit on Environmental Change and Health, London School of Hygiene and Tropical Medicine, Keppel Street, Camden, London WC1E 7HT, UK; Department of Public Health, Environment and Society, London School of Hygiene and Tropical Medicine, Keppel Street, Camden, London WC1E 7HT, UK. Grace Turner, NIHR Health Protection Research Unit on Environmental Change and Health, London School of Hygiene and Tropical Medicine, Keppel Street, Camden, London WC1E 7HT, UK; Department of Public Health, Environment and Society, London School of Hygiene and Tropical Medicine, Keppel Street, Camden, London WC1E 7HT, UK. Conflict of interest: None declared. Funding This work was supported by the National Institute for Health and Care Research (NIHR) Health Protection Research Unit in Environmental Change and Health (NIHR 200909), a partnership between UK Health Security Agency and the London School of Hygiene and Tropical Medicine (LSHTM), in collaboration with University College London, Office for Health Improvements and Disparities and the Met Office. The views expressed are those of the authors and not necessarily those of the NIHR, UK Health Security Agency, London School of Hygiene and Tropical Medicine, University College London, the Met Office or the Department of Health and Social Care. Data availability The data that supports this study is available from the corresponding author upon reasonable request. Ethical approval Ethical approval for this type of study is not required by our institute. Reflexivity statement The authors of this study range are considered inclusive and balanced. 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