# Pathogenic built environment? Reflections on modeling spatial determinants of health in urban settings considering the example of COVID-19 studies

## TL;DR

This paper explores how urban environments affect health, focusing on lessons from COVID-19 studies to improve future research methods.

## Contribution

The paper identifies key challenges in modeling spatial determinants of health and proposes guiding principles to avoid misinterpretation in urban health studies.

## Key findings

- Current approaches to spatial epidemiology risk falsely attributing health outcomes to the built environment due to complex assumptions.
- The study highlights the 'spatial trap' as a major pitfall in interpreting the relationship between urban environments and health.
- Recommendations are provided to clarify assumptions and improve the operationalization of spatial determinants in health research.

## Abstract

The triad of host, agent, and environment has become a widely accepted framework for understanding infectious diseases and human health. While modern medicine has traditionally focused on the individual, there is a renewed interest in the role of the environment. Recent studies have shifted from an early-twentieth-century emphasis on individual factors to a broader consideration of contextual factors, including environmental, climatic, and social settings as spatial determinants of health. This shifted focus has been particularly relevant in the context of the COVID-19 pandemic, where the built environment in urban settings is increasingly recognized as a crucial factor influencing disease transmission. However, operationalizing the complexity of associations between the built environment and health for empirical analyses presents significant challenges. This study aims to identify key caveats in the operationalization of spatial determinants of health for empirical analysis and proposes guiding principles for future research. We focus on how the built environment in urban settings was studied in recent literature on COVID-19. Based on a set of criteria, we analyze 23 studies and identify explicit and implicit assumptions regarding the health-related dimensions of the built environment. Our findings highlight the complexities and potential pitfalls, referred to as the ‘spatial trap,' in the current approaches to spatial epidemiology concerning COVID-19. We conclude with recommendations and guiding questions for future studies to avoid falsely attributing a built environment impact on health outcomes and to clarify explicit and implicit assumptions regarding the health-related dimensions.