Economic impact on local businesses of road safety improvements in Seattle: implications for Vision Zero projects

BACKGROUND

Local transportation agencies implementing Vision Zero road safety improvement projects often face opposition from business owners concerned about the potential negative impact on their sales. Few studies have documented the economic impact of these projects.

METHODS

We examined baseline and up to 3 years of postimprovement taxable sales data for retail, food and service-based businesses adjacent to seven road safety projects begun between 2006 and 2014 in Seattle. We used hierarchical linear models to test whether the change in annual taxable sales differed between the 7 intervention sites and 18 nearby matched comparison sites that had no road safety improvements within the study time frame.

RESULTS

Average annual taxable sales at baseline were comparable at the 7 intervention sites (US$44.7 million) and the 18 comparison sites (US$56.8 million). Regression analysis suggests that each additional year following baseline was associated with US$1.20 million more in taxable sales among intervention sites and US$1.14 million more among comparison sites. This difference is not statistically significant (p=0.64). Sensitivity analyses including a random slope, using a generalised linear model and an analysis of variance did not change conclusions.

DISCUSSION

Results suggest that road safety improvement projects such as those in Vision Zero plans are not associated with adverse economic impacts on adjacent businesses. The absence of negative economic impacts associated with pedestrian and bicycle road safety projects should reassure local business owners and may encourage them to work with transportation agencies to implement Vision Zero road safety projects designed to eliminate traffic-related injuries.

Ensuring equitable transportation for the disadvantaged: Paratransit usage by persons with disabilities during the COVID-19 pandemic

Paratransit services developed under the Americans with Disabilities Act are a critical transportation means for persons with disabilities to meet their basic needs, but the COVID-19 pandemic posed an unprecedented challenge to service providers. To safeguard transportation equity, this study used complete records of service trips and riders obtained from the Access Transportation Program in the Seattle region for an empirical analysis aimed at answering two research questions. First, how did the ridership and trip purposes of paratransit change after the outbreak of COVID-19? Second, what factors explained the users' changing levels of service usage in response to the pandemic? Statistical methods, including a Hurdle model, were employed as the analytical tools. The results show that paratransit ridership dramatically decreased during 2020 with the most substantial reductions of working and non-essential personal trips, and that most of the remaining trips were for medical purposes. The results also indicate that riders' service usage during the pandemic was associated with their sociodemographic characteristics, disability conditions, and pre-pandemic travel demand. When controlling for other factors, riders who lived in neighborhoods with lower income and lower access to personal vehicles were more dependent on the service. Based on the empirical findings, we recommend that when developing plans for future disruptive events, public transit agencies should promptly implement safety measures, identify and prioritize neighborhoods that are most in need of mobility services, and actively pursue collaboration with other organizations for innovative service delivery options.

Paratransit services for people with disabilities in the Seattle region during the COVID-19 pandemic: Lessons for recovery planning

INTRODUCTION

Along with all public transit services, paratransit services for people with disabilities experienced substantially reduced demand and an increased need to provide equitable services while protecting their clients and staff's safety during the COVID-19 pandemic. Paratransit services provide a lifeline for their clients' essential mobility needs, including access to medical appointments and grocery stores. In the absence of pre-existing pandemic response plans, examining transit agencies' responses to provide paratransit services during the pandemic can help inform planning for post-pandemic recovery and future disruptive events.

METHODS

In September 2020, we conducted semi-structured interviews with 15 decision-makers, planners, and drivers working for the primary transit agency in the Seattle region - King County Metro - and its paratransit contractors. Interview questions were designed to identify current services, policy gaps, and critical challenges for recovery planning and post-pandemic paratransit services. Interview transcripts were analyzed using NVivo software to obtain essential themes.

RESULTS

The interviewees provided insights about (1) paratransit service changes in response to the pandemic, (2) anticipated impacts of a returning demand on paratransit service efficiency, equity, and quality during the recovery period, and (3) innovative approaches for maintaining post-pandemic equitable paratransit services while balancing safety measures with available resources.

CONCLUSIONS

Study findings suggest that paratransit service providers should consider (1) developing guidelines for future disruptive events, (2) examining alternative methods for food delivery to clients, (3) planning scenarios for delivering equitable services in the post-pandemic recovery period, and (4) increasing resilience possibly by establishing partnerships with transportation network companies.

Moving Toward Physical Activity Targets by Walking to Transit: National Household Transportation Survey, 2001-2017

INTRODUCTION

Public transportation systems can help people engage in physical activity. This study assesses sociodemographic correlates and trends in the daily time spent walking to and from transit in the U.S. from 2001 to 2017.

METHODS

This cross-sectional study used data from the 2001, 2009, and 2017 National Household Transportation Survey. Data were analyzed in 2019 to assess the daily level of physical activity attained solely by walking to and from transit. Regression models were used to examine predictors of daily transit‒associated walking.

RESULTS

Compared with the full National Household Transportation Survey sample, transit users who walked to and from transit tended to be younger, from households earning <$25,000 per year, in areas with rail infrastructure, and did not have a household-owned car. Transit walkers spent a median of 20 minutes per day (95% CI=18.5, 21.5) walking to and from transit in 2017, compared with a median of 19 minutes (95% CI=17.5, 20.5) in 2001. Among transit walkers, daily transit-associated physical activity was 27% higher for those residing in areas with rail infrastructure (adjusted coefficient=1.27, 95% CI=1.11, 1.46) and 34% higher for those from households earning <$25,000 per year than those earning >$99,999 per year (adjusted coefficient=1.34, 95% CI=1.15, 1.56).

CONCLUSIONS

As documented in a growing literature, most public transit trips include at least some walking; thus, efforts to encourage transit use are favorable to public health. Continued monitoring by transportation surveys is important as new forms of mobility and changing demographics may impact future transit use and associated physical activity.

Changes in Self-Efficacy and Outcome Expectations From Child Participation in Bicycle Trains for Commuting to and From School

BACKGROUND

Active commuting to school (ACS) is associated with increased physical activity and lowered risk of obesity. In observational studies, ACS was associated with child self-efficacy, parent self-efficacy, and parent outcome expectations, although few experiments have assessed changes in these behavioral constructs.

AIM

This study examined the effects of a bicycle train intervention (BTI) on child self-efficacy, parent self-efficacy, and parent outcome expectations in a diverse, low socioeconomic status population.

METHOD

Data were from a 2014 BTI pilot randomized controlled trial (RCT) on fourth to fifth graders aged 9 to 12 years, n = 54, from four schools serving low-income populations in Seattle, Washington. The BTI was a group of children and study staff who cycled together to/from school daily, while controls received no intervention. Responses to validated child self-efficacy, parent self-efficacy, and parent outcome expectations questionnaires ranged from 1 to 3. Adjusted linear mixed effects models estimated standardized coefficients for child self-efficacy, parent self-efficacy, and parent outcome expectations comparing intervention and controls from Time 1 (preintervention) to Time 2 (final 4-6 weeks of intervention).

RESULTS

The intervention group had increases in child self-efficacy of 0.84 standard deviations (95% confidence interval [CI] [0.37, 1.31]), parent self-efficacy of 0.46 standard deviations (95% CI [0.05, 0.86]), and parent outcome expectations of 0.47 standard deviations (95% CI [0.17, 0.76]) compared with controls from Times 1 to 2 (all ps <.05).

CONCLUSION

A BTI improved child self-efficacy, parent self-efficacy, and parent outcome expectations, which warrants a larger RCT to examine long-term changes to these behavioral constructs and ACS.

Review of Education-Focused Health Impact Assessments Conducted in the United States

BACKGROUND

Health impact assessment (HIA) provides a structured process for examining the potential health impacts of proposed policies, plans, programs, and projects. This study systematically reviewed HIAs conducted in the United States on prekindergarten, primary, and secondary education-focused decisions.

METHODS

Relevant HIA reports were identified from web sources in late 2015. Key data elements were abstracted from each report. Four case studies were selected to highlight diversity of topics, methods, and impacts of the assessment process.

RESULTS

Twenty HIAs completed in 2003-2015 from 8 states on issues related to prekindergarten through secondary education were identified. The types of decisions examined included school structure and funding, transportation to and from school, physical modifications to school facilities, in-school physical activity and nutrition, and school discipline and climate. Assessments employed a range of methods to characterize the nature, magnitude, and severity of potential health impacts. Assessments fostered stakeholder engagement and provided health-promoting recommendations, some of which were subsequently incorporated into school policies.

CONCLUSIONS

Health impact assessment is a promising tool that education, health, and other stakeholders can use to maximize the health and well-being of students, families, and communities.

Understanding and Improving Arterial Roads to Support Public Health and Transportation Goals

Arterials are types of roads designed to carry high volumes of motorized traffic. They are an integral part of transportation systems worldwide and exposure to them is ubiquitous, especially in urban areas. Arterials provide access to diverse commercial and cultural resources, which can positively influence community health by supporting social cohesion as well as economic and cultural opportunities. They can negatively influence health via safety issues, noise, air pollution, and lack of economic development. The aims of public health and transportation partially overlap; efforts to improve arterials can meet goals of both professions. Two trends in arterial design show promise. First, transportation professionals increasingly define the performance of arterials via metrics accounting for pedestrians, cyclists, transit riders, and nearby residents in addition to motor vehicle users. Second, applying traffic engineering and design can generate safety, air quality, and livability benefits, but we need evidence to support these interventions. We describe the importance of arterials (including exposures, health behaviors, effects on equity, and resulting health outcomes) and make the case for public health collaborations with the transportation sector.

Change in Neighborhood Characteristics and Change in Coronary Artery Calcium: A Longitudinal Investigation in the MESA (Multi-Ethnic Study of Atherosclerosis) Cohort

BACKGROUND

Although some evidence shows that neighborhood deprivation is associated with greater subclinical atherosclerosis, prior studies have not identified what aspects of deprived neighborhoods were driving the association.

METHODS

We investigated whether social and physical neighborhood characteristics are related to the progression of subclinical atherosclerosis in 5950 adult participants of the MESA (Multi-Ethnic Study of Atherosclerosis) during a 12-year follow-up period. We assessed subclinical disease using coronary artery calcium (CAC). Neighborhood features examined included density of recreational facilities, density of healthy food stores, and survey-based measures of availability of healthy foods, walking environment, and social environment. We used econometric fixed-effects models to investigate how change in a given neighborhood exposure is related to simultaneous change in subclinical atherosclerosis.

RESULTS

Increases in density of neighborhood healthy food stores were associated with decreases in CAC (mean changes in CAC Agatston units per 1-SD increase in neighborhood exposures, -19.99; 95% confidence interval, -35.21 to -4.78) after adjustment for time-varying demographic confounders and computed tomography scanner type. This association remained similar in magnitude after additional adjustment for time-varying behavioral risk factors and depression. The addition of time-varying biomedical factors attenuated associations with CAC slightly (mean changes in CAC per 1-SD increase in neighborhood exposures, -17.60; 95% confidence interval, -32.71 to -2.49). Changes across time in other neighborhood measures were not significantly associated with within-person change in CAC.

CONCLUSIONS

Results from this longitudinal study provide suggestive evidence that greater access to neighborhood healthy food resources may slow the development of coronary atherosclerosis in middle-aged and older adults.

City planning and population health: a global challenge

Significant global health challenges are being confronted in the 21st century, prompting calls to rethink approaches to disease prevention. A key part of the solution is city planning that reduces non-communicable diseases and road trauma while also managing rapid urbanisation. This Series of papers considers the health impacts of city planning through transport mode choices. In this, the first paper, we identify eight integrated regional and local interventions that, when combined, encourage walking, cycling, and public transport use, while reducing private motor vehicle use. These interventions are destination accessibility, equitable distribution of employment across cities, managing demand by reducing the availability and increasing the cost of parking, designing pedestrian-friendly and cycling-friendly movement networks, achieving optimum levels of residential density, reducing distance to public transport, and enhancing the desirability of active travel modes (eg, creating safe attractive neighbourhoods and safe, affordable, and convenient public transport). Together, these interventions will create healthier and more sustainable compact cities that reduce the environmental, social, and behavioural risk factors that affect lifestyle choices, levels of traffic, environmental pollution, noise, and crime. The health sector, including health ministers, must lead in advocating for integrated multisector city planning that prioritises health, sustainability, and liveability outcomes, particularly in rapidly changing low-income and middle-income countries. We recommend establishing a set of indicators to benchmark and monitor progress towards achievement of more compact cities that promote health and reduce health inequities.

Effectiveness of Health Impact Assessments: A Synthesis of Data From Five Impact Evaluation Reports

Introduction

Since the 1990s, the use of health impact assessments (HIAs) has grown for considering the potential health impacts of proposed policies, plans, programs, and projects in various sectors. Evaluation of HIA impacts is needed for understanding the value of HIAs, improving the methods involved in HIAs, and potentially expanding their application. Impact evaluations examine whether HIAs affect decisions and lead to other effects.

Methods

I reviewed HIA impact evaluations identified by literature review and professional networking. I abstracted and synthesized data on key findings, success factors, and challenges from 5 large evaluations conducted in the United States, Europe, Australia, and New Zealand and published from 2006 through 2015. These studies analyzed impacts of approximately 200 individual HIAs.

Results

Major impacts of HIAs were directly influencing some decisions, improving collaboration among stakeholders, increasing awareness of health issues among decision makers, and giving community members a stronger voice in local decisions. Factors that contributed to successful HIAs included engaging stakeholders, timeliness, policy and systems support for conducting HIAs, having people with appropriate skills on the HIA team, obtaining the support of decision makers, and providing clearly articulated, feasible recommendations. Challenges that may have reduced HIA success were poor timeliness, underestimation of time and resources needed, difficulty in accessing relevant data, use of jargon in HIA reports, difficulty in involving decision makers in the HIA process, and absence of a requirement to conduct HIAs.

Conclusion

HIAs can be useful to promote health and mitigate adverse impacts of decisions made outside of the health sector. Stakeholder interactions and community engagement may be as important as direct impacts of HIAs. Multiple factors are required for HIA success. Further work could strengthen the role of HIAs in promoting equity, examine HIA impacts in specific sectors, and document the role of HIAs in a “health in all policies” approach.

What makes health impact assessments successful? Factors contributing to effectiveness in Australia and New Zealand

BACKGROUND

While many guidelines explain how to conduct Health Impact Assessments (HIAs), less is known about the factors that determine the extent to which HIAs affect health considerations in the decision making process. We investigated which factors are associated with increased or reduced effectiveness of HIAs in changing decisions and in the implementation of policies, programs or projects. This study builds on and tests the Harris and Harris-Roxas' conceptual framework for evaluating HIA effectiveness, which emphasises context, process and output as key domains.

METHODS

We reviewed 55 HIA reports in Australia and New Zealand from 2005 to 2009 and conducted surveys and interviews for 48 of these HIAs. Eleven detailed case studies were undertaken using document review and stakeholder interviews. Case study participants were selected through purposeful and snowball sampling. The data were analysed by thematic content analysis. Findings were synthesised and mapped against the conceptual framework. A stakeholder forum was utilised to test face validity and practical adequacy of the findings.

RESULTS

We found that some features of HIA are essential, such as the stepwise but flexible process, and evidence based approach. Non-essential features that can enhance the impact of HIAs include capacity and experience; 'right person right level'; involvement of decision-makers and communities; and relationships and partnerships. There are contextual factors outside of HIA such as fit with planning and decision making context, broader global context and unanticipated events, and shared values and goals that may influence a HIA. Crosscutting factors include proactive positioning, and time and timeliness. These all operate within complex open systems, involving multiple decision-makers, levels of decision-making, and points of influence. The Harris and Harris-Roxas framework was generally supported.

CONCLUSION

We have confirmed previously identified factors influencing effectiveness of HIA and identified new factors such as proactive positioning. Our findings challenge some presumptions about 'right' timing for HIA and the rationality and linearity of decision-making processes. The influence of right timing on decision making needs to be seen within the context of other factors such as proactive positioning. This research can help HIA practitioners and researchers understand and identify what can be enhanced within the HIA process. Practitioners can adapt the flexible HIA process to accommodate the external contextual factors identified in this report.

Characteristics of health impact assessments reported in Australia and New Zealand 2005-2009

Abstract

Objective

: To describe the use and reporting of Health Impact Assessment (HIA) in Australia and New Zealand between 2005 and 2009.

Methods

: We identified 115 HIAs undertaken in Australia and New Zealand between 2005 and 2009. We reviewed 55 HIAs meeting the study's inclusion criteria to identify characteristics and appraise the quality of the reports.

Results

: Of the 55 HIAs, 31 were undertaken in Australia and 24 in New Zealand. The HIAs were undertaken on plans (31), projects (12), programs (6) and policies (6). Compared to Australia, a higher proportion of New Zealand HIAs were on policies and plans and were rapid assessments done voluntarily to support decision-making. In both countries, most HIAs were on land use planning proposals. Overall, 65% of HIA reports were judged to be adequate.

Conclusion

: This study is the first attempt to empirically investigate the nature of the broad range of HIAs done in Australia and New Zealand and has highlighted the emergence of HIA as a growing area of public health practice. It identifies areas where current practice could be improved and provides a baseline against which future HIA developments can be assessed.

Implications:

There is evidence that HIA is becoming a part of public health practice in Australia and New Zealand across a wide range of policies, plans and projects. The assessment of quality of reports allows the development of practical suggestions on ways current practice may be improved. The growth of HIA will depend on ongoing organisation and workforce development in both countries.

An evaluation of health impact assessments in the United States, 2011-2014

Introduction

The Center for Community Health and Evaluation conducted a 3-year evaluation to assess results of health impact assessments (HIAs) in the United States and to identify elements critical for their success.

Methods

The study used a retrospective, mixed-methods comparative case study design, including a literature review; site visits; interviews with investigators, stakeholders, and decision makers for 23 HIAs in 16 states that were completed from 2005 through 2013; and a Web-based survey of 144 HIA practitioners.

Results

Analysis of interviews with decision makers suggests HIAs can directly influence decisions in nonhealth-related sectors. HIAs may also influence changes beyond the decision target, build consensus and relationships among decision makers and their constituents, and give community members a stronger voice in decisions that affect them. Factors that may increase HIA success include care in choosing a project or policy to be examined’ selecting an appropriate team to conduct the HIA; engaging stakeholders and decision makers throughout the process; crafting clear, actionable recommendations; delivering timely, compelling messages to appropriate audiences; and using multiple dissemination methods. Challenges to successful HIAs include underestimating the level of effort required, political changes during the conduct of the HIA, accessing relevant local data, engaging vulnerable populations, and following up on recommendations.

Conclusion

Results of this study suggest HIAs are a useful tool to promote public health because they can influence decisions in nonhealth-related sectors, strengthen cross-sector collaborations, and raise awareness of health issues among decision makers.

The effectiveness of health impact assessment in influencing decision-making in Australia and New Zealand 2005-2009

BACKGROUND

Health Impact Assessment (HIA) involves assessing how proposals may alter the determinants of health prior to implementation and recommends changes to enhance positive and mitigate negative impacts. HIAs growing use needs to be supported by a strong evidence base, both to validate the value of its application and to make its application more robust. We have carried out the first systematic empirical study of the influence of HIA on decision-making and implementation of proposals in Australia and New Zealand. This paper focuses on identifying whether and how HIAs changed decision-making and implementation and impacts that participants report following involvement in HIAs.

METHODS

We used a two-step process first surveying 55 HIAs followed by 11 in-depth case studies. Data gathering methods included questionnaires with follow-up interview, semi-structured interviews and document collation. We carried out deductive and inductive qualitative content analyses of interview transcripts and documents as well as simple descriptive statistics.

RESULTS

We found that most HIAs are effective in some way. HIAs are often directly effective in changing, influencing, broadening areas considered and in some cases having immediate impact on decisions. Even when HIAs are reported to have no direct effect on a decision they are often still effective in influencing decision-making processes and the stakeholders involved in them. HIA participants identify changes in relationships, improved understanding of the determinants of health and positive working relationships as major and sustainable impacts of their involvement.

CONCLUSIONS

This study clearly demonstrates direct and indirect effectiveness of HIA influencing decision making in Australia and New Zealand. We recommend that public health leaders and policy makers should be confident in promoting the use of HIA and investing in building capacity to undertake high quality HIAs. New findings about the value HIA stakeholders put on indirect impacts such as learning and relationship building suggest HIA has a role both as a technical tool that makes predictions of potential impacts of a policy, program or project and as a mechanism for developing relationships with and influencing other sectors. Accordingly when evaluating the effectiveness of HIAs we need to look beyond the direct impacts on decisions.

Walking associated with public transit: moving toward increased physical activity in the United States

OBJECTIVES

We assessed changes in transit-associated walking in the United States from 2001 to 2009 and documented their importance to public health.

METHODS

We examined transit walk times using the National Household Travel Survey, a telephone survey administered by the US Department of Transportation to examine travel behavior in the United States.

RESULTS

People are more likely to transit walk if they are from lower income households, are non-White, and live in large urban areas with access to rail systems. Transit walkers in large urban areas with a rail system were 72% more likely to transit walk 30 minutes or more per day than were those without a rail system. From 2001 to 2009, the estimated number of transit walkers rose from 7.5 million to 9.6 million (a 28% increase); those whose transit-associated walking time was 30 minutes or more increased from approximately 2.6 million to 3.4 million (a 31% increase).

CONCLUSIONS

Transit walking contributes to meeting physical activity recommendations. Study results may contribute to transportation-related health impact assessment studies evaluating the impact of proposed transit systems on physical activity, potentially influencing transportation planning decisions.

Impact of 2003 Power Outages on Public Health and Emergency Response

Introduction:

In 2003, a major power outage occurred in the midwest and northeast United States affecting some 50 million people. The power outages affected multiple systems in state and local municipalities and, in turn, affected public health.

Methods:

Semi-structured interviews were conducted using open-ended questionnaires, with a convenience sample of state- and locally selected subject matter experts from Ohio, Michigan, and New York. Respondents were interviewed in groups representing one of five areas of interest, including: (1) emergency preparedness; (2) hospital and emergency medical services; (3) municipal environmental systems; (4) public health surveillance and epidemiology; and (5) psychosocial and behavioral issues. The reported positive and negative impacts of the power outage on public health, medical services, and emergency preparedness and response were documented. Responses were categorized into common themes and recommendations were formulated.

Results:

The amount of time that the respondents' locations were without power ranged from <1 hour to 52 hours. Many common themes emerged from the different locations, including communications failures, alternate power source problems, manpower and training issues, and psychosocial concerns. There was minimal morbidity and mortality reported that could be attributed to the event.

Conclusion:

Power outages negatively impacted multiple municipal infrastructures, and affected medical services, emergency response, and public health efforts. Previous federal funding positively impacted public health and emergency response capabilities. Recommendations were made based upon the common themes identified by the respondents.

Recommendations may assist state and local health departments, medical service providers, and emergency responders in planning for future power outage problems.

Health impact assessment of the Atlanta BeltLine

BACKGROUND

Although a health impact assessment (HIA) is a tool that can provide decision makers with recommendations to promote positive health impacts and mitigate adverse health impacts of proposed projects and policies, it is not routinely conducted on most major projects or policies.

PURPOSE

To make health a decision criterion for the Atlanta BeltLine, a multibillion-dollar transit, trails, parks, and redevelopment project.

METHODS

An HIA was conducted in 2005-2007 to anticipate and influence the BeltLine's effect on health determinants.

RESULTS

Changes in access and equity, environmental quality, safety, social capital, and physical activity were forecast, and steps to maximize health benefits and reduce negative effects were recommended. Key recommendations included giving priority to the construction of trails and greenspace rather than residential and retail construction, making health an explicit goal in project priority setting, adding a public health professional to decision-making boards, increasing the connectivity between the BeltLine and civic spaces, and ensuring that affordable housing is built. BeltLine project decision makers have incorporated most of the HIA recommendations into the planning process. The HIA was cited in the awarding of additional funds of $7,000,000 for brownfield clean-up and greenspace development. The project is expected to promote the health of local residents more than in the absence of the HIA.

CONCLUSIONS

This report is one of the first HIAs to tie specific assessment findings to specific recommendations and to identifiable impacts from those recommendations. The lessons learned from this project may help others engaged in similar efforts.

Walking and cycling to health: a comparative analysis of city, state, and international data

OBJECTIVES

We sought to determine the magnitude, direction, and statistical significance of the relationship between active travel and rates of physical activity, obesity, and diabetes.

METHODS

We examined aggregate cross-sectional health and travel data for 14 countries, all 50 US states, and 47 of the 50 largest US cities through graphical, correlation, and bivariate regression analysis on the country, state, and city levels.

RESULTS

At all 3 geographic levels, we found statistically significant negative relationships between active travel and self-reported obesity. At the state and city levels, we found statistically significant positive relationships between active travel and physical activity and statistically significant negative relationships between active travel and diabetes.

CONCLUSIONS

Together with many other studies, our analysis provides evidence of the population-level health benefits of active travel. Policies on transport, land-use, and urban development should be designed to encourage walking and cycling for daily travel.

A model curriculum for a course on the built environment and public health: training for an interdisciplinary workforce

Despite growing evidence of the direct and indirect effects of the built environment on public health, planners, who shape the built environment, and public health professionals, who protect the public's health, rarely interact. Most public health professionals have little experience with urban planners, zoning boards, city councils, and others who make decisions about the built environment. Likewise, few planners understand the health implications of design, land use, or transportation decisions. One strategy for bridging this divide is the development of interdisciplinary courses in planning and public health that address the health implications of the built environment. Professional networking and Internet-based searches in 2007 led to the identification of six primarily graduate-level courses in the U.S. that address the links between the built environment and public health. Common content areas in most of the identified courses included planning and public health histories, health disparities, interdisciplinary approaches, air and water quality, physical activity, social capital, and mental health. Instructors of these courses collaborated on course content, assignments, and evaluations to develop a model curriculum that follows an active learning-centered approach to course design. The proposed model curriculum is adaptable by both planning and public health departments to promote interdisciplinary learning. Results show that students gain planning and public health perspectives through this instruction, benefiting from active-learning opportunities. Faculty implementation of the proposed interdisciplinary model curriculum will help bridge the divide between the built environment and public health and enable both planners and public health professionals to value, create, and promote healthy environments.

The built environment, climate change, and health: opportunities for co-benefits

The earth's climate is changing, due largely to greenhouse gas emissions resulting from human activity. These human-generated gases derive in part from aspects of the built environment such as transportation systems and infrastructure, building construction and operation, and land-use planning. Transportation, the largest end-use consumer of energy, affects human health directly through air pollution and subsequent respiratory effects, as well as indirectly through physical activity behavior. Buildings contribute to climate change, influence transportation, and affect health through the materials utilized, decisions about sites, electricity and water usage, and landscape surroundings. Land use, forestry, and agriculture also contribute to climate change and affect health by increasing atmospheric levels of carbon dioxide, shaping the infrastructures for both transportation and buildings, and affecting access to green spaces. Vulnerable populations are disproportionately affected with regard to transportation, buildings, and land use, and are most at risk for experiencing the effects of climate change. Working across sectors to incorporate a health promotion approach in the design and development of built environment components may mitigate climate change, promote adaptation, and improve public health.

Use of health impact assessment in the U.S.: 27 case studies, 1999-2007

OBJECTIVES

To document the growing use in the United States of health impact assessment (HIA) methods to help planners and others consider the health consequences of their decisions.

METHODS

Using multiple search strategies, 27 HIAs were identified that were completed in the U.S. during 1999-2007. Key characteristics of each HIA were abstracted from published and unpublished sources.

RESULTS

Topics examined in these HIAs ranged from policies about living wages and after-school programs to projects about power plants and public transit. Most HIAs were funded by local health departments, foundations, or federal agencies. Concerns about health disparities were especially important in HIAs on housing, urban redevelopment, home energy subsidies, and wage policy. The use of quantitative and nonquantitative methods varied among HIAs. Most HIAs presented recommendations for policy or project changes to improve health. Impacts of the HIAs were infrequently documented.

CONCLUSIONS

These completed HIAs are useful for helping conduct future HIAs and for training public health officials and others about HIAs. More work is needed to document the impact of HIAs and thereby increase their value in decision-making processes.

Urban planning and public health at CDC

Urban planning, also called city and regional planning, is a multidisciplinary field in which professionals work to improve the welfare of persons and communities by creating more convenient, equitable, healthful, efficient, and attractive places now and for the future. The centerpiece of urban planning activities is a "master plan," which can take many forms, including comprehensive plans, neighborhood plans, community action plans, regulatory and incentive strategies, economic development plans, and disaster preparedness plans. Traditionally, these plans include assessing and planning for community needs in some or all of the following areas: transportation, housing, commercial/office buildings, natural resource utilization, environmental protection, and health-care infrastructure. Urban planning and public health share common missions and perspectives. Both aim to improve human well-being, emphasize needs assessment and service delivery, manage complex social systems, focus at the population level, and rely on community-based participatory methods. Both fields focus on the needs of vulnerable populations. Throughout their development, both fields have broadened their perspectives. Initially, public health most often used a biomedical model (examining normal/abnormal functioning of the human organism), and urban planning often relied on a geographic model (analysis of human needs or interactions in a spatial context). However, both fields have expanded their tools and perspectives, in part because of the influence of the other. Urban planning and public health have been intertwined for most of their histories. In 1854, British physician John Snow used geographic mapping of an outbreak of cholera in London to identify a public water pump as the outbreak's source. Geographic analysis is a key planning tool shared by urban planning and public health. In the mid-1800s, planners such as Frederick Law Olmsted bridged the gap between the fields by advancing the concept that community design contributes to physical and mental health; serving as President Lincoln's U.S. Sanitary Commission Secretary; and designing hundreds of places, including New York's Central Park. By 1872, the disciplines were so aligned that two of the seven founders of the American Public Health Association were urban designers (an architect and a housing specialist). In 1926, the U.S. Supreme Court, in validating zoning and land-use law as a legal government authority in Village of Euclid v. Ambler Realty, cited the protection of public health as part of its justification. Other connections have included 1) pioneering urbanist Jane Jacobs, who during the 1960s, called for community design that offered safe and convenient options for walking, biking, and impromptu social interaction; and 2) the Healthy Cities movement, which began in Europe and the United States during the 1980s and now includes projects in approximately 1,000 cities that in various ways highlight the role of health as much more than the presence of medical care.

Growing the field of health impact assessment in the United States: an agenda for research and practice

Health impact assessment (HIA) methods are used to evaluate the impact on health of policies and projects in community design, transportation planning, and other areas outside traditional public health concerns. At an October 2004 workshop, domestic and international experts explored issues associated with advancing the use of HIA methods by local health departments, planning commissions, and other decisionmakers in the United States. Workshop participants recommended conducting pilot tests of existing HIA tools, developing a database of health impacts of common projects and policies, developing resources for HIA use, building workforce capacity to conduct HIAs, and evaluating HIAs. HIA methods can influence decisionmakers to adjust policies and projects to maximize benefits and minimize harm to the public's health.

Assessing the walkability of the workplace: a new audit tool

PURPOSE

Walking can be incorporated into most people's daily routines if the process is made convenient by a well-designed built environment. Walkability rarely is assessed in the workplace, where adults spend much of their time.

METHODS

From existing tools, we developed an instrument to audit walkability at a single government agency's facilities, which were located in multiple states. We used a five-point scale to evaluate nine elements of walkability: pedestrian facilities, pedestrian-vehicle conflicts, crosswalks, route maintenance, walkway width, roadway buffer, universal accessibility, aesthetics, and shade. Weighted scores ranged from 20 to 39 (poor), to 40 to 69 (fair), to 70 to 100 (good).

RESULTS

Of 79 walking route segments surveyed on 10 agency campuses, 34% were rated poor, 32% fair, and 34% good. Repeat assessment of 20 walking route segments by three independent observers yielded similar scores.

CONCLUSION

Facility planners may find this walkability instrument useful in identifying and eliminating barriers to convenient walking opportunities in workplaces such as office parks and university campuses.

Walking to public transit: steps to help meet physical activity recommendations

BACKGROUND

Nearly half of Americans do not meet the Surgeon General's recommendation of > or =30 minutes of physical activity daily. Some transit users may achieve 30 minutes of physical activity daily solely by walking to and from transit. This study estimates the total daily time spent walking to and from transit and the predictors of achieving 30 minutes of physical activity daily by doing so.

METHODS

Transit-associated walking times for 3312 transit users were examined among the 105,942 adult respondents to the 2001 National Household Travel Survey, a telephone-based survey sponsored by the U.S. Department of Transportation to assess American travel behavior.

RESULTS

Americans who use transit spend a median of 19 minutes daily walking to and from transit; 29% achieve > or =30 minutes of physical activity a day solely by walking to and from transit. In multivariate analysis, rail users, minorities, people in households earning <$15,000 a year, and people in high-density urban areas were more likely to spend > or =30 minutes walking to and from transit daily.

CONCLUSIONS

Walking to and from public transportation can help physically inactive populations, especially low-income and minority groups, attain the recommended level of daily physical activity. Increased access to public transit may help promote and maintain active lifestyles. Results from this study may contribute to health impact assessment studies (HIA) that evaluate the impact of proposed public transit systems on physical activity levels, and thereby may influence choices made by transportation planners.

Walking to public transit: steps to help meet physical activity recommendations

BACKGROUND

Nearly half of Americans do not meet the Surgeon General's recommendation of > or =30 minutes of physical activity daily. Some transit users may achieve 30 minutes of physical activity daily solely by walking to and from transit. This study estimates the total daily time spent walking to and from transit and the predictors of achieving 30 minutes of physical activity daily by doing so.

METHODS

Transit-associated walking times for 3312 transit users were examined among the 105,942 adult respondents to the 2001 National Household Travel Survey, a telephone-based survey sponsored by the U.S. Department of Transportation to assess American travel behavior.

RESULTS

Americans who use transit spend a median of 19 minutes daily walking to and from transit; 29% achieve > or =30 minutes of physical activity a day solely by walking to and from transit. In multivariate analysis, rail users, minorities, people in households earning <$15,000 a year, and people in high-density urban areas were more likely to spend > or =30 minutes walking to and from transit daily.

CONCLUSIONS

Walking to and from public transportation can help physically inactive populations, especially low-income and minority groups, attain the recommended level of daily physical activity. Increased access to public transit may help promote and maintain active lifestyles. Results from this study may contribute to health impact assessment studies (HIA) that evaluate the impact of proposed public transit systems on physical activity levels, and thereby may influence choices made by transportation planners.

The impact of community design and land-use choices on public health: a scientific research agenda

The design of a community's built environment influences the physical and mental health of its residents. Because few studies have investigated this relationship, the Centers for Disease Control and Prevention hosted a workshop in May 2002 to help develop a scientific research agenda on these issues. Workshop participants' areas of expertise included physical activity, injury prevention, air pollution, water quality, urban planning, transportation, architecture, epidemiology, land use, mental health, social capital, housing, and social marketing. This report describes the 37 questions in the resulting research agenda. The next steps are to define priorities and obtain resources. The proposed research will help identify the best practices for designing new communities and revitalizing old ones in ways that promote physical and mental health.

Zoning out crime and improving community health in Sarasota, Florida: "Crime Prevention Through Environmental Design"

Sarasota, Fla, used Crime Prevention Through Environmental Design (CPTED) principles to guide revitalization efforts in its crime-ridden North Trail area. A team of city planners, police officers, and architects examined land use and crime data and sought input from local businesses, residents, and community leaders. Beginning in 1990, interventions included increased police patrols to reduce prostitution and the creation of a new zoning district to encourage area redevelopment based on CPTED principles. Compared with the rest of Sarasota, from 1990 to 1998 the North Trail Corridor experienced decreases in calls for police service (P <.005), crimes against persons and property (P = not significant), and prostitution (P <.05). These results suggest that community design may be a useful tool for decreasing crime and improving community health.

Planning against biological terrorism: lessons from outbreak investigations

We examined outbreak investigations conducted around the world from 1988 to 1999 by the Centers for Disease Control and Prevention’s Epidemic Intelligence Service. In 44 (4.0%) of 1,099 investigations, identified causative agents had bioterrorism potential. In six investigations, intentional use of infectious agents was considered. Healthcare providers reported 270 (24.6%) outbreaks and infection control practitioners reported 129 (11.7%); together they reported 399 (36.3%) of the outbreaks. Health departments reported 335 (30.5%) outbreaks. For six outbreaks in which bioterrorism or intentional contamination was possible, reporting was delayed for up to 26 days. We confirmed that the most critical component for bioterrorism outbreak detection and reporting is the frontline healthcare profession and the local health departments. Bioterrorism preparedness should emphasize education and support of this frontline as well as methods to shorten the time between outbreak and reporting.

Planning against biological terrorism: lessons from outbreak investigations

We examined outbreak investigations conducted around the world from 1988 to 1999 by the Centers for Disease Control and Prevention's Epidemic Intelligence Service. In 44 (4.0%) of 1,099 investigations, identified causative agents had bioterrorism potential. In six investigations, intentional use of infectious agents was considered. Healthcare providers reported 270 (24.6%) outbreaks and infection control practitioners reported 129 (11.7%); together they reported 399 (36.3%) of the outbreaks. Health departments reported 335 (30.5%) outbreaks. For six outbreaks in which bioterrorism or intentional contamination was possible, reporting was delayed for up to 26 days. We confirmed that the most critical component for bioterrorism outbreak detection and reporting is the frontline healthcare profession and the local health departments. Bioterrorism preparedness should emphasize education and support of this frontline as well as methods to shorten the time between outbreak and reporting.

Use of epidemiology in clinical medical publications, 1983-1999: a citation analysis

Epidemiologists respond to the information needs of health professionals. Although medical professionals are routine users of epidemiologic information, use within medical specialties varies remarkably. To explore the variation in use of epidemiologic information across clinical medical specialties, the authors examined the scientific literature by analyzing patterns of citation of specific journal articles to and by the American Journal of Epidemiology (AJE). A total of 178,396 journal citations to and 126,478 citations by AJE were made from 1983 through 1999; citations were classified according to the subject category of the referencing or referenced journal. Clinical medical journals accounted for 50.6% of all citations combined (both referenced to and referenced by AJE); general/internal medicine (17.9%), cancer (10.4%), and cardiovascular (4.9%) journals had the highest number of citations. Few citations to and by AJE were found in publications specializing in dermatology, gastroenterology, orthopedics, allergy, anesthesiology, surgery, rheumatology, and other areas. Trend patterns of citations between clinical and epidemiologic literature indicated that citations to the fields of cardiovascular disease and cancer are increasing, whereas citations regarding pediatrics have remained stable. This analysis suggests an increasing interchange of information between epidemiologists and clinicians specializing in certain fields, uncovering potential research opportunities for epidemiologists.

Epidemiologic response to anthrax outbreaks: field investigations, 1950-2001

We used unpublished reports, published manuscripts, and communication with investigators to identify and summarize 49 anthrax-related epidemiologic field investigations conducted by the Centers for Disease Control and Prevention from 1950 to August 2001. Of 41 investigations in which Bacillus anthracis caused human or animal disease, 24 were in agricultural settings, 11 in textile mills, and 6 in other settings. Among the other investigations, two focused on building decontamination, one was a response to bioterrorism threats, and five involved other causes. Knowledge gained in these investigations helped guide the public health response to the October 2001 intentional release of B. anthracis, especially by addressing the management of anthrax threats, prevention of occupational anthrax, use of antibiotic prophylaxis in exposed persons, use of vaccination, spread of B. anthracis spores in aerosols, clinical diagnostic and laboratory confirmation methods, techniques for environmental sampling of exposed surfaces, and methods for decontaminating buildings.

U.S. medical students' rotations in epidemiology and public health at state and local health departments

Elective rotations in health departments expose medical students to public health practice and career opportunities in applied epidemiology and preventive medicine. State and county epidemiologists and health officers can serve as excellent role models for medical students. In 2000-2001, the authors identified such electives by consulting medical schools' Web sites and by contacting state epidemiologists, teachers of preventive medicine, and medical school associate deans. The authors found that electives were offered in nine state and five local health departments; these are described in detail. Those electives usually focused on infectious diseases, involved students in outbreak investigations when possible, lasted four or more weeks, were open to other students and medical residents, and were overseen by a health department preceptor with a medical school faculty appointment and a commitment to train students. Some electives included more didactic components, encouraged the student to publish a manuscript, or were coordinated by a preventive medicine residency director. The authors observe that health departments can benefit from training enthusiastic medical students via such electives; these students bring fresh ideas to the departments. Medical school catalogs, Web sites, and word of mouth are important means for promoting these electives. Ideally, in the future every medical school will offer a state or local health department elective so that all medical students will become aware of epidemiology and public health career options. The electives reported in this article can help guide additional medical schools and health departments as they initiate such rotations.

Epidemic intelligence service of the Centers for Disease Control and Prevention: 50 years of training and service in applied epidemiology

The Epidemic Intelligence Service (EIS) was established in 1951 at the Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, as a combined training and service program in the practice of applied epidemiology. Since then, nearly 2,500 professionals have served in this 2-year program of the US Public Health Service. The experience of an EIS Officer has been modified because of the increased need for more sophisticated analytical methods and the use of microcomputers, as well as CDC's expanded mission into chronic diseases, environmental health, occupational health, and injury control. Officers who have entered the EIS in the past 20 years are more likely than their predecessors to stay in public health either at the federal level or in state and local health departments. The EIS Program continues to be a critical source for health professionals trained to respond to the demand for epidemiologic services both domestically and internationally.

Hospitalization due to injuries in the military. Evaluation of current data and recommendations on their use for injury prevention

INTRODUCTION

Injuries inflict the largest health impact on military populations in terms of hospitalization. Hospitalized injuries result in the largest direct costs of medical care and the most lost workdays, include the largest proportion of disabling injuries, and have the largest impact on troop readiness. Efforts are now beginning to focus on how injury surveillance data can be used to reduce the burden of injuries. This article examines the value of administrative hospital discharge databases in the military for routine injury surveillance, as well as investigation of specific injury problems, including musculoskeletal conditions that are frequently sequelae of old injuries.

METHODS

Data on hospitalizations for injuries and musculoskeletal conditions were obtained from separate administrative agencies for the Army, Navy, and Air Force. Since 1989, a Standard Inpatient Data Record (SIDR) has been used to ensure uniformity in data collection across the services utilizing standard ICD-9 codes. Cause of injury was coded using special military cause codes (STANAG codes) developed by NATO. Data were analyzed on both nature and cause of injury. Denominator data on troop strength were obtained from the Defense Manpower Data Center (DMDC).

RESULTS

Hospital records data indicate that injuries and musculoskeletal conditions have a bigger impact on the health of service members and military/combat readiness than any other ICD-9 Principal Diagnostic Group (higher incidence and higher noneffective rate or days not available for duty). Hospitalization rates for injury appeared to decline for all services from 1980 to 1992. In 1992, service-specific injury hospitalization rates per 1000 person-years were 15.6 for the Army, 8.3 for the Navy (enlisted only), and 7.7 for the Air Force, while the corresponding hospitalization rate for musculoskeletal conditions was higher in all three services: 28.1, 9.7, and 12.0, respectively.

CONCLUSIONS

Military hospital discharge databases are an important source of information on severe injuries and are more comprehensive than civilian databases. They include detailed injury information that can be useful for injury prevention and surveillance purposes. Specifically, it can be used to identify high-risk groups or hazards for targeting prevention resources. These may vary widely by service, rank, and job tasks. Hospital discharge data can also be used to evaluate the effectiveness of interventions for reducing injury rates. Recommendations were submitted to further improve data collection and the use of hospital data for research and injury prevention.

An elective rotation in applied epidemiology with the Centers for Disease Control and Prevention (CDC), 1975-1997

INTRODUCTION

To increase awareness of and interest in public health and epidemiology, CDC initiated an elective in epidemiology and public health for senior medical students in 1975 and for veterinary students in 1982.

METHODS

A review of CDC records to describe participation in the elective, to assess whether students subsequently enrolled in another CDC training program, the Epidemic Intelligence Service (EIS), and, if enrolled, employment status following EIS. A review of documentation of board certification in preventive medicine to determine how many participants later chose this specialty, one indicator of public health and prevention as a career choice.

RESULTS

From 1975 through 1997, 632 students participated in the elective. Of these, 438 (69%) were assigned to infectious disease areas, 95 (15%) to environmental health, 59 (9%) to chronic disease, and 40 (7%) to other areas. Students participated in at least 278 official investigations of important public health problems including infectious disease outbreaks, natural disasters, chronic disease problems and access to health care. Of 530 students who had completed the elective through June 1995, 91 (17%) were enrolled in EIS by July 1997. Of 83 completing EIS by July 1997, 65 (78%) had continued in public health careers: 35 with CDC; 17 with local or state health departments; 7 with other federal agencies; 4 in academic public health; and 2 in international health. Of those not enrolling in EIS, at least 5% were certified by the American Board of Preventive Medicine, compared with 34% of those completing EIS.

CONCLUSION

An elective rotation in public health and applied epidemiology is valuable in introducing future physicians and veterinarians to the practice of public health, and can provide important role models for encouragement to pursue careers in public health.

Infant mechanical suffocation deaths in the United States, 1980-1997

PURPOSE

To document specific patterns and products associated with mechanical suffocation among infants younger than 13 months of age for the period 1980 to 1997.

METHODOLOGY

A total 2178 case summaries from the US Consumer Product Safety Commission's Death Certificate File were reviewed. A computerized database was created for information about the infants, products, and patterns of suffocation. The relationships among products, patterns, and age groups were analyzed by chi2. Thirty-eight investigations conducted on a subset of cases involving cribs were reviewed for details on crib age, structural integrity, and compliance with the federal crib regulation. Mortality rates were calculated based on the US population younger than 1 year old.

RESULTS

The most frequent causes of suffocation were 1) wedging between a bed or mattress and a wall and 2) oronasal obstruction by plastic bag. Patterns of suffocation were significantly related to age group, but not to sex. Pattern-specific mortality rates comparing three time frames for the the 16-year period from 1980 to 1995 showed continued increases for overlain and oronasal obstruction; an increase followed by a plateau for wedging, a decrease for hanging, and no substantial change for entrapment with suspension.

CONCLUSIONS

Suffocation hazards presented by beds, bedding, pillows, and plastic bags continue to be underrecognized by parents and caregivers. Bed-sharing and use of adult beds for infants should be discouraged. Only complying cribs should be used and maintained properly to ensure structural integrity. Suffocation deaths involving plastics should be investigated to determine the specific material characteristics and use patterns to design more effective interventions than selective labeling.