What is Smart Growth?

1. Assessing the Impact of Community Policy on Physical Activity and Health with Health Impact Analysis Candace Rutt, Ph.D.Division of Nutrition and Physical ActivityNational Canter for Chronic Disease Prevention and Health PromotionCenters for Disease Control and Prevention

2. What is Smart Growth? • Greater density • Greater land-use mix • Greater connectivity • Range of housing opportunities • Strong “sense of place” • Pedestrian friendly • Numerous transportation choices • Preserve exisiting greenspace

3. How Does the Built Environment Impact Health? • Physical activity (recreation and transportation) • Social Capital • Air quality • Water quality • Mental health

4. TRB/IOM • Changing the built environment to make it more activity conducive is desirable “even in the absence of the goal of increasing physical activity because of their positive social effects on neighborhood safety, sense of community, and quality of life”

5. Health Impact Assessment (HIA) A combination of procedures, methods, and tools by which a policy, program, or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population (Gothenburg consensus statement, 1999)

6. Health Impact Assessment • Tool to objectively evaluate a project/policy before it is implemented • Provide recommendations to increase positive and minimize negative health outcomes • Encompasses a variety of methods and tools • Qualitative and quantitative • Community input and/or expert opinion • Has been performed extensively in Europe, Canada and other countries • Regulatory and voluntary basis

7. Potential Contributions of HIA • Bring potential health impacts to the attention of policy-makers, particularly when they are not already recognized or are otherwise unexpected • Highlight differential effects on population sub-groups

8. Using HIA for Projects vs. Policies • Projects: Physical developments (highway, rail line, park, trail, housing complex, etc) • Affect smaller population • More detailed plans • Easier to define target population, stakeholders, and perform impact estimation • Policies: Set of rules and regulations that govern activities and budget expenditures (zoning, farm subsidies, living wage law, etc.) • Affect larger population • Greater impact on public health • Health impacts may be harder to quantify

9. HIA Level of Complexity • Qualitative – describe direction but not magnitude of predicted results • Easy to predict; hard to use in cost/benefit models • Example: Build a sidewalk and people will walk more • Quantitative – describe direction and magnitude of predicted results • Difficult to obtain data; useful for cost/benefit models • Hypothetical example: Build a sidewalk and 300 people who live within 200 yards of location will walk an average of 15 extra minutes per day

10. Voluntary vs. Regulatory • Voluntary (a tool used by a health officer to inform a planning commission) • Simpler, less expensive, less litigious • Less likely to be used if not required • More politically acceptable • Regulatory (modeled on a required environmental impact statement) • More complex, more expensive, more litigious • More likely to be used if required • Less politically acceptable

11. Community Involvement in Conducting an HIA • Increases community buy-in to project • Helps identify social issues as well as health issues • Commonly used in HIAs in Europe • May add substantially to time and resources needed to conduct HIA

12. HIA efforts outside the U.S. • Extensive work for nearly a decade • Increasing interest • Usually focused on local projects • Often linked to EIA or focused on facilitating community participation

13. HIA in the U.S. • To date only a handful have been completed • Voluntary basis • Very few people currently trained to complete HIAs • However, there is a lot of interest in HIA (APA, NACCHO, CDC, RWJF, FHWA, ARC, CQGRD)

14. Relationship of HIA to Environmental Impact Assessment • EIA • Regulatory • Thousands conducted each year • HIA components could logically fit within an EIA

15. Learning from EIA • But EIAs… • Long, complex documents • Process is time-consuming and expensive • Often litigious process • Tends to focus on projects, not policies • Tends to stop short of considering health outcomes

16. Steps in Conducting a Health Impact Assessment • Screening • Identify projects or policies for which an HIA would be useful • Scoping • Identify which health impacts should be included • Risk assessment • Identify how many and which people may be affected • Assess how they may be affected • Reporting of results to decision-makers • Create report suitable in length and depth for audience • Evaluationof impact on actual decision process

17. Screening – When to do HIA • In general, HIA is most useful • For policy-decisions outside health sector • When there are likely to be significant health impacts that are not already being considered • The HIA can be completed before key decisions are made and stakeholders are likely to use information • There are sufficient data and resources available

18. Scoping - Health Impacts to Consider in an HIA • Physical activity, obesity, CVD • Air quality, asthma, other respiratory diseases • Water quality, waterborne diseases • Food quality, food borne diseases, nutrition • Motor vehicle, pedestrian and other injuries • Accessibility for persons with disabilities • Noise • Mental health • Social capital • Social equity, environmental justice

19. Risk Assessment • Logic frameworks • Assessing research evidence • Qualitative vs. quantitative outcomes • Calculate estimates of morbidity and mortality • Cost-effectiveness when feasible

20. Examine Feasibility of HIA is U.S. • Received funding from RWJF to complete two case studies of HIA • Worked with UCLA to complete these case studies

21. Screening – Initial List of HIAs • General Walkability • Walk to School • Trails (recreation and transportation) • Active Commuting to Work • Worksite Interventions • Mass Transit • Zoning • Location Efficient Mortgage • Buford Highway • Beltine

22. Screening - Selection Criteria • Specific enough to create quantitative estimates • Impact physical activity • High quality data • Not overly complicated • Political interest • Target at risk populations • Foundation for other HIAs • Generalizability

23. Screening - Selecting Case Studies • Walk-to-school HIA • Natomas school district in Sacramento, CA • Buford Highway HIA • Highway redevelopment in Atlanta, GA

24. Screening - Site Selection • Sacramento was selected because: • Program already in-place, which facilitates determination of project and population parameters • Program staff interested in cooperating with research team • Minimal seasonality • Ethnically-mixed, modest income population • 24% of students currently walking to school

25. Diverse Student Populationin Natomas Schools

26. Streets around the target schools

27. Scoping - Create Logic Model Policy Proximal Intermediate Health Impacts Impacts Outcomes Education: safety training Air and noise pollution Asthma Social norms Obesity walkability Engineering: improve pedestrian facilities, traffic calming Physical activity (long-term) CVD risk factors safety Perceptions of risk Insulin sensitivity Enforcement: increase police presence, crossing guards Motor vehicle use cancers osteoporosis Physical activity (short-term) Dedicated resources: walking school busses Mental health Injury

28. Risk Assessment • More thorough literature review of all identified proximal, intermediate, and health outcomes • Determine which health impacts will be done qualitatively versus quantitatively • Physical activity • BMI • Gather data and perform quantitative analysis

29. Risk Assessment – Baseline Data

30. Risk Assessment – Baseline Data

31. Risk Assessment – Estimated Impact

32. Risk Assessment – Expected Outcomes on Physical Activity • 39% of students are expected to walk after the intervention (64% increase) • Avg. of 15 min/day additional walking

33. Risk Assessment – Expected Outcomes for BMI * estimates from Berkey et al, 2003

34. Increase in Daily Hours of PA by Number of Days Walked to School 0.60 0.45 Average Daily Hours of PA 0.30 0.15 0.00 1 2 3 4 5 # Days Walked to School Number of days walked to school vs. average daily hours of physical activity among participants; Assuming 24% baseline walking, 0.6 miles one-way & 64% increase in walking due to intervention

35. Decrease in BMI (overweight) by Days Walked to School Number of days walked to school vs. average decrease in BMI among obese participants; Assuming 24% baseline walking, 0.6 miles one-way & 64% increase in walking due to intervention

36. Increase in Daily Hours of PA by Intervention Effect

37. Traffic-related injury • Walk-to-school programs can actually decrease pedestrian injury rates: • No injuries reported in first two years of Marin County program • Orange County program reported a decrease in injury rates • Estimating changes pedestrian injury rates not feasible for small numbers/small areas

38. Air pollution:Expected Impacts • Walk-to-school programs may increase or decrease exposure to air pollution depending on • Current mode • Exposure to several pollutants 50-400x times higher inside diesel school buses than outside(Sabin, Behrentz, Winer et al., 2003) • Inhalation rates • Duration of trip • Traffic density along walking routes • Time and season • Marginal increase or decrease is probably small relative to PA-related impacts

39. Assumptions for Kids Walk • Assume a best-case scenario modeled after Marin county (different demographics) • Relationship between time spent walking and BMI from Berkey et al (2003) apply to younger children • 1 year time horizon for effects • Average distance walked to school is 0.6 miles (NHTS, 2001) • Average walking speed is 1.8 miles/hour

40. Implications of Case Study • Walk-to-school programs are important, but only part of the solution of childhood obesity • HIA can either temper expectations, provide justification for termination, or provide strong support for programs/policies

41. Key Challenges of HIA • Uncertainties (data, models, policy) • Timeliness • Relevance to stakeholders and decision makers

42. Summary • HIA is a new and evolving science in the U.S., however it is a promising new approach to quantify health impacts of a wide variety of policies and projects • HIA provides only one piece of information (health) in complex decisions and stakeholders may have different priorities • HIA provides an outlet for health to be appropriately factored into complex decisions