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.

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.

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.

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.

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.

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.

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.

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.

The 2019 Conference on Health and Active Transportation: Research Needs and Opportunities.

Active transportation (AT) is widely viewed as an important target for increasing participation in aerobic physical activity and improving health, while simultaneously addressing pollution and climate change through reductions in motor vehicular emissions. In recent years, progress in increasing AT has stalled in some countries and, furthermore, the coronavirus (COVID-19) pandemic has created new AT opportunities while also exposing the barriers and health inequities related to AT for some populations. This paper describes the results of the December 2019 Conference on Health and Active Transportation (CHAT) which brought together leaders from the transportation and health disciplines. Attendees charted a course for the future around three themes: Reflecting on Innovative Practices, Building Strategic Institutional Relationships, and Identifying Research Needs and Opportunities. This paper focuses on conclusions of the Research Needs and Opportunities theme. We present a conceptual model derived from the conference sessions that considers how economic and systems analysis, evaluation of emerging technologies and policies, efforts to address inclusivity, disparities and equity along with renewed attention to messaging and communication could contribute to overcoming barriers to development and use of AT infrastructure. Specific research gaps concerning these themes are presented. We further discuss the relevance of these themes considering the pandemic. Renewed efforts at research, dissemination and implementation are needed to achieve the potential health and environmental benefits of AT and to preserve positive changes associated with the pandemic while mitigating negative ones.

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.

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.

Optimizing the health benefits of climate change policies using health impact assessment.

Health impact assessment (HIA) is a tool that can be used to examine the potential health impacts of proposed climate change policies and offer recommendations to promote health and mitigate adverse health consequences of such policies. We used an HIA database, a literature search, and expert consultation to identify 12 HIAs of the proposed climate change policies from six states in the U.S. These policies included cap-and-trade legislation, heat-wave and sea-level-rise mitigation and adaptation, transportation policy impacts of climate change, carbon-reduction strategy scenarios, soil- and water-conservation strategies, urban forest canopy for climate adaptation, overheating buildings, and regional transportation plan and sustainable communities strategies. In four descriptive summaries, we found that HIAs foster stakeholder engagement and provide useful health-promoting recommendations. HIAs can facilitate cross-sector collaboration, help optimize the health co-benefits of climate change policies, and raise awareness among decision makers of health impacts of those proposed policies.

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.

Investment in safe routes to school projects: public health benefits for the larger community.

INTRODUCTION: The Safe Routes to School (SRTS) program is designed to encourage active and safe transportation for children to school. This report examines the potential broader impact of these programs on communities within 0.5 mile (0.8 km) of schools. METHODS: We used a geographic information system to generate estimates of the land area within 0.5 mile of public schools in 4 U.S. Census-defined categories: 37 large urban areas, 428 small urban areas, 1088 metropolitan counties (counties in metropolitan statistical areas excluding the urban areas), and 2048 nonmetropolitan counties. We estimated population at the county level or at the U.S. Census-defined urban-area level using data from the 2000 U.S. Census. RESULTS: In large urban areas, 39.0% of the land area was within 0.5 mile of a public school, and in small urban areas, 26.5% of the land area was within 0.5 mile of a public school. An estimated 65.5 million people in urban areas could benefit from SRTS projects. In nonurban areas, 1% or less of land is within 0.5 mile of a public school. CONCLUSION: Results suggest that SRTS projects in urban areas can improve the walking and bicycling environment for adults as well as for children, the target users. Investment in SRTS can contribute to increased physical activity among children and adults.