The North Central Texas Council of Governments (NCTCOG), the metropolitan planning organization for the Dallas-Fort Worth region, has integrated health into its transportation planning process, including its most recent long-range transportation plan. By considering health in the transportation planning process, NCTCOG recognized the health benefits of initiatives it was already pursuing, such as those related to safety and air quality. NCTCOG is also using data on health-related indicators to assess the health of counties today and to measure changes in the future.
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Considering existing health efforts
In the summer of 2013, NCTCOG began to think through how many of its transportation initiatives and policies related to health. NCTCOG had completed an update of its long-range transportation plan, Mobility 2035, in June 2013, and wrote an internal white paper on the elements of the plan that impact health. The white paper framed transportation initiatives related to health as programs that would support sustainability, quality of life, and livable communities. Health-related programs in the plan included:
- Air quality. Through working with partners to adopt energy-efficient and low-emitting fleets, advancing clean technologies, and encouraging changes to daily behaviors, NCTCOG aimed to reduce emissions and improve air quality.
- Active transportation. The plan aimed to increase physical activity through developing bicycle and pedestrian facilities, including improving infrastructure near schools through the Safe Routes to Schools Program, and developing a regional “Veloweb” network of off-street shared-use paths.
- Sustainable development. The plan incorporates economic development, environmental protection, and social equity considerations into planning and programming. This includes a Sustainable Development Funding Program that allocates transportation funds to land-use projects that promote alternative transportation modes or reduced automobile use.
Health indicators and strategies
When it came time to develop its next long-range transportation plan, Mobility 2040, NCTCOG put a strong effort into incorporating health into its process. NCTCOG used resources developed by the Centers for Disease Control and Prevention (CDC) to evaluate how counties in the region compared to peer counties in terms of specific health indicators, and to identify strategies that NCTCOG was already pursuing that improve health outcomes.
NCTCOG collected data from the CDC’s Community Health Status Indicators dataset, which allowed them to move beyond the limited set of public health indicators they had used previously, such as those related to air quality, to a broader set of measures. Out of over 40 indicators included in the dataset, NCTCOG selected eight that it thought could be affected by transportation programs:
- Unhealthy ozone days;
- Unhealthy fine particulate matter (PM2.5) days;
- Motor vehicle deaths;
- Unintentional injury (including motor vehicle injuries);
- Living near highways;
- Access to parks; and
- Adult obesity.
Then, NCTCOG used the CDC data to compare how the 12 counties within the region were performing on these indicators as compared to peer counties.1 This analysis showed that, in general, many of the counties within the Dallas-Fort Worth region are performing the same or better than peer counties on the selected public health indicators. However, some of the counties scored worse than their peers on particular indicators, highlighting potential areas for improvement (see Figure 1).
NCTCOG also incorporated into Mobility 2040 six transportation strategies to improve health outcomes based on the CDC’s Transportation Health Impact Assessment Toolkit, which identifies transportation design and infrastructure strategies that promote positive health outcomes and/or reduce negative health outcomes. The strategies are:
- Reduce vehicle miles traveled (VMT);
- Expand public transportation;
- Promote active transportation;
- Incorporate healthy community design features;
- Improve safety for all users; and
- Ensure equitable access to transportation networks.
NCTCOG identified how the policies, programs, and initiatives included in Mobility 2040 support these six strategies, and summarized the findings in an appendix. For example, for the strategy of reducing VMT, Mobility 2040 includes policies and programs related to implementing travel demand management, such as an employer trip reduction program, a regional vanpool program, and park-and-ride facilities (see Figure 2). Related to active transportation, Mobility 2040 includes a goal of supporting the planning and design of a multimodal transportation network that promotes walking and bicycling as equals with other transportation modes. It also includes programs and activities that promote pedestrian and bicycle safety.
By applying the CDC indicators and strategies to its long-range transportation plan, NCTCOG was able to consider how many of the policies and programs throughout its plan support improved health outcomes, even if they do not explicitly focus on health.
|Reduce Vehicle Miles Traveled (VMT)|
|TDM3-001: Support the Congestion Management process, which includes explicit consideration and appropriate implementation of Travel Demand Management, Transportation System Management, and Intelligent Transportation Systems strategies during all stages of corridor development and operations.|
|TDM3-002: Support an integrated planning process that maximizes existing transportation system capacity before considering major capital infrastructure investment in the multimodal system.|
|TDM3-003: Request local agency staff and North Central Texas Council of Governments staff to meet with all major employers (defined as employers of 250 or more employees) to discuss and encourage the implementation of voluntary employer trip reduction programs.|
|TDM2-100: Employer Trip Reduction Program|
|TDM2-200: Regional Vanpool Program|
|TDM2-300: Park-and-Ride Facilities|
|TDM2-400: Transportation Management Associations|
|TSMO2-001: Intersection Improvement Program|
|TSMO2-003: Bottleneck Improvement Program|
|TSMO2-004: Special Events Management Program|
|TSMO2-005: Bottleneck Program for Regional Corridors|
|TSMO2-006: Intelligent Transportation Systems Implementation Program|
|TSMO2-007: Regional Intelligent Transportation Systems Architecture Program|
|TSMO2-008: Advanced Traveler Information System Implementation Program|
|TSMO2-009: Advanced Traffic Management System Implementation Program|
|TSMO2-010: Advanced Public Transportation System Implementation Program|
|TSMO2-011: Intelligent Transportation Systems Interoperability Program|
|FT3-007: Additional and improved interchanges, frontage roads, and auxiliary lanes should be considered and implemented as appropriate on all freeway/tollway facilities in order to accommodate a balance between mobility, access, operational, and safety needs.|
|SD3-001: Support mixed-use, infill, and transit-oriented developments that utilize system capacity, reduce vehicle miles of travel, and improve air quality through improved rail mobility and access management.|
By using data and resources developed by the CDC, NCTCOG was able to apply a health lens to its long-range transportation plan and identify how many of the transportation strategies it was already pursuing improve the health of the region. NCTCOG will continue to include health indicators and strategies in its next long-range transportation plan. It is also interested in coordinating with public health professionals on shared research goals and to ensure that transportation planners and public health professionals are speaking a common language. Eventually, NCTCOG is considering developing public health performance measures to incorporate into its planning process.
The Centers for Disease Control and Prevention monitors community health status indicators that are important in understanding the health of communities. Results for each indicator are available at the county level and allow communities to compare their county to peer counties in the US that have similar demographic, population density, and household income characteristics.1 The following graphs illustrate how counties within the Dallas-Fort Worth Metropolitan Planning Area (MPA) score compared with their peer counties for several community health status indicators. If no bar is shown for a county, the county received a 0 for that indicator. Green bars indicate that the county performs better than peer counties across the nation for that particular indicator, orange bars represent moderate performance compared with peer counties, red bars represent worse performance compared with peer counties, and blue bars represent the US median. Unhealthy Ozone Days: When ozone occurs at ground level, it acts as an air pollutant that threatens health. This indicator measures the number of days that the maximum average ozone concentration, measured over eight hours, exceeds national standards. Though the MPA is in nonattainment for ozone, only five counties have more days above the NAAQS than peer counties. Unhealthy PM2.5 Days: When particulate matter (PM) occurs at ground level, it acts as an air pollutant that threatens health. This indicator measures the number of days with PM2.5 levels above the NAAQS. Though the MPA is in attainment for PM2.5, one county (Ellis) has more days above the NAAQS than peer counties. 1 Centers for Disease Control and Prevention’s Community Health Status Indicators Website, http://wwwn.cdc.gov/CommunityHealth/home
Motor Vehicle Deaths: Motor vehicle deaths are the leading cause of death for people aged 5 to 34 years and are more common in rural areas. This indicator measures the number of motor vehicle related deaths per 100,000 residents. Seven counties within the MPA perform at the same level as their peer counties
Death Caused by Unintentional Injury (including motor vehicle): Unintentional injuries were the fifth leading cause of death in the US in 2010. Unintentional injuries are the leading cause of death for Americans aged 1 to 44, as well as a leading cause of disability for all ages, regardless of sex, race/ethnicity, or socioeconomic status. This indicator measures the number of unintentional deaths per 100,000 residents. Most counties within the MPA perform at the same level as their peer counties in this indicator. Unemployment: The association between unemployment and poor physical and mental health is well established. Unemployed people tend to have higher annual illness rates, lack health insurance and access to health care, and have an increased risk for death. This indicator is based on the percent of the civilian labor force, age 16 and older, that is unemployed but seeking work in 2013. Three counties within the MPA perform better than peer counties, while eight counties perform at the same level as their peers. One county (Rockwall) performed worse for this indicator. 0 5 10 15 20 25 30 35 Number of deaths per 100,000 people County Motor Vehicle Deaths 0 10 20 30 40 50 60 70 Number of Deaths County Deaths Caused by Unintentional Injury (Including Motor Vehicle) 0.0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 7.0% 8.0% % Unemployed County Unemployment Appendix C: Environmental Considerations C3 Mobility 2040 Living near Highways : Several studies have documented that concentrations of traffic -related pollutants are highest close to roads . A recent review determined that there is sufficient evidence to show a causal association between exposure to traffic -related air pollution and asthma exacerbation; the review also found suggestive evidence of a causal association for onset of childhood asthma, non – asthma respiratory symptoms, impaired lung function, all -cause mortality, cardiovascular mortality, and cardiovascular morbidity. This indicator measures the percent of the population living within 150 meters of a highway. One county (Hood) performed better than its peer counties. Five counties performed at the same level as peer counties, and six performed worse.
Access to Parks: Parks, trails, and gardens provide safe and affordable places where residents can engage in physical activity. This indicator measures the percentage of the population that lives within one -half mile of one of these areas. Three counties (Ellis, Hunt, and Johnson) within the MPA perform better than peer counties while seven counties are comparable to peer counties . Adult Obesity : Obese people face health problems that can generate medical costs that are more than $1,000 greater per year than medical costs of people who are not obese. This indicator measures the percent of adults age 20 and over who report that their body mass index is 30 or higher. Five counties (Dallas, Denton, Hood, Kaufman, and Parker) within the MPA perform worse than their peer counties. Two counties (Rockwall and Wise) perform better.
1 The CDC developed a method and variables for peer county groupings based on an iterative process guided by subject matter experts. For more information on this methodology, see https://wwwn.cdc.gov/CommunityHealth/info/HowtoUseReport/TX/Bosque/#PeerComparison.
Transportation Health Impact Assessment Toolkit for Planning and Health Professionals
Reduced drinking and driving and increased seatbelt use—these transportation policies have helped save many lives. Transportation policies can also be about infrastructure—how people get from place to place. These policies can help or block people from healthy lifestyle choices, such as making regular doctor visits, accessing good jobs, and choosing healthy food. This is especially true for underserved residents, children, older adults, and households without automobiles.
When health is considered among the goals of transportation policy and land use planning, the resulting policy can help reduce air pollution; prevent traffic injuries and deaths; and lower obesity, diabetes, cardiovascular disease, and cancer rates. Such outcomes can happen when roads are designed to be pedestrian-, cyclist- and public transit-friendly. Roads that are designed for people as well as for cars and trucks can increase physical activity, enhance community quality of life, and increase access to community services.
How can public officials, community members, and planners ensure that future transportation policies consider health? One way is to use a health impact assessment (HIA). Transportation HIAs help policymakers see and address the potential health effects of a proposed transportation project, plan, or policy before it is built or implemented. A transportation HIA can ensure that all people, regardless of age, income, or ability, are able to move about their community easily and safely.
A community’s transportation planning process can have many stages. For example, a Long-Range Transportation Plan made by states and Metropolitan Planning Organizations (MPOs) sets the vision for transportation over a twenty-year timeline. A Transportation Improvement Program identifies which projects will be funded and constructed over the next four years. As a policy tool, transportation HIAs can help prioritize local and statewide project proposals by identifying the health value. The HIA process can also encourage all stakeholders, including the MPO, project managers, elected officials, public health officials, the residents, and commuters to work together on improving public health.
The Transportation HIA Toolkit provides a framework for public health departments, city planners, project managers, and other stakeholders to conduct HIAs on proposed transportation projects, plans, and policies. If your are seeking the Transportation and Health Tool developed by CDC and the U.S. Department of Transportation, go here.
The elements of the CDC Transportation HIA Toolkit are:
General HIA resources
Sectors from education to housing to community design use HIAs to identify opportunities to improve public health. Visit the Centers for Disease Control and Prevention’s (CDC’s) Healthy Places Health Impact Assessment page for an HIA overview and the steps involved in any HIA process. You can also find links to online HIA courses and other resources.
HIA Background Information and HIA Indicators
To conduct an HIA, practitioners will need to research background information on the project area and affected population. The HIA Background Information and HIA Indicators section links to national databases and provides guidance on relevant indicators that assess the health impact of transportation projects. This section also directs practitioners to local sources for data specific to an area.
Strategies for Health-Oriented Transportation Projects and Policies
HIAs make evidence-based recommendations to promote positive health outcomes and minimize negative consequences. The Strategies for Health-Oriented Transportation Projects and Policies section identifies transportation design and infrastructure strategies recognized in published HIAs. It also provides resources to inform recommendations. The strategies and evidence are divided into six categories:
- Reduce Vehicle Miles Traveled (VMT)
- Expand Public Transportation
- Promote Active Transportation
- Incorporate Healthy Community Design Features
- Improve Safety for All Users
- Ensure Equitable Access to Transportation Networks
In the case studies, you can find existing HIA reports on transportation-related projects and policies, ranging from walking and biking improvements and public transit expansion to VMT legislation.
Other Transportation HIA Resources:
Transportation and Health Toolkits
- Transportation and Health ToolThe tool was developed by the U.S. Department of Transportation and the Centers for Disease Control and Prevention to provide easy access to data that practitioners can use to examine the health impacts of transportation systems.
- Convergence Partnership: Transportation and Health Toolkit
- American Public Health Association: Transportation and Health ToolkitThis site has tools to help you explain to others the connection between transportation and health.
- UCLA Health Impact Assessment Clearing House
- Transportation Web page
- Data sources for HIA: Demographic and health risk data for describing affected populations
- Partnership for Prevention (US). Transportation and Health: Policy Intervention for Safer, Healthier People and Communities. Washington, DC: Partnership for Prevention; 2011. Available at: http://www.convergencepartnership.org/site/c.fhLOK6PELmF/b.4950415/
k.4FF7/Transportation_and_Health_Toolkit.htm. Accessed on 21 July 2011.
The Partnership for Prevention collaborated with the University of California, Berkeley’s Safe Transportation Research and Education Center, Booz Allen Hamilton, and the Centers for Disease Control and Prevention. The resulting report examines the effects of transportation policies on public health in three key areas—environment and environmental public health; community design and active transportation (human-powered transportation for getting around like biking and walking); and motor vehicle-related injuries and fatalities.
- Dora C, Phillips M, editors. Transport, environment and health. World Health Organization. WHO Regional Publications, European Series, No. 89. 2000. http://www.euro.who.int/document/e72015.pdf[PDF – 1.24 MB].
A major purpose of this book is to alert policy analysts, decision-makers and politicians to current knowledge about the health effects of transport and the means to reduce them.
- Bell J, Cohen L, Malekafzali S. The transportation prescription: bold new ideas for healthy equitable transportation reform in America. 2009. PolicyLink. http://www.convergencepartnership.org/atf/cf/%7B245a9b44-6ded-4abd-a392-ae583809e350%7D/TRANSPORTATIONRX.PDF [PDF – 552 KB].
This guide outlines a new vision for American transportation networks by improving mobility from place to place and residents’ access to their communities. The guide includes information on how transportation options and infrastructure can affect on health and what transportation policy changes would improve public health.
- Douglas M, Thomson H, Jepson R, Hurley F, Higgins M, Muirie J, Gorman D (eds). Health Impact Assessment of Transport Initiatives: A Guide. NHS Scotland Edinburgh, 2007. 110 pages. http://www.healthscotland.com/documents/2124.aspx.
This guide to Scotland’s transportation HIAs contains resources for on how to use evidence to support recommendations (chapter 6). It also summarizes findings on evidence that connects transportation policies and projects to health outcomes (appendix 4).