Healthy Community Design


Smart Growth & Regional Collaboration

Healthy Community Design Info Bank

Regional Planning Agencies influence the health of their communities. This community-of-practice website builds on a series of calls and workshops and provides resources to help Regional Planning Agencies improve public health.

MAPC partnered with the Massachusetts Department of Public Health and the Pioneer Valley Planning Commission and worked Harvard T.H. Chan School of Public Health on this project.


While these concepts were developed specifically for transit-orientated development, it also applies to public transit infrastructure as well.

Transportation infrastructure can impact daily life that can influence lifelong health, such as access to healthy foods and affordable housing options.

The health benefits of physical activity have been well documented, yet less than half (48%) of all adults meet the Surgeon General’s recommended 30 minutes of moderate intensity physical activity on most days of the week (Centers for Disease Control and Prevention 2010; Besser and Dannenberg 2005; Freeland et al. 2013). A recent study by Lee et al. (2012) estimates that physical inactivity causes 6% of the global burden of disease from coronary heart disease, 7% of type 2 diabetes, 10% of breast cancer, 10% of colon cancer, and 9% of premature mortality. If inactivity were decreased by 10% to 25%, between 533,000 and 1.3 million deaths could be prevented every year.

In recent years, research has attempted to address this issue by working to understand the built environment and its connection to active transport, defined as walking, biking, and public transportation (which typically requires some walking or biking). For the most part, this literature is consistent in demonstrating that active transport correlates with many of TOD’s characteristics including: density, mixed land-use, availability of destinations, design, and distance to transit (Ewing and Cervero 2010; Freeman et al. 2012; Giles-Corti et al. 2013; McCormack and Shiell 2011; Litman 2013). Supported by concepts from the field of transportation planning, land use patterns shape the proximity of destinations and transportation systems connect destinations, which together determine the feasibility of walking, cycling, or mass transit use. Neighborhoods that have higher population densities, access to destinations, more grid-like street patterns, and access to high quality bicycle and pedestrian infrastructure are positively associated with physical activity. Additionally, several studies show that walking to and from transit help people meet physical activity recommendations (Besser and Dannenberg 2005; Freeland et al. 2013; Lachapelle et al. 2011). Furthermore, there is emerging research that investigates TOD’s efforts to reduce vehicle trips that has found that housing type and tenure, local and sub-regional density, bus service, and off- and on-street parking availability play a more important role than rail access (Chatman 2013).

In sum, there is convincing evidence that the built environment is associated with physical activity and active transport, although it is important to note that most studies are cross-sectional and observational (Ewing and Cervero 2010; Freeman et al. 2012; McCormack and Shiell 2011; Ding and Gebel 2012).

Well-lit and well-maintained walkable spaces with good visibility and access to shops, parks, and other amenities have been shown to reduce rates of crime and fear of crime (Foster, Giles-Corti, and Knuiman 2010; Hedayati Marzbali et al. 2012; Nasar and Jones 1997; Paulsen 2012; Dannenberg et al. 2003; Anderson et al. 2013). Still, one concern of TOD is the fear that crime rates will increase because of the perception that criminals travel on public transit (Paulsen 2012; Billings, Leland, and Swindell 2011). While fear of crime is more prevalent than actual victimization, fear can heighten feelings of anxiety and may constrain some people’s social and physical activities as they attempt to avoid certain places or situations that they perceive to be unsafe (Foster, Giles-Corti, and Knuiman 2010; Hale 1996; Liska, Sanchirico, and Reed 1988). However, actual crime levels at transit stations and stops vary by the type of transit. Serious crime such as assault and robbery are generally low in train stations—with minor crimes such as pick-pocketing slightly elevated—while bus stops tend to have higher rates of crime, but the majority of it is concentrated at a small percentage of stops (Paulsen 2012). Moreover, numerous studies show that crime is not necessarily associated with transit stations as much as with the design and layout of adjacent neighborhoods, as well as the types of uses surrounding transit stations (Lipton et al. 2013; Minnery and Lim 2005; Paulsen 2012). In particular, areas that feature alcohol outlets (e.g. bars or liquor stores), check cashing services, vacant properties, and alleys with poor natural surveillance are associated with higher crime (Lipton et al. 2013; Minnery and Lim 2005; Paulsen 2012).

Growing up in poverty, where a household does not have enough income to meet basic needs, increases a child’s risk for poor health and increases risk for school failure (Brooks-Gunn and Duncan 1997). This is a factor linked to future employment and income potential. Childhood health problems often follow into adulthood and may result in reduced earnings and ability to work fewer hours (Conroy, Sandel, and Zuckerman 2010; Duncan, Ziol-Guest, and Kalil 2010).

We are interested in economic opportunity, or the ability to improve one’s financial conditions, because a key social determinant of health is socioeconomic status. Socioeconomic status is the result of multiple variables such as educational level, occupation and income. Higher income is known to lead to better health outcomes, and there is evidence of increased risks for mortality, morbidity, and unhealthy behaviors for those with lower incomes (Lindahl 2002; Rehkopf et al. 2008). For example, individuals from families with average incomes of $15,000 to $20,000 are three times more likely to die prematurely than those from families with incomes greater than $70,000 (Yen and Bhatia 2002). In addition, there is a higher prevalence of obesity and type II diabetes among groups with the lowest levels of income and education and in the most deprived areas (Drewnowski 2009).

As a strategy for developing compact residential and commercial areas in places that are accessible by public transit, TOD holds great potential for supporting existing employment centers and spurring new economic development. Although recent decades have seen a decentralization of jobs from traditional central business districts, nearly a quarter of existing jobs in regions served by transit are located within a half-mile of transit stations (Center for Transit-Oriented Development 2011).

Researchers have long known that negative “psychological” risk factors such as social isolation and stress can harm health, while social support and social cohesion can promote it. Social isolation, for example, can lead to greater levels of stress, which has well-documented health effects, as well as many other negative health impacts including increased risk of heart disease, mental health problems, and even death (Berkman and Kawachi 2000; Kawachi and Kennedy 1997).

Social cohesion, which describes the extent of connectedness and solidarity of a community, and social support are associated with positive health outcomes. Communities with greater levels of social cohesion—often characterized by high levels of trust and respect, participation in community activities and public affairs, and increased participation in community groups—have better health outcomes than those with low levels (Kawachi and Kennedy 1997; Marmot and Wilkinson 2009; Sampson 2003). This is true on an individual level as well. Those with rich social environments—who have more friends and social interactions, hold a greater level of trust in their neighbors, and are part of a more tightly knit community—have access to a greater network of social resources which in turn help them stay healthier (S. Cohen and Wills 1985). These social resources can manifest as emotional support in difficult times, material support such as a ride to work when the family car breaks down, or simply through health-promoting information shared amongst neighbors. Access to social support such as this is associated with protective health effects including improved mental health outcomes, reduced stress, better cardiovascular health, better immune system functioning and more (Berkman and Kawachi 2000; Uchino, Cacioppo, and Kiecolt-Glaser 1996).

Community public space may play an important role. In fact, neighborhoods with more public space also tend to be safer and the residents of those neighborhoods that are more walkable are more likely to report knowing their neighbors, trusting others, and being involved in social and civic events (Richard et al. 2009).

Recent studies have found that green spaces, such as parks, trails, and other open spaces, improve individual health and the community-social environment (Weich et al. 2002). Access to parks, open space, and greenery may protect against poor mental health outcomes (Parra et al. 2010; Sugiyama et al. 2008) by encouraging more socializing and thus fostering greater social support and encouraging more socializing, particularly among women (Fan, Das, and Chen 2011; Leventhal and Brooks-Gunn 2003; Truong and Ma 2006; Maas et al. 2006). Access to green space in particular may also provide opportunities for physical activity or provide members of a community with sanctuary from stress (Stigsdotter et al. 2010; van den Berg et al. 2010; Maas et al. 2009).

Further research suggests that the presence of trees themselves, in addition to other vegetation, may also promote community health. Trees and other vegetation remove air pollutants and promote cleaner and more breathable air (Jim and Chen 2008). By providing shade for streets and buildings, for example, trees shade their surrounding environments thereby perhaps reducing the presence of heat islands, UV exposure and skin cancer risk (Grant, Heisler, and Gao 2002; Stanton et al. 2004). Finally, trees more so than bushes or shrubs may also play an important role in promoting positive mental health outcomes and positive social behavior (Taylor, Kuo, and Sullivan 2001) and have even been linked to reductions in crime (Kuo and Sullivan 2001).

New commercial and residential developments, especially those that involve previously vacant land or buildings, generate new trips by motorists, pedestrians, bicyclists and transit users. With the addition of new trips, there is potential for an increase in the number of traffic-related crashes that occur on the surrounding transportation system.

Motor vehicle crashes are responsible for more than 30,000 fatalities each year in the United States (National Center for Environmental Health 2012). Automobile collisions are one of the leading causes of death among people 34 years old and younger, and account for 3.2 million nonfatal injuries annually. Motor vehicle crashes impact pedestrians and bicyclists as well as motorists. In 2009, 630 cyclists and 4,092 pedestrians were killed in traffic crashes in the United States (National Highway Traffic Safety Administration 2009). The impact of crashes with pedestrians and bicyclists has more potential to lead to severe injury or fatality. As an example, a pedestrian hit at 35 mph is nearly three times more likely to die than one hit at 25 mph (Tefft 2013).

Integrated land use and transportation strategies can be used to reduce reliance on the automobile and its related effects like crashes, while creating new biking and walking facilities. One particular expression of these integrated investments is TOD. Transit use tends to be between two to five times higher among those who live and work in the TOD as compared to others traveling in the same region (Arrington and Cervero 2008). As a result, TOD often results in fewer vehicle trips that would be estimated using standard trip generation procedures (e.g., Institute of Transportation Engineer’s Trip Generation manual).

Furthermore, land use and transportation investments like TOD that support public transit have the potential to reduce injury and death from transportation-related crashes through three means:
1. Changing the mode of travel from automobile to another that carries a lower risk of injury.
2. Changing the potential risk of vehicular collision for other vehicles and pedestrians.
3. Providing transportation alternatives to people with impairments that put them at high risk of injury (UCLA-CLIC 2013).

There is an extensive body of literature linking vehicular air pollution to mortality and hospitalizations due to asthma exacerbation, chronic lung disease, heart attacks, ischemic heart disease, and major cardiovascular disease (US EPA and Abt Associates, Inc 2010; Roman et al. 2008; Schwartz et al. 2008; Health Effects Institute 2003; Moolgavkar 2000b; Moolgavkar 2000a; Peters et al. 2001a). The Environmental Protection Agency (EPA) identifies 6 criteria air pollutants that have important human health impacts: Ozone (O3), carbon monoxide (CO), particulate matter (PM), nitrogen dioxide (NO2), sulfur dioxide (SO2), and lead (Pb). The Clean Air Act requires the EPA to establish public health and welfare-based exposure standards for these six criteria air pollutants and States must develop plans to achieve these standards. Because the developments assessed will likely to lead to changes in traffic patterns, below we detail four criteria air pollutants most closely linked to vehicular traffic pollution.

Ozone:Ground level ozone, a chief ingredient in “smog,” is not emitted directly into the air, but is created by chemical reactions between NOx and volatile organic compounds (VOCs) in the presence of sunlight. Emissions from motor vehicle exhaust and gasoline vapors are some of the major sources of NOx and VOC (MassDEP 2012a; EPA 2012b). Breathing ozone can irritate the respiratory system, reduce lung function, heighten sensitivity to allergens, and may contribute to premature death in people with heart and lung disease (MassDEP 2012a). In general, as concentrations of ground-level ozone increase, more people experience health symptoms, the effects become more serious, and hospital admissions for respiratory problems increase (MassDEP 2012a). When ground-level ozone reaches unhealthy levels, children and people with asthma or other respiratory diseases are the group at highest risk.

Particulate MatterParticulate matter (PM) air pollution comes mainly from automobiles and power plants, and has been linked to higher rates of mortality and coronary disease (Dockery et al. 1993; Pope et al. 1995). Health effects include asthma exacerbation and difficult or painful breathing, especially in children and the elderly. Cardiovascular disease events account for most of the excess mortality attributed to PM exposure. Additionally, epidemiologic evidence has accumulated for a relationship between acute PM and nonfatal cardiovascular events, including: hospital admissions (Goldberg et al. 2001; Francesca Dominici et al. 2003; F. Dominici et al. 2006), myocardial infarction (Peters et al. 2001b; Zanobetti and Schwartz 2005), and cardiac arrhythmias (Dockery et al. 1993; Peters et al. 2001b; MassDEP 2012b).

Carbon MonoxideCarbon monoxide (CO) is a poisonous gas that forms from incomplete combustion. CO is invisible and has no odor, but it can be dangerous to health and potentially fatal in high concentrations. Motor vehicle exhaust contributes roughly 60 percent of all carbon monoxide emissions nationwide, and up to 95 percent in cities. Air concentrations of CO can be particularly high in areas with heavy traffic congestion. People who suffer from cardiovascular diseases are at risk of experiencing chest pain and other cardiovascular symptoms if exposed to carbon monoxide. People with cardiovascular and respiratory problems such as cerebrovascular disease, chronic obstructive lung disease, congestive heart failure and anemia also are at greater risk from carbon monoxide exposure, as are young infants and developing fetuses (MassDEP 2013a).

Nitrogen DioxideNitrogen dioxide (NO2) is one of a group of highly reactive gases containing nitrogen and oxygen in varying amounts (known collectively as oxides of nitrogen, or NOx). Many of these gases are colorless and odorless. But one, nitrogen dioxide (NO2), often is seen along with particle pollution as a reddish-brown layer in the air over urban areas. Primary sources of NOx emissions include motor vehicles, electric utilities and other industrial, commercial and residential sources that burn fuels. Nitrogen dioxide irritates the nose and throat, especially in people with asthma, and appears to increase susceptibility to respiratory infections. When nitrogen dioxide and/or ground-level ozone reach unhealthy levels, children and people with respiratory disease are most at risk (MassDEP 2013b).

A brownfield is defined by the CDC as “abandoned or underused portions of land occupied by vacant businesses or closed military structures, located in formerly industrial or urban areas” (National Center for Environmental Health 2013). While there is no formal definition of the term "brownfields" in Massachusetts, brownfields are typically abandoned or for sale or lease and have been used for commercial or industrial purposes. Brownfields may have been reported to the MassDEP because contamination has been found or they may not have been assessed due to fear of unknown contamination conditions (MassDEP 2012c).

There are an estimated 450,000 brownfields in the US. Health impacts due to brownfields and contaminated sites include:
- Safety due to abandoned structures, open foundations, other infrastructure or equipment that may be compromised due to lack of maintenance, vandalism or deterioration, controlled substance contaminated sites (i.e., methamphetamine labs) and abandoned mine sites;
- Social and economic concerns due to blight, crime, reduced social capital, reductions in the local government tax base and private property values that may reduce social services; and,
- • Environmental issues due to biological, physical and chemical site contamination, groundwater impacts, surface runoff or migration of contaminants as well as wastes dumped on site (EPA 2006)

Exposure to environmental contamination can have numerous health effects depending on the specifics of the prior land use and the materials remaining on the site that might be harmful to human health. Cleaning up and reinvesting in brownfields/land reuse properties has the potential to improve and protect the environment, economy, and surrounding community’s health and well-being (ATSDR 2010).

State brownfields program incentives are available to buyers, and sometimes sellers, of contaminated property provided there is a commitment to cleanup during redevelopment. State incentives can help parties identify risk, limit liability, and fund the cleanup of brownfields sites enabling their reuse for industry, housing and other purposes. Parties who conduct site assessment or cleanup at any property in Massachusetts must do so under the state's cleanup law, Chapter 21E, and cleanup regulations, the Massachusetts Contingency Plan (MCP). A Licensed Site Professional (LSP) must be hired to conduct the site assessment. Brownfields sites require the same level of investigation and remediation as any other site in the MCP system. However, the MCP process allows property owners to take planned future reuses into account when performing a cleanup.

Transportation in the context of this HIA focuses on issues related to the school commute of students. The school commute encompasses the trips and travel modes—car, bus, walking, bicycling—used to transport students to and from a school location. For this HIA, the school commute focuses on those traveling to and from public schools.

Many factors such as distance from home to school, school policies (e.g. parking fees and bus fees), land use context (urban vs. suburban vs. rural), and traffic safety influence the transport mode a student uses to get to and from school, such as walking, biking, school bus, or car (Giles-Corti et al. 2009). Distance has been shown to be a strong predictor for active transport. For example, it has been found that students who live a half-mile or less from their school are more likely to walk or bike than those who live farther away (Timperio et al. 2006).

The mode of transportation that students use has implications for their health. It affects their potential exposure for vehicular crashes and exposure to environmental factors such as air pollution as well as health risk behaviors.

School Commute and Physical Activity:
In 1969, nearly half of students aged 5-18 in the US walked or biked to school. By 2001, only slightly more than one in ten commuted by foot or bicycle (M. C. Lee, Orenstein, and Richardson 2008a; Bungum et al. 2009; Eyler et al. 2008), with most of these trips being replaced by vehicular trips (e.g. drop-off, school buses). Similarly, the percentage of US Kindergarten to eighth grade school students who live less than a mile from their school fallen almost by half (45% to 23%) (M. C. Lee, Orenstein, and Richardson 2008b). During this same period, the percentage of students who are overweight and obese has increased. In 2009, 14% of high school students in Massachusetts were overweight and 11% were obese (CDC Obese Youth Over Time, 2014) – percentages that have remained relatively constant for almost 10 years. Overweight and obesity predispose youth to future overweight and obesity, as well as a variety of risk factors, conditions, and chronic diseases like Type II diabetes and cardiovascular disease (CDC, 2014).
A number of studies have examined the connection between commute modes and physical activity, with most finding a positive association between active commuting to school and level of physical activity among students (Davison, Werder, and Lawson 2008). This research has shown that students who walk or bicycle to school have higher daily levels of physical activity and are more likely to meet physical activity rec¬ommendations than those traveling to school by car or bus. Physical activity is protective against becoming overweight and obese (M. C. Lee, Orenstein, and Richardson 2008a); however, we were not able to identify any studies that looked specifically at the impact walking to school has on the rates amongst students through our literature review. Physical activity also protects against other physical and psychological risk factors and illnesses. Regular physical activity has been found to reduce risk for some cancers and developing type 2 diabetes, and it can improve an individual’s mental health and mood, decreasing risk of depression. Among students, those that are more physically active – in and outside of school – are more likely to perform better academically (Trost 2007).
Research investigating elements of the physical environment suggests that students are more likely to walk or bicycle when the route to school is direct, there are few steep roads on the route, and neighborhoods surrounding the student’s home are considered walkable (e.g., by measurements of residential density, intersection density, and land use mix) (Timperio et al. 2006; Kerr et al. 2006; McMillan 2007). In the social context, the literature shows that public school students are more likely to actively commute to school than private school students and suggests that students from low socioeconomic (SES) backgrounds are more likely than students from high socioeconomic SES backgrounds to walk or bike for their school commute. Research also shows that students are more likely to have an active school commute when their parents perceive that other students in the area walk or bike to school (Timperio et al. 2006; Y. Yang et al. 2010), and other family members agree with allowing a student to walk or bicycle to school (McMillan 2007).

School Commute and Traffic Safety:
Motor vehicle crashes are the top cause of death among people ages 5 to 34 in the United States, and a leading cause of injury among all age groups (Centers for Disease Control and Prevention 2011). Each year approximately 800 school-aged children are killed in motor vehicle crashes during normal school travel hours. Normal school travel hours are defined as 6am to 8:59am and 2pm to 4:59pm. Of these 800 deaths, about 20 (2%)—5 school bus passengers and 15 pedestrians—are school bus-related. The other 98% of school-aged deaths occur in passenger vehicles or among pedestrians, bicyclists, or motorcyclists. A disproportionate share of these passenger vehicle–related deaths (approximately 450 of the 800 deaths, or 55%) occurs when a teenager is driving (National Academy of Sciences 2002). Additionally, approximately 152,000 school-age children are non-fatally injured during normal school travel hours each year. More than 80% (about 130,000) of these nonfatal injuries occur in passenger vehicles; only 4% (about 6,000) are school bus-related (about 5,500 school bus passengers and 500 school bus pedestrians), 11% (about 16,500) occur to pedestrians and bicyclists, and fewer than 1% (500) are to passengers in other buses (National Academy of Sciences 2002).
Vehicular crashes are the leading cause of death for teens in the United States(CDC 2014). The most at-risk group for crashes is teens ages 16-19, who are 3 times more likely to crash than those over the age of 20 (CDC 2014). Teen drivers tend to underestimate hazardous conditions, are more likely to speed, and have the lowest reported rates of seatbelt use. Only 54% of US high school students reported wearing a seatbelt (CDC 2014).
Pedestrians and bicyclists are particularly vulnerable for injury or fatality from motor vehicle crashes. For example, if a pedestrian is struck by a vehicle traveling 20 mph, the risk of a fatality is 6%; at 30 mph, the risk rises to nearly 20%, and at 45 mph, the risk of the pedestrian being killed is 65% (Health Resources in Action 2013). Based on 2012 crash data, 6% of pedestrian crash fatalities and 18% of pedestrians injured in traffic crashes were children under the age of 15 (NHTSA 2014a). Among bicyclists, children age 15 and under accounted for nearly 10% of all fatalities involving bicycle crashes and 20% of the bicyclists injured in crashes in 2012(NHTSA 2014b).
School bus transportation offers increased safety over driving. Buses tend to have lower crash rates as well as less injuries, when compared to other vehicles (J. Yang et al. 2009). Some reasons cited for the increased safety of school buses are the flashing red lights and stop sign that alert drivers to students crossing the street. Additionally, buses are brightly colored, have crush standards as well as reinforced sides, are equipped with multiple mirrors, and drivers are screened and trained more extensively than other drivers on the road (NHTSA).

Traffic Congestion:
Recent research has focused on differences in traffic patterns and specific car characteristics, and how these influence air quality. Traffic congestion can occur during rush hours (morning and evening) and in work zones, and it is under these conditions that carbon dioxide (CO2) emissions and gasoline usage peak (Zhang et al., 2011a). Research has also demonstrated that car and bus idling frequently occurs outside of schools, especially in the morning, and this can significantly contribute to traffic congestion and emissions. One 2011 study that looked at National Household Travel Survey data (McDonald et al. 2011) reported that 7% of morning rush hour vehicle miles traveled and 10-14% of all vehicles on the road are attributable to school transportation. Car emissions that contribute to poorer air quality near schools also contribute to asthma cases in children (McConnell et al. 2010).

Traveling in Personal Vehicles:
Studies of air pollutants have found that in-vehicle concentrations are higher than ambient concentrations for most pollutants measured (HEI 2010; Brugge, Durant, and Rioux 2007b; Zuurbier et al. 2010). For example, in one study it was found that in-vehicle average concentrations of PM2.5 and CO were 2.5 and 6 times higher than concentrations measured at nearby sites (HEI 2010). A study of a low density city found that CO concentrations were highest in cars, compared to public transit buses and bicycles, while ultra-fine particle concentrations were highest among public transit bus and car occupants (Kingham et al. 2013). This may be because the high pollutant concentration is due to the proximity of the in-car microenvironment to the sources of air pollution - vehicles on the roadway.
The air exchange rate in cars is much higher than the rate in buildings, meaning that air pollution flows into cars easily, with the car offering little protection. This phenomenon holds regardless of the type of vehicle and ventilation settings (HEI 2010). The main factors impacting air pollution in a vehicle are the quantity of exhaust emitted immediately in front of a vehicle, and roadway congestion. Closely following a heavily emitting vehicle can increase air pollutant concentrations in the car behind. For example, following a diesel-powered truck or bus could double short-term PM concentrations inside the vehicle immediately behind (HEI 2010). Recent studies have suggested that using air conditioning with air filters can improve in-car air quality and modify the negative health effects of particulate matter (Chuang et al. 2013).

Traveling in School Buses:
Studies have shown that some of a conventional school bus’s own exhaust ends up in the bus cabin, or in other words, that buses can be self-polluting (Sabin et al. 2005), though there is some ambiguity about the primary source of contaminants in buses (Borak and Sirianni 2007). The literature indicates that passengers in school buses may be more exposed to air pollutants and that the air pollution during the bus rides can be a significant portion of total daily pollution exposure for youth (Behrentz et al. 2005; Adar et al. 2008, Ireson et al. 2011). This exposure may also vary in relation to density of surrounding land uses as another study found that the pollutant levels were higher on urban routes than rural/suburban routes (Sabin et al., 2005).
Many studies have shown currently available control technologies can nearly eliminate particulate self-pollution (Adar et al. 2008; Borak and Sirianni 2007; Zhang and Zhu 2011). In terms of the cost-benefit of retrofitting, Marshall & Behrentz (2005) found that even if emission reductions were more expensive per gram emitted for school buses than for a typical vehicle, it would still be cost-effective, due to the high volume inhaled by students in bus cabins. In addition to benefitting the children riding school buses, the community health impacts of retrofitting are potentially significant. A study in Washington analyzed retrofits involving DOCs and crankcase ventilation [“CCV”] filter retrofits, and found that districts adopting the DOC retrofits experienced 5.4 fewer asthma and bronchitis cases per 100,000 children per month and 1.8 fewer asthma and bronchitis cases for those with chronic conditions per 100,000 adults per month (Beatty and Shimshack 2011).

Active Transportation and Near Roadway Exposures:
Those walking and biking are also exposed to vehicular emissions. Although identifying the source of the emissions can be difficult, those who walk or bicycle along higher volume roadways can be directly affected by TRAP. In particular, cyclists can potentially experience greater exposure to emissions due to their higher rates of respiration as compared to those traveling by other modes (e.g., pedestrians, drivers) (Jarjour et al. 2013; Zuurbier et al. 2010; Chertok et al. 2004).
Exposure can be reduced for pedestrians and bicyclists through the use of lower traffic volume routes or paths that are located away from higher volume roadways (Jarjour et al. 2013) . Additionally, some studies suggest that even if walkers or bikers use routes with higher vehicular traffic volumes, the benefits of increased physical activity can outweigh risk posed by pollutants (Grabow et al. 2012, Hartog et al. 2011). For example, Hartog and colleagues (2010) found that for individuals who shift from car to bicycle the benefits of increased physical activity are substantially larger (3-14 months gained) than the potential mortality effect of increased inhaled air pollution does (0.8-40 days lost) and the increase in traffic crashes (5-9 days lost) in terms of life-years gained or lost.
Other studies have noted that increasing the number of active commuters in general has the potential to reduce exposure for those who walk or bike. Modeling the shift of commuters from vehicles to foot or bicycle or shifting to low emission and electric vehicles is estimated to produce a reduction of vehicular emissions and traffic along local routes, thus reducing potential for exposure (David Rojas-Rueda et al. 2011, D Rojas-Rueda et al. 2012, Grabow et al. 2012).

Motor vehicle crashes are the top cause of death among people ages 5 to 34 in the United States, and a leading cause of injury among all age groups (Centers for Disease Control and Prevention 2011). Decreasing traffic speeds increases the amount of time drivers have to react to road hazards, potentially averting collisions, and makes crashes that do happen less severe (Rune Elvik 2012). Consistent evidence over the past century has confirmed that lowering traffic speeds decreases the frequency of crashes, as well as rates of fatalities and injuries due to vehicle collisions. This holds true on urban and residential roads (Lindenmann 2005; Kloeden, Woolley, and McLean 2007). This impacts both individuals traveling in vehicles, as well as pedestrians and cyclists who often share roadways with vehicles. Therefore, there is great potential for the Speed Limit Bill to decrease motor vehicle collisions and subsequent fatalities and injuries associated with these crashes.


  • HEAT Tool The health and economic assessment tool (HEAT) is designed to help conduct an economic assessment of the health benefits of walking or cycling by estimating the value of reduced mortality that results from specified amounts of walking or cycling. Click here for more information on the background on the HEAT tool.
    The Center For Disease Control's (CDC) WISQARS™ (Web-based Injury Statistics Query and Reporting System) is an interactive, online database that provides fatal and nonfatal injury, violent death, and cost of injury data from a variety of trusted sources. Use WISQARS™ to learn more about the public health and economic burden associated with unintentional and violence-related injury in the United States.
  • BenMAP
    BenMAP-CE is a open-source computer program that calculates the number and economic value of air pollution-related deaths and illnesses. The software incorporates a database that includes many of the concentration-response relationships, population files, and health and economic data needed to quantify these impacts.
  • PEQI
    The Pedestrian Environmental Quality Index (PEQI) helps to prioritize improvements in pedestrian infrastructure during the planning process. The PEQI draws on published research and work from numerous cities to assess how the physical environment impacts whether people walk in a neighborhood. The PEQI is an observational survey that quantifies street and intersection factors empirically known to affect people's travel behaviors and is organized into five categories: intersection safety, traffic, street design, land use and perceived safety. For more information on the tool's background click here.

See below for the RPA Healthy Community Design meeting materials related to Visualizing Healthy Communities.

Visualizing Health Communities PDF


Framing and Communications

Health Indicators

Presenters, hosts, and other contacts

Barry Keppard
Public Health Division Manager

Metropolitan Area Planning Council

Dillon Sussman
Senior Planner

Pioneer Valley Planning Commission

Ben Wood
Healthy Community Design Coordinator
Massachusetts Department of Public Health

Catherine Ratte
Principal Planner/Section Manager
Pioneer Valley Planning Commission



Factors to consider when shaping interventions:

  1. Local health concerns
  2. How environment affects these health concerns
  3. Modifiability of built environment features

Behaviors and Risk Factors most associated with preventable deaths in the US

Data source: Danaei et al., The Preventable Causes of Death in the United States: Comparative Risk Assessment of Dietary, Lifestyle, and Metabolic Risk Factors, PLoS Medicine, 6(4), 2009


Presenters, Hosts, and other contacts

Metropolitan Area Planning Council

Noémie Sportiche
Public Health Planner and Research Analyst

Barry Keppard
Public Health Division Manager

Affiliates and Partners

Rachel Banay
Doctoral Candidate, Harvard T.H. Chan School of Public Health

Ben Wood
Healthy Community Design Coordinator, Massachusetts Department of Public Health:

Dillon Sussman
Senior Planner, Pioneer Valley Planning Commission

Catherine Ratte
Principal Planner/Section Manager, Pioneer Valley Planning Commission:


Follow up to questions

I'd love to hear some more detail on the scale of increased physical activity, and also more about the specifics of the built environment characteristics. E.g. what density makes a difference: 4 units per acre, 10 units per acre, 20 units per acre.

Most studies of this type don't qualify the length of time exercising associated with units of density, unfortunately, which would be of good practical use. Instead, they estimate the likelihood of meeting standard physical activity recommendations (or another similar metric) at different levels of density - density is usually estimated by Census tract or other administrative unit, with study results reported by quantile (e.g. "the densest 20% of neighborhoods") rather than by units per acre. That said, the attached reviews by Ding et al. and Saelens et al. summarize some of the recent research on density and physical activity, and might be useful resources. I'm happy to help dig into them further if there's interest.

What are the average daily traffic counts at which biking is no longer recommended on roadways? i.e. at what point does the exposure to pollution or accident risk outweigh the benefit of biking? This question was asked in relation to complete streets policies.

There aren't many studies directly examining the relationship between traffic volume and bicycle safety. I found one, however, that reported that the risk of accidents involving cyclists was between 3-5 times higher on roadways with 250-749 vehicles/hr and between 2-3 higher on roadways with ≥750 vehicles/hr compared to roadways with ≤250 vehicles/hr. (Romanow et al., 2012) There's a lot more interesting information in the Romanow et al. study.

Is there any evidence that links the success of smoking cessation efforts for hard core smokers with built environment features?

In general, the neighborhood factors associated with smoking include dissatisfaction with neighborhood, disorder, violence/safety, and low social cohesion, though studies on these topics have reported mixed results. Unsurprisingly, proximity to tobacco retailers strongly predicts smoking. Successful interventions have involved policy approaches like increasing tobacco prices or limiting tobacco sales by retailers, and banning smoking in public places. See the Stead et al. and Wilson et al. reviews attached for more info. 

Focus on Community Health Needs Assessments

Please find below a link to the presentation from the March 2016 Regional Planning Agency Healthy Community Design technical assistance call and webinar. Also included and to be updated are relevant links and materials:

Additionally, MAPC has been inventorying CHAs for the Metro Boston region and a listing (with links) to these plans is available here.

Climate Change

Please find below a link to the presentation from the May 2016 Regional Planning Agency Healthy Community Design technical assistance call and webinar.

Included and to be updated are links and materials related to Climate Change impacts to public health: