Healthy Communities

IN THIS SECTION, THE BENCHMARKING REPORT LOOKS AT THE CONNECTIONS BETWEEN BICYCLING AND WALKING, AND HEALTH. THIS INCLUDES HOW COMMUNITY ACTIONS TO PROMOTE BICYCLING AND WALKING ARE RELATED TO PHYSICAL ACTIVITY PROMOTION, AS WELL AS THE HEALTH BENEFITS OF BICYCLING AND WALKING.

Making the Case: How Bicycling and Walking Lead to Healthy Communities

• The Case for Physical Activity as an Intervention for Common Chronic Diseases
• The Case for Individualized Marketing as a Health Intervention
• The Case for Bicycle Friendly Communities for Health

Advancing Understanding: Health and Transportation

Embracing Equity: Community Health Depends on Inclusive Actions

HEALTHY COMMUNITIES

WHAT IS A HEALTHY COMMUNITY? According to a CDC publication, “A healthy community is one in which local groups from all parts of the community work together to prevent disease and make healthy living options accessible. ¹ ”Another way to think of a healthy community is as the outcome of efforts to promote community health. Community health is the public health concept of “Working at the community level [to promote] healthy living, help[ing] to prevent chronic diseases and bring the greatest health benefits to the greatest number of people in need. ² ” Together, these definitions suggest healthy communities are focused on processes in addition to outcomes. ³

Creating bikeable and walkable communities is an important way to promote health because bicycling and walking are common activities accessible to most people. As stated in Step it Up! The Surgeon General’s Call to Action to Promote Walking and Walkable Communities ⁴ , “Walking is an excellent way for most people to increase their physical activity. It is a powerful public health strategy for the following reasons:

• Walking is an easy way to start and maintain a physically active lifestyle.
• Walking is the most common form of physical activity for people across the country.
• Walking can serve many purposes. It can be a way to exercise, have fun, or get to school, work, or other nearby destinations.
• Making walking easier can help communities by improving safety, social cohesion, and local economies and reducing air pollution.”

Bicycling is not as common as walking. According to data from the Bureau of Labor Statistics, 30.4% of Americans walk as  an exercise activity on any given day, while only 3.1% ride a bicycle; even with that percentage difference, bicycling is still one of the 10 most commonly reported exercise activities. ⁵ One recent survey found that “34 % of Americans over the age of three [rode] a bike at least once in the last year.” ⁶ Bicycling is also an activity accessible to persons with disabilities, and it was reported as one of the five most common physical activities by persons with multiple sclerosis. ⁷   As with walking, bicycling can serve many purposes and has many, if not all, of the same community benefits as walking.

Bicycling and walking are often referenced together as active transportation. This may include transit as well because transit users spend a median of 19 minutes a day walking to and from transit. ⁸ These active transportation modes are reported in American Community Survey commute mode share data that will form the basis for a variety of analyses found in this report.

HOW BICYCLING AND WALKING LEAD TO HEALTHY COMMUNITIES

The Case for Physical Activity as an Intervention for Common Chronic Diseases

Chronic diseases related to physical inactivity are widespread and increasing. In 2008 and 2018, the Physical Activity Guidelines Advisory Committee reviewed the scientific literature on physical activity and concluded that, compared to inactive adults, the most-active adults had approximately a 30% lower risk of premature death from all causes. ⁹ Translated to the population level, physical inactivity contributes to an estimated 11% of premature deaths in the United States. These findings have informed the Physical Activity Guidelines for Americans, which recommend adults do at least 150 minutes a week of moderate intensity aerobic activity and avoid prolonged periods of inactivity. ¹⁰

FIGURE 3.1.1 – DATA SHOWING THAT PHYSICAL ACTIVITY DECREASES THE RISK OF DYING PREMATURELY

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The Benchmarking Report has focused on chronic diseases related to physical inactivity that are monitored by the CDC’s Behavioral Risk Factor Surveillance System (BRFSS). The Benchmarking Report chose five indicators from the BRFSS as benchmarks (references found on following page):

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Data on these chronic disease health indicators can be found in each section of Chapter IV: Show Your Data, although. An examination of health disparities (differences in the prevalence of chronic disease incidence associated with demographic, regional, or other factors) for each of these chronic disease health indicators was outside of the scope of the Benchmarking Report. However, health disparities can be significant for different socioeconomic and demographic groups. The American Public Health Association has urged public health and social justice practitioners, organizations, researchers, and philanthropists to support transportation and land use policies that help address inequities, particularly for communities with low incomes and communities of color experiencing health inequities. ²⁴

The Case for Individualized Marketing as a Health Intervention

The average one-way bicycle commute is 19 minutes, for a total of nearly 40 minutes of bicycling each commute day. ²⁵ –How can we get more people to take advantage of this type of physical activity? One intervention that has demonstrated promise is individualized marketing as a way to provide resources on bicycling to work. Individualized marketing is marketing that is personalized to an individual, often based on data available about that person and with the intent to reflect and appeal to the unique wants and habits of the individual. ²⁶  

In addition to community efforts that promote biking and walking, evidence exists that individualized interventions can shift people to non-driving transportation options that involve physical activity. According to consultants at Alta Planning + Design, “Individualized Marketing  (IM) programs offer households (typically in a targeted neighborhood) transportation resources and events with  the goal of reducing drive-alone trips and encouraging greater use of transportation options. ²⁷   “As some examples, individualized marketing may be conducted through private companies seeking ways to reduce the costs of employee parking, health professionals helping patients become more physically active, or other people advocating for behavior change. At its core, however, individualized marketing is a series of one-to-one messages based on data about a single person.

Some evidence suggests IM is cost-effective. For instance, Oregon Department of Transportation  partnered  with the Oregon Health Authority to prepare and apply the Integrated Transport and Health Impact Modeling Tool (ITHIM) to measure public health benefits from an IM program called “Drive Less Save More: SouthTown.” Conducted in Corvallis, Oregon, this intervention resulted in a 1.4% increase in walking and a 3.8% reduction in the percentage of people driving alone to work. According to ITHIM estimates, these mode shifts may have resulted in $115,300 in health savings from a decrease in premature mortality and years lived at less than full health. ²⁸

The Case for Bicycle Friendly Communities for Health

The League of American Bicyclists’ Bicycle Friendly Community (BFC) program provides insight into the range of actions that communities can and do take as they work to get more people riding bicycles and try to improve bicyclist safety and public health. The League’s data show that communities that have received a BFC award have a bicyclist fatality rate that is less the half the fatality rate of communities that apply but do not receive awards. ²⁹ As award levels increase, the prevalence of bicycling, safety of bicycling, and prevalence of bicycle infrastructure all increase. Each of these indicators support connections between BFC efforts and better health outcomes.

The BFC Program, started in 1995, was updated to its current “5 E” framework (engineering, education, encouragement, enforcement, and evaluation/planning) in 2002. Since 2002, the League has collected data on bicycling-related efforts by more than 800 communities. The goal of the BFC Program throughout its 23 years has been to meet communities where they are, recognizing that there is no single route to becoming a Bicycle Friendly Community. Indeed, the League believes that each community can capitalize on its own unique strengths to make bicycling better.

Recently, the Bicycle Alliance of Minnesota (BikeMN) used funding from Blue Cross Blue Shield of Minnesota to provide technical assistance and training throughout the state and enabled more than 20 communities, including small and rural towns, to participate in bicycle promotion efforts structured around the BFC program. This work has built on the national BFC Program, resulting in part in a Resource Guide for Minnesota communities; ³⁰ BikeMN’s capacity-building efforts have been recognized as an approved intervention by the state’s Health Improvement Partnership. ³¹

Despite the diversity of actions reported by communities that apply to the BFC program, some activities are especially common among awarded communities, including the following:

The Building Blocks of a Bicycle Friendly Community

There’s no single route to becoming a Bicycle Friendly Community. In fact, the beauty of the BFC program is the recognition that no two communities are the same and each can capitalize on its own unique strengths to make biking better. The data in this chart show key benchmark averages from the past 4 years, and over 500 applications, for each BFC award level. Learn more about the BFC program at https://bikeleague.org/community.

ADVANCING UNDERSTANDING: HEALTHY TRANSPORTATION

When talking about active transportation and health, a clear connection exists between physical activity and better health outcomes. However, less clear is how the interventions that encourage more people to choose bicycling and walking tie to specific health outcomes. To better communicate the value of changes in transportation behavior to decision makers, researchers has developed health impact models to frame the discussion. Stakeholders can find at least two internationally accepted models for bicycling and walking as health interventions:

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The National Association of County and City Health Officials (NACCHO) included both HEAT and ITHIM in its Collection of Health Impact Assessment Predictive Modeling Tools. ³⁷ This collection features 26 modeling tools,   including at least three tools that estimate walking and/or bicycling trips or health effects related to projects or changes in active transportation. Based on NACCHO’s data, ITHIM has been used and publicized in places like Sacramento ³⁸ and Nashville. ³⁹ The use of ITHIM has also been highlighted in a guidebook on Building Healthy & Prosperous Communities, produced by Transportation for America and the American Public Health Association. ⁴⁰

To further understanding of the health impacts of transportation projects, additional evaluation studies are needed. The Centers for Disease Control and Prevention provide potential evaluation methods as part of “Be Active: Connecting Routes+ Destinations,” which encourages communities to “whenever possible, evaluate impact.” ⁴¹ This resource also helps communities understand when evaluation is appropriate.

Wildcat Wheels on May 8, 2018. Photo by Mark Cornelison | UKphoto

EMBRACING EQUITY: COMMUNITY HEALTH DEPENDS ON INCLUSIVE ACTIONS

Increasingly, healthcare providers and policymakers are defining healthcare to include not just treatment services, but also socioeconomic conditions that affect health outcomes. These efforts are often based on the work done by public health professionals, who focus on systems, policy, and environmental approaches to improve health. Broadly, the conditions that affect health outcomes are referred to as “social determinants of health.” Some examples of how the public health community has embraced and defined social determinants of health as a basis for addressing health and health inequities are provided below:

• The World Health Organization (WHO) defines social determinants of health as “the conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels.” ⁴²  
• Community health activities often explicitly include activities to address social determinants of health and health disparities through community-level, rather than individually focused, actions. A 2013 report by Health Resources  in Action notes that the community health movement focused on “empowerment and community-driven change rather than on pre-determined activities, on process rather than outcomes, on policy change and environmental strategies rather than on individual interventions, and on social determinants of health rather than on the treatment of disease.” ⁴³ This focus on community-driven change can be contrasted with transportation safety messaging that often focuses on individual actions. ⁴⁴  
• The Department of Health and Human Services’ “Healthy People 2020 initiative organizes the social determinants of health around five key domains: (1) Economic Stability, (2) Education, (3) Health and Health Care, (4) Neighborhood and Built Environment, and (5) Social and Community Context.” ⁴⁵
• American Public Health Association, Public Health Institute, and the California Department of Health created Health in All Policies: A Guide for State and Local Governments ⁴⁶ as a guide for groups outside of public health to engage with the environmental justice and health equity concepts that have been pursued by public health agencies. This guide calls for increased collaboration since “[r]esponsibility for the social determinants of health falls to many nontraditional health partners such as housing, transportation, education, air quality, parks, criminal justice, energy, and employment agencies.” ⁴⁷

Agency staff and partners in the transportation sector also are   responsible for addressing social determinants of health and the ways that transportation plays a role in the impact of those determinants. At the federal level, “[t]he Executive Order on Environmental Justice (EJ) directs federal agencies to identify and address disproportionately high and adverse environmental and health impacts on low-income populations and racial and ethnic communities.” ⁴⁸ Among transportation partners, the Untokening’s principles state, “Communities have the  right to demand and expect healthy environments and EQUAL ACCESS to the benefits of green space—and remediation of past environmental harms.” ⁴⁹ The Untokening is “a multiracial collective that centers the lived experiences of marginalized communities to address mobility justice and equity.” ⁵⁰

Whether people can safely bike, walk, or use transit and whether they can access jobs or healthcare without access to a car,  are important elements of the conditions in which people are born, grow, live, work, and age. While bicycling and walking are often thought of in terms of transportation, and most bike/walk organizations primarily work with transportation agencies, ⁵¹ both agencies and organizations may benefit from a shift like the one that has occurred in the health sector through the incorporation of the social determinants of health. Transportation agencies can benefit from thinking beyond travel speeds or congestion metrics, just as healthcare agencies can benefit from thinking about societal factors that influence health outcomes.