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Metropolitan Area Transportation Planning for Healthy Communities

Chapter 3: Case Studies

Many Metropolitan Planning Organizations (MPOs) across the United States are considering public health in their transportation planning by developing plans, programs, and policies intended to improve the health of their communities. In some cases, these linkages between transportation and health are formalized and visible at key stages of the metropolitan area transportation planning process (see Figure 2). This chapter includes case studies investigating four MPOs that are working with partner organizations, elected leaders, and citizens to integrate consideration of public health benefits and impacts into on-going transportation planning and decision-making. The four featured MPOs are the:

Based on these cases, the project team provides a framework that describes how MPOs can strongly embed health considerations into the planning process. The framework focuses on aspects of the planning process such as regional vision and goals, the Long-Range Transportation Plan (LRTP), Transportation Improvement Program (TIP), and system performance monitoring, as highlighted in Figure 2 (see the section on Metropolitan Area Transportation Planning Products for more information on these MPO plans).

This chapter:

As stated in the introduction, this research is specifically focused on how MPOs take a comprehensive and balanced, or holistic approach to health, considering, for example, health implications of safety, clean air, physical activity, and safety, in combination. The case studies and related analysis reflect this holistic approach.

Figure 2: Metropolitan Area Transportation Planning Process. Source: FHWA/FTA TPCB Briefing Book

This image shows the Metropolitan Area Transportation Planning Process, starting with regional visions and goals and moving through monitoring system performance. There are feedback loops in both directions. Click for a text version.

Methodology

The project team selected the MPOs featured in the case studies from a group of MPOs identified as leading their peers in health-related planning activities. MPOs were identified from a review of relevant webinar series and national reports and from recommendations from Federal Highway Administration (FHWA) staff. The authors researched and confirmed innovative planning activities in the areas of transportation and health of 12 MPOs. Appendix C Table 1 lists the MPOs, their primary partners and initiatives, areas of health and transportation connections, and resulting relevant plans and products.

Health Topics Considered by MPOs

These leading MPOs are dispersed throughout the country, but with concentrations in the western States and in the Midwest. The topical areas through which these MPOs are considering health include:

Safety and air quality are key topics for the integrated approach to health in transportation, as defined by the project team, but they are not identified as a separate topic in Appendix C Table 1 because they are standard established practice for MPOs. Although standard MPO approaches to safety and air quality are not considered innovative practice for this report, the incorporation of the two topics within a balanced and comprehensive approach to health is considered an innovative practice for this research.

MPO Activities Incorporating Health

In addition, the MPOs in the scan demonstrated the following specific activities:

Many of these MPOs have also developed Complete Streets programs,[51] integrated health and transportation into land-use plans, provided guidance on transportation for aging residents, and conducted studies related to health and transportation.

Notably, nearly all of the MPOs reviewed have active engagement of public health and other partner organizations to extend the reach of their transportation programs to consider health. In some cases, the MPOs are active contributors to the work of health agencies and organizations, resulting in a two-way relationship in which transportation organizations learn from and contribute to the work of the health organizations. The two-way relationship might be interpreted as: 1) using the participation of the health sector to bring health considerations into the MPO process and considering health goals in transportation decisions; and 2) bringing transportation into public health programs and activities through introducing transportation considerations explicitly into public health decisions.

Selection Criteria

While all 12 of the MPOs in Appendix C Table 1 have notable accomplishments related to consideration of health that merit further evaluation, the project team selected three MPOs for this paper to provide a diverse picture of the range of strategies that MPOs and their partners are using to connect health and transportation. The project team selected Nashville Area MPO, PSRC, and SACOG based on the following factors:

After completing these three case studies, the project team added SANDAG to include an MPO that has worked on health impact assessments and is focused on capacity building, and to build upon the connection between State and MPO initiatives found in California.

Each of the case studies outlines the background and structure of the MPO, motivations for its transportation and health activities, and the related focus areas for the MPO, including how the MPO defines the relationship between transportation and health. The case studies also summarize and provide links for plans, studies, and programs that have resulted from planning activities and the roles of partner organizations in these initiatives. Finally, each case study summarizes the MPO's evolution in incorporating health and main observations and challenges, including a timeline of the major health-related activities.

Synthesis and Framework

The four MPOs featured in the case studies have all produced visible and significant results through connecting transportation planning activities to health considerations. However, they differ in their sources of motivation, the parts of the planning process they have focused on, and the steps they have taken to incorporate health. These results and different approaches represent a flexible framework for connecting health and transportation. The framework helps explain why an MPO would pursue these connections; where in the planning process these connections can occur; and how these connections can be made. The components of this framework are displayed in Figure 3.

Figure 3 Components of Framework

Motivation (why?). Incorporation into planning process (what/where?). Early actions. (How?). Structural changes. (How?). Incorporation into decision making.This image shows the Metropolitan Area Transportation Planning Process, starting with regional visions and goals and moving through monitoring system performance. There are feedback loops in both directions

Motivation

Based on the four case studies, MPOs often initiate a comprehensive approach to integration of health and transportation in response to, or with support from, an external policy direction, partner initiative, expression of community interest, or most commonly, some combination thereof. The motivator can be directly health-related, such as the Tennessee Obesity Taskforce (TOT), a statewide obesity prevention initiative, or have indirect connections to health, such as the concerns and requirements for air quality and climate change in California. The motivation can lead to contracting of MPO services, such as SANDAG's work for the county health agency; direct MPO action, such as Nashville Area MPO's participation in TOT; or interest and participation of others in the MPO, such as the involvement of the county health departments with PSRC. More generally, a cultural shift towards healthier lifestyles that attracts the attention of local leaders and the public can facilitate MPO consideration of health, as was reported by PSRC.

An external interest in health implications of transportation can logically lead MPOs to identify new planning tasks in their Unified Planning Work Program, such as examining pedestrian or bike access to transit, schools, or healthy food. Additionally, analytical efforts, such as SACOG's investment in GIS data on nonmotorized facilities and collaboration with others on quantifiable benefits of such facilities, might lead to new interest in physical activity and health issues for the MPO as a whole. These various sources of motivation, with examples from the case studies, are provided in Table 1 and Appendix C Table 2.

Table 1: Motivation/Input for the Case Study MPOs

MPO

Motivation/Input Examples

Partner Initiatives

Community Interest

Local and State Government Initiatives

National Priorities and Programs

Research and Analysis

Nashville Area MPO

Safe Routes to School (local health department)

Tennessee Obesity Taskforce

CDC grant and CDC partnership

TIP criteria from data analysis

PSRC

Local county health departments

MPO member interest

CDC and HUD grants

Research study of land use, transportation, air quality, and health

SACOG

Rural Urban Connection Strategy

Air quality, quality of life and rural issues

State-mandated Sustainable Communities Strategy

HUD grant

I-PLACE3S health modules

SANDAG

County's Live Well, San Diego! Initiative

CDC grants

Model health module, HIA training, mapping

Integrating Health throughout the Transportation Planning Process

Most MPOs that have begun to engage in health activities are still early in the process and have yet to fully integrate health into their transportation planning. However, the case studies and expanded summary of 12 MPOs show components of a robust but evolving approach to how transportation planning can assume a role in creating healthy communities. Based on the analysis for this report, the project team identified critical opportunities for comprehensive structural integration of health into the transportation planning process. These opportunities lie in four main steps in the planning process, as illustrated in Figure 2 and highlighted by case study MPOs in Table 2 with further detail in Appendix C Table 3.

Although presented chronologically, from vision to plan to investment decisions, MPOs can begin to incorporate health at any of these stages, depending on opportunities and challenges. The different levels of emphasis on health in each step for the case study MPOs are shown in Table 2 and Appendix C Table 3 by the intensity of the color, where darker blue means greater integration. PSRC has followed a more chronological and sequential approach, with relatively more emphasis on vision and goals, while the Nashville Area MPO instead focuses on targeting investment decisions. SACOG provides balanced treatment across the three steps. SANDAG is also proceeding fairly simultaneously, but with a main focus on supporting factors, such as capacity and tool building.

Table 2 Incorporation of Health into the Transportation Planning Process by Case Study MPOs

MPO Name

Regional Vision and Goals

Development of Transportation Plan

Development of S/TIP

Monitor System Performance

Nashville Area MPO

low high high high

PSRC

high high low high

SACOG

high high high high

SANDAG

high high low low

Darker colors signify greater progression in activity

Table 2 also reflects a critical and broad role for performance measures at all stages of the transportation planning process to support consideration of health. An integrated transportation planning process for healthy communities would necessarily include broad application of performance measures to:

Specifically, performance measures can respond to community or partner input to a vision plan; translate goals in the MTP into outcomes that are understandable and important to stakeholders and the public; and define a baseline at the beginning of an MTP or TIP horizon, and for monitoring and reporting results of plans or investments.

Early Actions and Structural Changes

The MPOs in the case studies engaged early in a mixture of outreach, communications, and technical research activities (see Table 3) that can eventually lead to structural changes in the MPO's planning process, as shown in Table 4.

These early actions occur within the established MPO planning process, and include informal participation of health partners in the development of the MTP and TIP but not necessarily the addition of goals in the MTP or new health criteria in development of the TIP. These actions reflect use of important messaging and relationship-building tools that over time can establish the foundation for improved understanding and future levels of support for health-related activities necessary to allow MPO leadership to engage in more structural changes.

Structural changes result in concrete, measurable, and institutionalized integration of health considerations into the core stages of the metropolitan area transportation planning process, as described in Table 4. Structural elements may be the most visible evidence that MPOs are integrating health considerations into transportation planning in substantial ways that may actually influence or change decisions, and may have the potential for long term continuity. Structural aspects of the planning process reflect the formal "3-C" (Continuing, Cooperative, and Comprehensive,) multimodal planning process called for in joint Federal transportation planning requirements.[52] Structural changes have a greater likelihood of continuing through shifts in political leadership and policy priorities, whether at national, State, regional, or local levels.

The early actions and structural changes are two pieces of the framework for a full integration of health considerations in transportation plans and programs. While the order and extent may vary between MPOs, as captured in the timelines presented in the case studies, the actions listed in Table 3 and Table 4 provides a spectrum within the framework of how MPOs integrate and institutionalize health into their planning activities.

Considering the potential for introducing new expectations for the planning process and metropolitan area transportation system itself, it is understandable that the case study MPOs are undertaking these new approaches incrementally, as shown by the intensity of the color in Table 3 and Table 4. This demonstrates the value of making progress at one stage before undertaking another. Although these MPOs have approached health incrementally, they also demonstrate high level policy support necessary to consider health in regional decisions. Overall, the case study MPOs demonstrate an incremental approach to considering health, building on initial efforts to expand toward more comprehensive approaches as MPOs, staff, and stakeholders gain an understanding of health implications of transportation actions.

Table 3 Early Actions by MPOs to Incorporate Health into the Planning Process

Action

Nashville Area MPO

PSRC

SACOG

SANDAG

Define and document connections between health, land use, and transportation

low high high high

Engage and enlist support of partners

low high high high

Identify ways for public health partners to participate in MPO activities

high high low high

Darker colors signify greater progression in activity

Table 4 Structural Changes by MPOs to Incorporate Health into the Planning Process

Action

Nashville Area MPO

PSRC

SACOG

SANDAG

Incorporate health into MTP goals

low high high low

Develop staff and technical capacity in health-related approaches and tools

high low high high

Establish standing technical or other advisory committees with designated responsibility to oversee health topics

high high high high

Formalize participation of health stakeholders into planning process

high high low low

Incorporate health into TIP project selection criteria

high high low low

Develop performance measures that capture impact on health

high low high high

Darker colors signify greater progression in activity

The remainder of this section expands upon early actions and structural changes, including examples. Additional examples of how the MPOs studied incorporate health at different stages of their planning process are detailed in the four case studies following this section. These and other best-practice MPOs can serve as models for other MPOs. The case study MPOs noted that they continue to benefit from examples of successful practice in this area.

Early Actions

MPOs that are in early stages of building support for the consideration of health in transportation planning use communication and closer ties to partners as early actions that may eventually lead to structural changes. The visibility of structural activities, and the potential policy commitment that these activities entail, necessarily requires strong support among MPO leadership, partners, stakeholders, and citizens, backed up by technical staff capacity to complete the analysis necessary to support possible new expectations. Early actions can develop this level of support and capacity through the following:

1. Define and document the connection between health, land use, and transportation. The establishment of this connection is the foundation for communication and partnerships from which greater support for health and transportation planning is built. Persistent and clear messaging throughout the planning process is among the most valuable tools for building leadership and community support. The messaging should focus on co-benefits of health-based transportation planning, where solutions to transportation problems or needs can also benefit the environment, economy, and health. An example of such messaging is describing pedestrian and bicycle improvements as "active transportation" designed to increase the activity levels of citizens, and as more than a modal alterative to meet mobility needs. Some MPOs have focused on research studies and data collection to establish this link; for example, SACOG uses models and research by partners to help establish the transportation, land use, and health connection in the region, and contributes to advancement of the state of the practice in related analysis and modeling nationally.

This messaging can allow the MPO to brand their planning process, plan, decisions, and ultimately, mission, as contributing to a healthy community.

2. Engage and enlist the support of partners and the public. Partners are critical to introducing linkages between transportation and health, advancing consideration of health in MPO agendas, and building support for transportation decisions among a broad constituency concerned with health.

Partner organizations are often the most critical avenues for gathering data and extending outreach efforts on the importance of connecting health with transportation planning. Partners introduce new information, tools, and constituencies and potentially broaden the base of support for transportation decisions. Potential partners include:

MPOs that successfully engage health partners used the following strategies:

Since health is an issue that the public is more likely to understand and value than aspects traditionally related to metropolitan area transportation planning process, such as traffic delay or road condition, MPOs can use this interest as a means to enhance essential public and stakeholder involvement in broader on-going MPO activities.

3. Find ways for public health partners to participate in MPO activities. Once partners begin to collaborate with MPOs, they can play roles that utilize their expertise and any available resources (data, financial, staff, or new partners) to help shape transportation plans and programs. Partners can be given membership or advisory roles on committees that review, recommend, or approve transportation plans and projects. Public health may be a topic that initially motivates new members of the public to participate in advisory committees or other aspects of the MPO process, thereby strengthening the process. This additional participation is valuable because many MPOs encounter difficulty interesting the public in a process that can seem abstract, technical, and distant from immediate concerns.

Partners can provide direct feedback on relevant plans or projects, as well as formal input into the development of transportation plans and other planning processes. Finally, partners can be involved in the pursuit of funding opportunities for broader initiatives, such as CDC CPPW and HUD Sustainability grants or from other State, local, on foundation sources. Through on-going participation, new partners can gain an understanding of the transportation planning process itself, including the range of goals pursued and the need to trade-off priorities, including health, in making decisions.

Structural Changes

With partner involvement and clear and consistent messaging on the health benefits and impacts of transportation projects, MPOs can begin to identify opportunities to make structural changes to begin considering health throughout their planning process. The case study MPOs provided the following recommendations in approaching structural change to incorporate health into the planning process:

1. Start small with modest and understandable strategies that have co-benefits in other priority areas. For example, prioritization of active transportation and improving access to healthy food provide mobility and accessibility benefits alongside social and environmental benefits, in addition to improving public health. Emphasizing co-benefits, particularly through using performance measures, can easily enlist support from partners and community groups. As feasible, develop clear high level goals in the MTP that support establishment of these strategies.

2. Consider health in project screening or selection criteria. The team's research identified project selection or screening criteria that can include:

These criteria should reflect the larger goals of the MPO, its partners, the State, and the Federal government, beyond traditional transportation goals; as applicable, these can include health, social, environmental, and economic goals.

3. Consider designating funding for projects that meet health-related goals. Aligning funding priorities to support accomplishment of health-related goals is one of the strongest assurances that planned transportation projects will result in beneficial health outcomes. Nashville Area MPO called for 15 percent of its Surface Transportation Program (STP) funding to be used for active transportation projects. This was a major change in how the MPO programs available funds and could only be achieved after building strong public support. This structural step in the planning process is one most likely to be accomplished after making considerable progress on early steps in the planning process, as the Nashville Area MPO has.

4. Develop performance measures that account for health outcomes. MPOs can develop performance measures to assess how transportation projects impact health. These measures can serve a variety of critical functions in the transportation planning process:

Partners can be involved in developing and tracking progress using these measures, recognizing that health benefits can be difficult to measure at a project scale or locally, and may in practice be easier to capture at the regional level considered by MPOs. The use of direct and proxy measures (e.g., increased walking or bicycling trips or reduced vehicle miles travelled as proxies for physical activity) can help build future support for more advanced applications of transportation and health planning through communication of measurable health-related choices and outcomes. Public health analysts can then use these transportation outcomes to estimate specific health outcomes, for example, related to obesity.

5. Consider long-term capacity for health-related transportation research and analysis. MPOs that are able to achieve structural change have the ability and assume a new responsibility to develop documents and policies that connect transportation programs and projects with their health impacts. Both Nashville Area MPO and SACOG plan future data collection and analysis to support activities linking transportation and health. With the support of Federal grant funding, SANDAG has been able to hire staff for health-related tasks and fund work on health-related tools throughout the agency. The establishment of methods to link transportation projects with health outcomes can also assist if MPOs and their partners choose to undertake formal health impact assessments. The routine use of data, performance measures, and forecast tools to analyze health implications can ensure the continuity and longevity of planning for transportation and health activities by establishing these considerations within the technical analysis that is the core of the MPO planning process.

Case Study: Nashville Area MPO

Background

A map showing the area that the Nashville MPO serves, including Sumner County, Robertson County, Davidson County, and Wilson County.

The Nashville Area MPO covers a planning area of approximately 1.5 million people. The MPO includes the Nashville-Davidson and the Murfreesboro urbanized areas, as well as other small cities and rural communities within the planning area. The MPO Executive Board consists of elected leaders from all communities in the planning area with a population of at least 5,000, and most communities send their mayors to the monthly board meetings. The MPO Executive Board programs the Federal transportation funds and has project selection authority for the urban Surface Transportation Program (STP) funds. While the Tennessee Department of Transportation makes funding decisions for rural areas outside of the MPO boundary, the MPO works with these rural areas to document needs and coordinate the development and implementation of transportation solutions. The MPO therefore serves a unique role in planning for rural needs and delivering its metropolitan planning program.

MPO staff has long been engaged in linking transportation planning to public health. The linkages began when MPO staff and public health officials developed relationships through working on initiatives such as Safe Routes to Schools, and they grew under supportive leadership from the MPO Executive Director. Through the staff's vision for bringing public health into MPO activities, the Nashville Area MPO became a leader in concurrent statewide efforts to combat obesity.

According to CDC behavior surveys, Tennessee residents are among the most physically inactive, overweight, and obese people in the United States (measured on a variety of health metrics and compared to other States). Reacting to these rankings and the need to reduce preventable diseases related to obesity and inactivity, stakeholders from around Tennessee came together in 2007 to form the Tennessee Obesity Taskforce (TOT) to develop a statewide plan to combat obesity. The resulting plan, "Eat Well, Play More Tennessee," was published in September 2010. More than six hundred organizations throughout Tennessee, including the State health and transportation departments, are actively working to implement the plan by 2015 (the project currently has grant funding for implementation through 2013). The TOT has a Built Environment and Transportation (BEAT) team that has overseen the adoption of Complete Streets policies, data gathering on school siting, and expansion of Safe Routes to Schools programs throughout the State.

Health Activities

This section describes the MPO's various health-related activities, which are presented along a timeline at the end of the case study.

Motivation and Focus Areas

The Nashville Area MPO reports that it uses transportation planning to address obesity, asthma, traffic injuries, and other health conditions that have been linked to decreased physical activity as part of daily travel as well as worsening air quality, in part by mobile air sources such as vehicles. MPO staff focuses on active transportation, food access, and bicycle/pedestrian safety due to their disease-prevention and public health benefits.

The statewide agenda for obesity prevention has been one strong driver of Nashville Area MPO's attention to health issues. Nashville Area MPO staff served as a co-chair of the TOT from 2010 to the end of 2011, which has kept the MPO at the forefront of strategies to increase physical activity and access to healthy food, as well as efforts to collect data to measure progress. Through its work with TOT, MPO staff cites better understanding of public health practices and have had the opportunity to educate public health staff about the relationship between transportation and obesity.

The TOT and the resulting five-year plan is only one motivation for Nashville's integration of health into their transportation planning activities. MPO staff count their relationships with Federal, State, and local health partners as their strongest impetus for health activities. Through surveys and committees, the MPO staff has a close working relationship with the CDC, with whom they exchange policy recommendations and serve on review committees. In addition, the Nashville Area MPO has over a decade of experience working with a local health department for Safe Routes to School in Nashville. This experience and that of working on the TOT helped enhance the focus on bicycle and pedestrian planning to include health outcomes in addition to focusing on mobility and safety for bicyclists and pedestrians. Stakeholders and citizens throughout the MPO area are increasingly recognizing bicycle and pedestrian infrastructure as a way to encourage active transportation and improve the health of its citizens.

Integration of Health into RTP and TIP

Nashville Area MPO's 2035 regional transportation plan (RTP), published in December 2010, identifies health as a key component of regional quality of life, and allocates funding in accordance with economic, environmental, and health RTP goals. After drafting general goals for improved quality of life, MPO staff noted that the most appropriate solutions to meet these goals simultaneously addressed public health, economic and environmental sustainability objectives. These solutions included mass transit, walkable communities, and enhancement and preservation of the roadway system with a complete streets and technology focus. As a result, the MPO developed project evaluation criteria to address health, economic, and environmental impacts of transportation projects.

Among the most notable accomplishments of the Nashville Area MPO is its designation of STP funding, which is its primary Federal funding source for all surface transportation, for nonmotorized, transit, and technology and operations projects, as follows:

Projects funded under the general STP funds (70 percent) go through project selection during the RTP and Transportation Improvement Program (TIP) development processes. For the 30 percent of STP funds dedicated to nonmotorized, transit, and ITS, the MPO opens the call for applications after the publication of the TIP, which describes the types of projects to be included, rather than specific projects. With the new funding allocations, seventy percent of projects in the RTP contain nonmotorized enhancements, up from an estimated two percent in the previous RTP.

The current TIP, adopted concurrently with the RTP, represents the first iteration of projects selected under this new funding distribution. The project selection criteria for general projects include a multi-modal and multi-functional data analysis focusing on mobility, safety, multimodal elements, freight, future growth, and health elements. As part of its project-level analysis, MPO staff delineated grocery stores to determine proximity and access and to emphasize the corridor's potential to connect people to healthy food. The MPO will use new food desert data to improve this project-level analysis in the future. MPO staff also identified "high health impact areas," signifying areas with greater health disparities. Due to limited availability of health data at a fine scale, the MPO uses census data with high concentrations of low-income, minority, and elderly populations as a proxy measure for the locations of populations with higher rates of chronic disease and health disparities. The MPO more favorably evaluates projects that improve physical activity, such as through including nonmotorized options, or access in these "high health impact areas."

The TIP includes a policy safeguard to ensure that selected projects maintain their nonmotorized enhancements during any revisions or budget reductions. The MPO adopted 15 policies in the TIP that describe budget management for included projects; these policies include enforcing the scope of work described in the RTP and adding a checkpoint before project implementation to ensure consistency with the RTP.

In June 2011, a team contracted by the U.S. Centers for Disease Control and Prevention visited the Nashville Area MPO to conduct a pre-evaluation assessment of physical activity initiatives as part of a larger project to assess local programs and policies that impact nutrition, physical activity, and obesity. The team noted the progress of the MPO's initiatives, focusing on those included in the RTP, and commended staff commitment and leadership. The team recommended Nashville for further evaluation as a model for peer organizations. The Center of Excellence for Training and Research Translation, a CDC-supported Prevention Research Center at the University of North Carolina, has also conducted a favorable policy evaluation of the MPO's targeted funding for active transportation.

Active Transportation

The Nashville Area MPO's bicycle and pedestrian activities have grown more robust in recent years, building on a regional bicycle and pedestrian study that was part of the development of the 2035 RTP. Approximately 2,400 people provided input about barriers and opportunities for bicycle and pedestrian networks, frequently citing health as a motivation for improving these networks. The MPO has a citizen-based Bicycle and Pedestrian Advisory Committee with a formal role in reviewing and scoring nonmotorized projects (15 percent of STP funds). The advisory committee helped shape the Bicycle and Pedestrian Study and developed qualitative and quantitative scoring criteria included in the Bicycle and Pedestrian Study that are used in addition to the general RTP project selection criteria to measure the broader value, reach, and impacts of proposed projects. Related future activities include analyzing bicycle and pedestrian crash data from an equity perspective to understand if certain communities or populations are more prone to nonmotorized crashes, with an eye towards targeting funding to these areas.

Partners

Through its work on the TOT, the Nashville Area MPO has formal and informal relationships with health stakeholders throughout the region and State. Additionally, its presence in the State capital has enabled close relationships with the State departments of transportation, environment and conservation, and health and with the CDC. The CDC has assisted the MPO in outreach presentations on transportation and health linkages, engaged in data sharing, and provided representation on the MPO's steering committee for the regional household travel survey. The region's largest county health department (Nashville-Davidson) has a seat on the Bicycle and Pedestrian Advisory Committee and the Regional Transportation and Health Study steering committee. MPO staff note that they are actively engaged in the public health arena, in terms of sharing transportation strategies and expertise that can shape public health policy.

Children near Nashville walking along a road to school.

Persistent case-making and communications led to a significant shift in funding towards active transportation projects. MPO staff observed that the active citizen-led advisory committee is unique and notable for its role in project selection of nonmotorized projects. Involvement in multi-agency policy efforts throughout the State gives the MPO clout and connections to improve its capacity for planning. Simple transportation strategies with proven health benefits are an easy first step for MPOs to integrate into their planning programs, prior to engaging in complex assessments. ,Photo Sources (clockwise from top left): The Tennessean, Tennessee Department of Transportation, and Wesley Aldridge. All via Nashville Area MPO
A bicycle and pedestrian design charette.
Bicycle paths near Nashville.

Evolution of Activities

Nashville Area MPO recognizes that there are many transportation strategies that can be implemented to improve health impacts, such as increasing mode shift to biking and walking and improving access to healthy food, and they plan to focus on those strategies in the near term. In the future, the MPO will also focus on data collection and measuring health impacts in its communities, to support existing and future investment strategies. Data correlations between transportation improvements and obesity rates are difficult, because many factors influence health, but the MPO staff are learning about ways to translate transportation data to quantify the impacts of policies. The MPO is planning to add a health component to its next household travel survey with questions related to physical activity, food access, and health for all household members. A subset of respondents will participate in a health study in which they wear devices that measure their physical activity and answer a more detailed questionnaire about how their built environments impact health behaviors. This data will establish a baseline for future studies.

Nashville Area MPO currently uses systems-level analysis for performance measurement, and they would like to make an overall shift to performance-based planning at the project level. While the MPO is involved in some small-scale health impact assessment (HIA) pilot programs, the MPO staff plan to focus on the many "obvious" solutions that will bring health benefits before using HIAs to select solutions.

Observations and Conclusions

Timeline

Year

Health-related Activity

2005

  • Nashville Area MPO publishes the 2030 LRTP; an estimated two percent of projects have non-motorized enhancements.

2006

2007

  • Tennessee Obesity Taskforce established; work begins on statewide plan.
  • MPO begins planning for its 2035 LRTP.

2008

  • Regional Bicycle and Pedestrian Study begins

2009

  • November: MPO adopts its Bicycle and Pedestrian Study

2010

  • September: Taskforce adopts "Eat Well, Play More Tennessee"
  • December: MPO adopts its 2035 LRTP and 2011-2015 TIP; seventy percent of road projects have non-motorized enhancements; fifteen percent of STP funds are targeted for active transportation projects.

2011

  • MPO Bicycle and Pedestrian Advisory Committee and staff develop the criteria for the Active Transportation Program and issue the call-for-projects for the first round of funding.

2012

  • January: First round of Active Transportation Program projects are awarded for a total of 2.5 million in Federal U-STP dollars.
  • Data collection for the regional household travel survey, which will include physical activity, food access, and health behavior components
  • Development of Activity Based Travel Demand Model that will help to incorporate physical activity and health considerations into the travel demand modeling process.

2015

  • Planned adoption of 2040 LRTP
  • Implementation complete for the "Eat Well, Play More Tennessee"

Case Study: Puget Sound Region Council

Background

A map of Washington State showing the area served by the Puget Sound Regional Council.

The Puget Sound Regional Council (PSRC) covers a transportation management area of approximately 3.6 million people. The MPO encompasses Kitsap, Pierce, King, and Snohomish counties and the Seattle, Tacoma, and Everett urbanized areas. The MPO membership also includes many other smaller cities and rural communities within the planning area, two Tribes, and various transit agencies.

PSRC was created in 1991 under authority embodied in Federal and State laws for transportation, air quality, and growth management but its focus is now on regional transportation, growth management, and economic development. PSRC distributes Federal funding, produces regional data to support planning, and establishes a vision and steps needed to achieve that vision.

PSRC's member representatives meet annually as the General Assembly but elects members to a governing Executive Board, which meets monthly. Both the General Assembly and the Executive Board use weighted votes based on population. The Transportation Policy Board and Growth Management Policy Board consist of member representatives and make recommendations to the Executive Board.

A map of Washington State showing the area served by the Puget Sound Regional Council.

According to CDC data, Washington State has relatively higher physical activity rates and mid-range obesity rates compared to other States.[55] In addition, a number of initiatives within the region have sought to connect public health and the environment, especially around issues such as active transportation, climate change, and access to healthy food. Regional leaders in these efforts include PSRC, its members (in particular, its four county public health departments), and the State government. Initiatives include the following:

Health Activities

This section describes the MPO's various health-related activities, which are presented along a timeline at the end of the case study.

Motivation and Focus Areas

PSRC has worked with State and local partners to define and expand its involvement in health issues. It has been an evolving process. In the past, PSRC has focused on the health issues of safety considerations in modeling and congestion management, air quality conformity, and greenhouse gas emissions as a State priority for climate change. More recently, PSRC began to focus on the promotion of active living (including nonmotorized transportation) and equitable access to jobs and housing in response to emphases in VISION 2040 and Transportation 2040 (the region's long-range transportation plan, or LRTP) and interest by MPO leadership in health and transportation benefits. Most recently, the Board included health in the list of topics for PSRC to consider for transportation investment prioritization in Transportation 2040.

PSRC's activities around health have been supported by local county public health departments. Public Health - Seattle & King County (PHSKC) has had the longest involvement with PSRC, beginning with LUTAQH and a 2004 health issue paper developed to inform the 2008 LRTP update and related policy document. Beginning in 2010, PHSKC has been joined by the Kitsap County Health District, Snohomish Health District, and Tacoma-Pierce County Health Department. The four agencies have partnered in an effort to improve regional public health representation on several PSRC groups, although the partnership so far has been unsuccessful in securing membership to the Transportation Policy Board. The group meets quarterly and has developed a talking points document on public health issues related to land use and transportation, which encompasses air quality and climate change, healthy eating, active living, affordable healthy housing, equity, and safe and injury free transportation. Representing different regions and operating within different political circumstances, the four health agencies have found they are better able to represent the region when working together.

As one public health official noted, “Transportation and public health officials have many common interests and reasons to coordinate and collaborate.”

Members of the public health partnership report that their interest in PSRC is a result of a shift in their agencies' overall approach to improving health. Previously, much of the focus was on individual behavior change to improve health, but that has now shifted to policies, environments, and systems that support decisions to incorporate healthy behaviors into daily life (e.g., improving access to healthy foods; making walking to school safe, fun, and convenient). The public health community also shares PSRC's interest in the co-benefits for health, environment, and economic development from addressing transportation issues such as congestion, mode share, and transit investments. For example, reducing congestion and shifting mode share away from single occupancy vehicle (SOV) to transit, walking and bicycling can:

Integration of Health into Regional Policy and the Long Range Transportation Plan

PSRC has developed VISION 2040, which provides a policy-level land use, economic development, and transportation strategy for the region, and Transportation 2040, PSRC's long range transportation plan and an implementation component of VISION 2040.

VISION 2040, which was adopted in 2008, is the region's policy-level land use, economic development, and transportation strategy for accommodating an increase of 1.5 million people and 1.1 million jobs by 2040. Health is featured prominently in the document, including the following regional goal for transportation: "The region will have a safe, cleaner, integrated, sustainable, and highly efficient multimodal transportation system that supports the regional growth strategy, promotes economic and environmental vitality, and contributes to better public health." VISION 2040's triple bottom line (people, prosperity, and planet) is viewed by the public health partners as recognizing the link between a healthy environment, healthy economy, and healthy people. In addition to continuing PSRC's interest in safety, VISION 2040 calls out other health-related topics, including the built environment and health, air and water pollution from vehicles, and chronic diseases related to exposure to pollutants, physical inactivity and lack of access to healthy foods.

Transportation 2040, adopted in 2010, is PSRC's long range multimodal transportation plan and an implementation component of VISION 2040. Transportation 2040 focuses on providing mobility while improving the region's environmental health and economy. The Transportation 2040 Prioritization Working Group, a subcommittee of the Transportation Policy Board, is working on a proposal for how to prioritize LRTP investments using a set of nine draft measures based on VISION 2040. Although health is not included as its own measure, PSRC worked with its members and public health partners to incorporate health into the definition of several measures, in particular travel, air quality, and Puget Sound land and water. The measures may be used for a variety of applications; first and foremost will be the evaluation of projects in the Transportation 2040 Plan. The intent of the measures is to serve as a scorecard that is accessible for both the public and decision-makers. By including quantitative and qualitative measures, the reported information will enable consideration of factors (including health) that are not included in the PSRC model and benefit-cost analysis results. This is a decision-making tool rather than a funding tool. PSRC has convened a VISION 2040 Monitoring Committee that will identify performance measures for VISION 2040 as a whole. It is anticipated that the nine LRTP prioritization measures will be incorporated into this broader set of measures.

Grants

PSRC and its partners received two grants in 2010 that have health-related components. PHSKC received a Communities Putting Prevention to Work grant from the U.S. Department of Health and Human Services and the CDC to address the leading causes of death in King County: obesity and tobacco. The PSRC applied for and received funding from PHSKC and this grant to develop a bicycle and pedestrian toolkit for local jurisdictions and to integrate health into the LRTP prioritization proposal. The project strengthened the partnership between PSRC and PHSKC by demonstrating that public health was able to offer resources in addition to consultation and technical assistance. PSRC also received a HUD Sustainable Communities Regional Planning Grant for its proposal, Growing Transit Communities, which focuses on facilitating transit-oriented development but includes considerations of equity and affordable housing. Public health partners note this project as an opportunity to apply the more abstract collaboration occurring with the VISION 2040 and LRTP to the community level and in particular to address important public health issues of equity.

Research and Capacity Building

PSRC has been resourceful in identifying a number of ways in which to build its capacity to connect health and transportation planning. In November 2010, it hosted a Federal Highway Administration (FHWA) / Federal Transit Administration (FTA) Transportation Planning Capacity Building (TPCB) Peer Exchange on "Project Prioritization for Regional Long-Range Transportation Plans" where it learned that other MPOs were incorporating health into their LRTPs. At the event, PSRC connected with Translink, the transportation authority for Vancouver, British Columbia, as a resource. This relationship resulted in PSRC's participation in a one-day symposium in October 2011 on integrating active transportation and health into municipal and regional transportation planning, sponsored by the University of British Columbia's Health & Community Design Lab. The Bicycle Pedestrian Advisory Committee organized a webinar with the Nashville Area MPO on how to frame projects to address active living and health. Finally, PSRC was able to use FTA Section 5307 funding to support regional planning efforts to link the bicycle, pedestrian, and transit networks.

Partners

“Show up. If you’re not at the table – either the big table or the little table in the back room – you are not going to have a say. – Tacoma-Pierce County Public Health Department official

As mentioned previously, PSRC has strong partners in the four county public health departments, which are represented by staff in the following PSRC groups:

“Five years ago the public health professional’s voice was not at the transportation planning table.” – PSRC staff

For the Bicycle Pedestrian Advisory Committee, a PHSKC staff member served as vice-chair since 2008 and is the chair as of January 2012.

Evolution of Activities

PSRC views health as an evolving topic in transportation planning. PSRC has been able to successfully document health and transportation connections, integrating health into policy-level documents, and begin to integrate health into considerations for implementation. PSRC sees integrating health considerations into the Transportation 2040 project prioritization and funding process as a possible future next step.

An additional step is broadening understanding about interdependencies between health, environment and economy. PSRC staffers and others have used the sustainability framework within VISION 2040 to make connections between people, planet, and prosperity. Some participants in the transportation planning process still think there are inherent conflicts between environmental or health outcomes and economic outcomes. This dichotomy is a barrier to more fully integrating public health into land use and transportation planning, and to achieving the sustainability goals of VISION 2040.

“You can either see the donut or the hole. The hole is all the exempted funded projects and unfettered growth that we don’t influence. The donut is the areas we can and are influencing. If we institutionalize public health in the decision-making process and conversations, we will make a difference.” – Tacoma-Pierce County Public Health Department official


Recreational boaters near Seattle.

Photo source: PSRC

The cover of PSRC's VISION 2040 plan.
Photos of commuters on Bike to Work day in Seattle.

There is recognition by both PSRC and its public health partners that public health issues need to be chosen strategically to maintain political and public support and that outreach and education on new ideas will be important to build political will. For example, many in the public health community are interested in the use of health impact assessments but not all agree that HIAs are an appropriate priority for all communities in the region at this time, given limited community and agency capacities. For now, public health leadership and staff hope to continue participating in discussions and to provide consultation and technical assistance to PSRC boards and committees.

The public health partners anticipate continuing to provide an advisory role rather than conducting data collection or research in the near future. The public health partners acknowledge that it is difficult to translate public health research into planning because of the long time frame, data limitations, and the current lack of research to quantify the health benefits of specific actions (such as installing 10 miles of sidewalk). The public health partners would like to work with PSRC to improve its technical capacity related to health factors. The public health partners would also like to assist PSRC in the communication of this technical information in manner that is easy to understand and resonates with broader audiences.

Observations and Conclusions

  1. The process of institutionalizing public health into MPO planning can be viewed as a series of steps that reflect the involvement of public health partners. The process does not have a specific order but can include providing documentation of the connection between health, land use and transportation; aligning public health messages with high level goals of regional planning; gaining membership in work groups and committees; providing input into the development of plans, processes, and documents; sharing information and perspectives with officials and staff; and holding the MPO accountable to institutionalized plans, processes, and documents. In addition, PSRC public health partners have found that bringing funding (grants) to the table strengthens their role as partners.
  2. Public health issues need to be chosen strategically so as to maintain political and public support, but outreach and education are still important to move the conversation forward and build political will. PSRC public health partners have found that it is important to prioritize issues based on opportunities, capacity, political support, and financial cost, and to stay focused rather than try to be overly ambitious.
  3. Reframing projects to address health provides increased rationale and support for a project. The PSRC Transportation 2040 LRTP prioritization process is attempting to reframe projects by evaluating them on several qualitative measures that go beyond benefit-cost analysis and modeling.
  4. It is possible to combine and leverage funding opportunities to expand resources for planning for transportation and health. PSRC has been able to explore health by organizing webinars, participating in peer exchanges, and drawing from FTA Section 5307 funds for regional bicycle, walking and transit planning.
  5. Federal funding requirements for coordination between planning and public health provide a great impetus for MPO action. For example, by requiring health and equity as part of the application, the HUD Sustainable Communities grant program has encouraged many land use and transportation agencies to consider health.
  6. MPOs benefit from following precedents set by peer MPOs in coordinating transportation planning and health. Once an MPO becomes aware of actions taken by other MPOs, the easier it is for the MPO and its Board to pursue those same actions due to the success record and the incentive to be competitive with others; PSRC has been able to achieve support from its Board by demonstrating that other MPOs, such as Nashville Area MPO, are conducting similar initiatives.
  7. Each MPO will need to adapt to the characteristics of its public health agencies and help those agencies adapt to the MPO. Public health agencies are not the same in every jurisdiction and they differ in resources, extent of surveillance, and focus areas. This diversity will translate into different levels of involvement and opportunities for partnership.

Timeline

Year

Health-related Activity

2002

  • Land use, transportation, air quality, and health (LUTAQH) two-year study begins

2003

  • Washington State Department of Health launches the Washington State Nutrition and Physical Activity Plan

2004

  • Issue paper for health written and adopted for the Vision 2020 +20 Update
  • Healthscape (Phase II of LUTAQH) launches and begins development of assessment tools

2005

2006

2007

2008

  • VISION 2040 adopted, with significant focus on the importance of health for people, prosperity, and the planet
  • Washington State Nutrition and Physical Activity Plan updated
  • Pierce County receives an Action Communities for Health, Innovation, and EnVironmental ChangE (ACHIEVE) grant

2009

  • "VISION 2040 & Health" brochure created, emphasizing the link between environment and health and how health is addressed in VISION 2040

2010

  • March: King County receives DHHS/CDC Communities Putting Prevention to Work grant for tackling tobacco use and obesity
  • May: Transportation 2040 adopted
  • October: PSRC receives a HUD Sustainable Communities Regional Planning Grant to implement VISION 2040
  • November: PSRC requests and hosts a peer exchange on "Project Prioritization for Regional Long-Range Transportation Plans" that includes health

2011

  • Transportation 2040 Prioritization Working Group drafts Decision Guide proposal, with nine measures
  • Tacoma-Pierce County Health Department and Washington State Department of Health receive DHHS/CDC Community Transformation Grants for chronic disease prevention

2012

  • VISION 2040 Monitoring Committee to develop measures for VISION 2040
  • Transportation 2040 Prioritization to be completed and integrated into the 2014 update of Transportation 2040.

2013

2014

  • Planned update of Transportation 2040

Case Study: Sacramento Area Council of Governments

Background

The six-county SACOG Region. Yolo, Sutter, Yuba, Placer, El DOrado, and Sacramento counties.

The Sacramento Area Council of Governments (SACOG) encompasses a six-county region that includes 22 member cities and over 2 million people.

SACOG was formed in 1980 under a Joint Powers Agreement (JPA) but was preceded by the Sacramento Regional Area Planning Commission, which was formed in 1963. The current JPA, adopted in July 2003, identifies a Board of Directors that is comprised of county supervisors and city council members appointed by member jurisdictions. SACOG has three committees that report to the Board: Government Relations & Public Affairs, Land Use & Air Quality, and Transportation. SACOG is responsible for transportation planning and funding as well as the identification and resolution of regional issues and the distribution of affordable housing.

One of the regional issues in which SACOG is involved is public health. The following information on significant regional health issues and related initiatives and regulations is provided to establish the context for SACOG's progress on incorporating health into its planning processes. Two major public health issues for the Sacramento Region related to transportation are surface ozone-related impacts and obesity. Several State and national research studies originating in the SACOG region support the importance of these public health issues in the region.

The American Lung Association's State of the Air ranks the Sacramento region as the fifth worst metropolitan area for ozone levels, which are heightened in part by the burning of fossil fuels such as gasoline in motor vehicles. In response to air quality - or "dirty air" - concerns, a coalition consisting of local groups focused on business, health, and the environment partnered to form the Cleaner Air Partnership. The Partnership works to reduce ozone-forming emissions from vehicles by promoting technologies, smart growth, and a variety of transportation demand management strategies, such as telecommuting (telework), carpooling, and bicycling.

The California Physical Fitness Report indicates that approximately a third of students in Sacramento County are overweight. The Sacramento County Childhood Obesity Prevention Coalition formed in 2004 in response to regional concern over increasing rates of childhood obesity. The Coalition issued a report in 2008 that cites change to the built environment resulting in more sedentary lifestyles as a significant factor in childhood obesity for the region. The Coalition has focused on physical activity and access to healthy food, among other initiatives. Another local study, the 2011 Healthy Youth/Healthy Regions report by the UC Davis Center for Regional Change, found that the built environment and transportation have health implications for youth; for example, lack of sidewalks or bike lanes are barriers to active transportation and inadequate or expensive public transportation are barriers to accessing health care, recreation, and other destinations.

California has been a national leader in climate change mitigation and adaptation, smart growth, and multimodal transportation, all of which have positive implications for air quality and obesity health concerns. Such leadership at the State level has had direct impacts on the State's capital; the most significant, relevant State legislation includes the following:

Health Activities

This section describes the MPO's various health-related activities, which are presented along a timeline at the end of the case study.

Motivation and Focus Areas

SACOG traditionally has focused on the transportation impacts on public health from poor air quality by guiding regional land use and transportation investments and adopting clean engine and other programs. In recent years, SACOG has expanded its focus to a broader suite of issues, including active transportation, transit-oriented development (TOD), and lifeline transit service for disadvantaged populations to reach essential destinations. SACOG says this shift is a result of statewide and regional emphasis on integrated planning and decision-making, in particular the region's Blueprint Project, an extensive study of the linkages between transportation, land use, and air quality that resulted in the development of different future scenarios based on projected growth of 1.7 million residents and one million jobs by 2050. SACOG also cited the recent focus on quality of life by its Board, advocacy groups, and general public.

Another area of interest for SACOG is rural issues. SACOG's membership consists of rural, urban, and suburban communities that are interested in how different approaches apply to the different lifestyles and needs of their areas. For example, urban areas are focusing on Complete Street strategies for all modes, with an emphasis on improving air quality and opportunities for active transportation, while rural areas may still be trying to add shoulders or improve intersections to improve safety for bicyclists and pedestrians.

Even as the focus has expanded, air quality remains an important consideration; SACOG has been paying attention to the tradeoffs between health benefits and risks of infill development and TOD. A perceived risk is that such sites have increased levels of toxic air contaminants and fine particulate matter (PM2.5) from diesel engines. However, benefits from such sites could include improved access to health care, lowered transportation costs, better housing, and increased opportunities for physical activity. The Sacramento Metropolitan Air Quality Management District (SMAQMD) has developed its own protocol for project developers to use in assessing potential risks to residents from siting in particular locations, and mitigation strategies to address any identified risks. The protocol is currently a voluntary tool but a new regional air quality management plan for PM2.5 is under development that will establish an attainment year and may specify necessary mitigation, known as transportation control measures.

Integration of Health into LRTP and TIP

SACOG's long-range transportation plan, or the Metropolitan Transportation Plan (MTP), is currently in the process of being updated and includes the State-required sustainable communities strategy (SCS). At the broad level, SACOG staff report that the draft MTP/SCS is intended to advance the Blueprint Scenario by conserving natural resources and investing in compact, mixed use growth to meet multiple goals, including supporting healthy communities through reducing emissions and increasing active transportation. The previous MTP had an appendix on public health and safety but the update integrates health considerations throughout the plan. This change is a result of increasing awareness of how health and transportation interrelate, advocacy by interest groups, and the evolution of regional planning due to SB 375.

The draft MTP/SCS specifically mentions health in the context of equity, housing, safety, air quality, public transportation, and bicycling and walking. The plan identifies a number of strategies that aim to incorporate public health into project evaluation and performance measures with a specific focus on transit access, active transportation, and reducing vehicle miles traveled (VMT) so as to improve air quality and public health. SACOG was not able to specify measures for physical activity or obesity because of data and modeling limitations, but the plan adds several new measures to Environmental Justice area impacts, including transit access to parks, cited as important for physical activity, health, and recreation. Finally, the plan States that SACOG hopes to build expertise and analytical capacity in several areas for future updates, including measures of public health benefits resulting from planning efforts, such as access to food and walkability.

According to SACOG staff, although the projections for growth and revenue in the draft MTP/SCS were lower than those made in the previous MTP in response to the region's economic downturn, projections for investment in multi-modal projects is proportionally higher per capita, thus setting the table for a long-term policy of bicycle/pedestrian investments.

A bi-annual funding program provides an opportunity every two years for SACOG to direct the allocation of funding from pooled State and Federal funding sources that flow through SACOG. These sources include the State Transportation Improvement Program, Regional Surface Transportation Program and the Congestion Mitigation and Air Quality Program). On average, $100 million is available bi-annually for road, transit, or bicycle/pedestrian projects from this pool of funding; in 2011, the total available was $115 million but the total requested was $160 million. Prior to 2003, SACOG distributed the funds based on population. Starting in 2003, however, SACOG began a competitive application process. In the last two funding rounds since 2009, the application process has involved an initial screening followed by an evaluation of performance outcomes in which applicants are asked to demonstrate benefit to the following important Board policy outcomes as thoroughly as possible:

Although applicants can address these criteria qualitatively, SACOG is working to provide applicants with more data and tools to provide more precise justification, although some measures, such as reduced VMT, are harder to quantify than others. The application is intended to align with performance outcomes in State and Federal grants so that if a project does not receive TIP funding, applicants can use the same application for other competitive grant programs.

Although the criteria do not explicitly address health aside from safety, SACOG views mode shift as a proxy, or indirect measure, of active transportation that supports physical activity and improved air quality due to reduced emissions. Under this new process, SACOG has seen an increase in bicycle and pedestrian investments. In 2011, $10 million of the bi-annual funding awards were made to "exclusive" bicycle and pedestrian projects, while approximately 50 percent of the projects funded had a strong a bicycle/pedestrian component. In addition to the support given to mode shift by the TIP criteria, Regional Surface Transportation Program funding for road rehabilitation requires funded projects to incorporate Complete Street features.

Grants

SACOG received a HUD Sustainable Communities Regional Planning Grant in 2010 to increase transit-oriented development (TOD) and improve quality of life. The project is being coordinated with the development of the MTP/SCS. The grant work consists of five case studies of TOD to examine the barriers and opportunities for TOD in the region, coordination with the MTP/SCS, and a final Regional Plan for Sustainable Development. The grant work is being overseen by a Steering Committee and has four working groups (Natural Resources, Infrastructure, Economic Development, and Equity, Housing, and Health) that are open to anyone who wants to join the Sustainable Communities Regional Consortium. Many of the interest groups involved in this effort have an interest in health - especially health equity and Complete Streets - and the marketing around infill development cites health benefits. As one SACOG staff member remarked, "Health is a big part of [the question] 'Is this a good place to live?' "

The workgroup on Equity, Housing, and Health identified a number of performance measures, some of which SACOG has been able to include in the MTP/SCS while others require additional research. For example, SACOG has been able to measure access to healthcare employment but not to health care; fortunately, there is a regional interest in collaborating on this issue. Other health-related measures of interest for refinement are access to parks, higher education, and jobs.

Modeling and Research

SACOG is an innovator in its regional modeling, with a strong data and technical mapping capacity. It currently manages I-PLACE3S, a scenario planning tool originally developed by the California Energy Commission (CEC), the California Department of Transportation and the U.S. Department of Energy. I-PLACE3S was used for the Blueprint Project, MTP 2035, the Rural-Urban Connection Strategy (described below), and MTP/SCS. In 2009, SACOG partnered with Lawrence Frank, director of the Health & Community Design Lab at the University of British Columbia, to develop health and climate change / air pollution modules for I-PLACE3S.[56] The modules have so far only been tested in King County, Washington.

The Rural-Urban Connection Strategy (RUCS)

The Rural-Urban Connection Strategy (RUCS) began in 2007 in response to interest in exploring the region's growth from a rural perspective by developing integrated planning for economic vitality and environmental sustainability for rural areas. RUCS has five areas of interest: land use and conservation, infrastructure of agriculture, economic opportunities, forest management, and regulations. RUCS has so far consisted of coordination, outreach, the development of three working papers and a GIS tool to assess agricultural production for incorporation into I-PLACE3S, and initial work on a community case study on rural agricultural and economic development. One area of interest for transportation and health is local consumption and distribution of local crops, in particular fresh produce, to urban neighborhoods. It is estimated that currently only five percent of what is grown in the region is consumed in the region. A number of organizations are supporting SACOG in this effort, including the SMAQMD, mentioned above, and Valley Vision, an "action tank" focused on improving social, environmental and economic health.

Other

SACOG offers a variety of programs that support reducing VMT and that can be explored on its 511 traveler information website, such as urban and rural vanpools, rideshare matching, and an online trip planner for bicycles. SACOG has partnered with the local Complete Streets Coalition to develop the Complete Streets Toolkit, which includes resources on health and safety, livability, and other areas. In addition to the toolkit, SACOG is working on other Complete Street efforts, including developing walkability audits with WALKSacramento.

Partners

As mentioned above, SACOG has collaborated with many regional entities, including the SMAQMD, Valley Vision, WALKSacramento, and the UC Davis Center for Regional Change. In addition, several other entities are actively involved in related issues: Design Sacramento for Health, Sacramento County Childhood Obesity Prevention Coalition, and the Cleaner Air Partnership. These entities educate the public about the connections between health and quality of life and transportation, offer critique and support of SACOG plans and initiatives, and in some cases provide funding, staff, and resources to assist in developing a program or project. They also present opportunities for new or expanded partnerships and broadened support for SACOG's ongoing planning process.

Evolution of Activities

SACOG has seen an evolution in the incorporation of health issues from stakeholder outreach and broad discussion to specific initiatives and policies. For the future, it sees a potential role for SACOG in providing process support and technical assistance in the area of health and transportation.

In addition to the incorporation of health into larger initiatives-the Sustainable Communities grant, RUCS, and the MTP/SCS - SACOG staff cited small-scale accomplishments, such as emphasizing active transportation in investment priorities, developing the Complete Streets Toolkit, and starting a dialogue between transit agencies on non-emergency health care access and anticipated needs for the aging population. SACOG staff considers all of these activities as part of "setting the table for future outcomes."

SACOG anticipates that the broadened stakeholder community and its issues and concerns will inform and drive future MPO planning, project selection, and funding criteria. In the future, SACOG is interested in improving its technical capacity, expanding on data-driven health and equity performance measures, and incorporating the results of current initiatives into future MTP updates and MTIP prioritization. Toward that end, SACOG would like to identify and pursue funding to operationalize a health module for I-PLACE3S and advance research on the relationship between urban form and physical activity. SACOG would also be interested in building its capacity to conduct Health Impact Assessments at the local level. Finally, SACOG seeks to take advantage of corollary work, such as the HUD grant's case studies, to test performance measures that may be able to be scaled up to a regional analysis level or added to the MTP criteria eventually.

In the immediate future, SACOG is exploring opportunities for linking transit formula grants to new metrics and is planning a forum in 2012 regional care providers to better coordinate health care facility planning with planning for transit and other transportation infrastructure.

Observations and Conclusions

  1. Statewide initiatives can help introduce health into policy discussions and MPO initiatives and investments. For example, California's statewide initiatives for greenhouse gas reduction have provided a foundation for considering air quality impacts more broadly. Measures that support reduction in GHG emissions and other regulated air pollution also improve air quality and encourage active transportation.
  2. Linkages between different planning efforts eliminate stovepipes and provide opportunities for health-related integration. SACOG has taken a leadership role in linking transportation and sustainable development planning with its MTP/SCS and HUD grant. This linkage has resulted in the expansion of health-related measures for the plan and interest in developing more.
  3. MPOs may require training and resources to improve health-related transportation data but such needs can also be an opportunity for expanded activities. SACOG has made great progress developing technical capacity for analyzing health implications. For the future, SACOG identifies both a need to build technical, research, and data collection around health-related transportation research and analysis and an opportunity to provide technical assistance to develop health-related data, projections, and analysis, including eventually health impact assessments at the local level.
  4. Partnerships are an important place for MPOs to start working on health. SACOG has found that if an MPO is open to listening and being challenged, it will be able to leverage common interests and resources to successfully collaborate on initiatives. For example, an MPO can coordinate with air quality districts and city GIS offices to build a network of shared resources and skills. There are also important grant opportunities specific to health-related initiatives that are available.
  5. Rural and urban perspectives on health and transportation are important to address. Like many MPOs, SACOG membership represents rural, urban, and suburban areas and there is growing interest in how best to translate traditionally urban approaches to transportation and health to rural areas and how best to match urban needs with rural resources. For example, SACOG has been exploring local food production and access as part of RUCS.

Timeline

Year

Health-related Activity

1997

  • Caltrans Bicycle Transportation Account program established under the California Bicycle Transportation Act (1994)

2002

  • Sacramento Region Blueprint Project begins, using IPLACE3S scenario planning model

2003

  • Bi-annual funding allocation by SACOG changes to competitive process.

2004

  • Preferred Blueprint Scenario adopted by SACOG
  • Sacramento County Childhood Obesity Prevention Coalition formed

2005

2006

  • California Global Warming Solutions Act of 2006 passed

2007

  • Rural-Urban-Connection Strategy (RUCS) launched by SACOG

2008

  • March: MTP adopted by SACOG
  • April: Creating Healthy Communities report released by Obesity Prevention Coalition
  • September:
  • The Sustainable Communities and Climate Protection Act of 2008 (SB375)
  • The California Complete Streets Act of 2008

2009

  • Bi-annual funding application process includes an initial screening followed by an evaluation of performance outcomes (including nonmotorized mode share)
  • Health and Climate/Air Pollution modules added to IPLACE3S scenario planning tool by SACOG and partners

2010

  • SACOG awarded HUD Sustainable Communities grant

2011

  • Draft MTP/SCS released for comment

2012

  • Planning Forum with health care providers proposed for 2012

Case Study: San Diego Association of Governments

Background

Map of San Diego area as described in the text.

The jurisdiction of the San Diego Association of Governments (SANDAG) comprises the county of San Diego and the 18 cities within the county. In 1966, the local governments created the Comprehensive Planning Organization (CPO) as a long-range planning department, which was then renamed SANDAG in 1980. As of 2010, the region contained just over 3 million people. In addition to meeting the Federal transportation planning requirements for Metropolitan Planning Organizations (MPOs), SANDAG's responsibilities include transit planning, funding allocation, project development and construction. SANDAG is governed by a Board of Directors from the 19 local governments, each with one vote (except the City and County of San Diego, which each have two votes), as well as other agencies, such as the California Department of Transportation (Caltrans) and San Diego Unified Port District. These additional agencies serve in a non-voting, advisory capacity.[57] SANDAG has several committees, which include the topics of: Borders, Environment, Land Use and Regional Growth, Public Safety, and Transportation.

One issue of concern for the MPO is public health. SANDAG considers health as relevant to transportation and land use in four major categories: level of daily physical activity and active transportation, air quality, injury prevention and safety on streets, and level of access to daily goods and services. Although the SANDAG Board of Directors has not formally adopted an official policy or priority for health, it has supported on-going initiatives to integrate health into the MPO's work at several important stages of the planning process. Furthermore, while SANDAG does not directly have control over land use, it has been able to support implementation of land use policies to improve public health at the local and regional level through providing incentives, tools, and grants to various agencies.

The MPO has also responded to statewide initiatives and requirements that promote public health policies. California is a national leader in promoting climate change mitigation, smart growth, and multimodal transportation, all of which have positive impacts on public health. One of the most significant and relevant State legislation is California's Sustainable Communities and Climate Protection Act of 2008 (SB 375)[58] which requires the California Air Resources Board to develop regional greenhouse gas (GHG) emission reduction targets for passenger vehicles and light trucks for each MPO region. SB 375 also requires each MPO to develop a Sustainable Communities Strategy (SCS) that demonstrates how the MPO will meet its GHG targets through integrated land use, housing, and transportation planning. Many of the strategies that have climate change benefits also support improved health outcomes. For example, promoting active transportation as a means to reduce vehicle miles traveled, which in turn reduces greenhouse gas emissions, also results in increased physical activity, improved safety and air quality, and enhanced access. The SCS must be integrated into the MPO's Long Range Transportation Plan, which guides transportation investments for the region over 20 or more years, as required by the Federal government.

Health Activities

This section describes the MPO's various health-related activities, which are presented along a timeline at the end of the case study.

Motivation and Focus Areas

SANDAG's approach to public health is a holistic one, consistent with the approach outlined in this report. Staff reported that SANDAG's health initiatives promote physical activity and access to healthy foods through built environment strategies that support compact, mixed use and transit-oriented communities with walkable streets, access to schools, parks and grocery stores, and a range of transportation options that meet the diverse needs of residents and businesses in the region. These strategies are intended to support four key health-related outcomes:

  1. Increased physical activity that people of all ages and abilities can get from everyday walking and bicycling in their neighborhoods or to work;
  2. Access to daily goods and services such as parks, schools, grocery stores, and transit stations within walking or biking distance;
  3. Improved air quality in neighborhoods and the region as a whole as more people rely less on the automobile for their transportation needs; and
  4. Improved safety for pedestrians, bicyclists and drivers on streets.

SANDAG has been able to promote its public health initiatives in large part due to its partnership with the County of San Diego's Health and Human Services Agency (HHSA), and funding and resources from Federal grants received.

Integration of Health into Planning Products

SANDAG has recognized the link between public health and land use and transportation planning in a number of its regional policy documents including, the 2004 Regional Comprehensive Plan (RCP) , the 2030 Regional Transportation Plan (2030 RTP), and the 2050 Regional Transportation Plan and Sustainable Communities Strategy (2050 RTP/SCS).

The RCP, adopted in 2004, serves as the long-term strategic framework for the San Diego region and is based on smart growth principles. The RCP was the first SANDAG planning document to acknowledge the relationship between health and the built environment. It established a regional objective to "create more walkable and bicycle-friendly communities consistent with good urban design concepts." In 2007, the SANDAG Board of Directors approved the 2030 RTP, which addressed public health from an air quality and physical activity perspective. The 2030 RTP recognized the link between levels of physical activity and compact and mixed use communities, and discusses the public health benefits of promoting active transportation and public transit in the region.

In October 2011, SANDAG adopted the 2050 RTP/SCS, in compliance with the requirements of SB 375. A typical LRTP uses a 20 or 25 year timeline; the longer (40 year) timeline allowed the RTP to identify and use revenues available from the voter-approved transportation sales tax program described below. The 2050 RTP/SCS reaffirmed SANDAG's commitment to address public health at the local and regional level. As mentioned in the 2050 RTP/SCS, in 2007, 33 percent of county residents were overweight and nearly 22 percent were obese. The 2050 RTP/SCS describes the link between public health and land use and transportation, promotes walkable, bikeable, and transit-oriented communities, and allocates resources to implement projects that will improve health outcomes in the region. The 2050 RTP/SCS has allocated 36 percent of the local, State and Federal transportation funds toward transit in the first ten years, with an increasing amount in each subsequent decade, reaching 57 percent in the last ten years of the plan. The 2050 RTP/SCS also approved $6.5 million to fund early implementation of high priority projects from the 2010 Regional Bicycle Plan. These high priority projects are intended to increase the number of people who bike in the region, as well as encourage the development of Complete Streets. The 2050 RTP/SCS allocated a total of $3.8 billion to active transportation projects over the next 40 years.

In addition to Federal and State funding, the San Diego region has a one-half cent sales tax, called TransNet, to support transportation projects included in the Regional Transportation Improvement Program (RTIP), which identifies transportation projects to be funded over the next five years. The initial TransNet program generated $3.3 billion between 1998 and 2008; the money was distributed in equal proportions to transit, highway, and local road projects. In addition, $1 million was earmarked for bicycle programs and projects annually. The program also funded eight Walkable Community Demonstration Projects, which were intended to show the benefits of walkable communities and smart growth planning. Four of the projects were construction projects, focused on streetscape and pedestrian improvements, and four were planning projects for corridors.

In 2004, voters approved extension of the program until 2048. The extension allocates $280 million (2 percent of total) to the Smart Growth Incentive Program and another $280 million to the Active Transportation Grant Program, which covers bicycle, pedestrian, and neighborhood safety projects.[59] The Smart Growth Incentive Program supports a grant program and led to the developed of the Smart Growth Toolbox, which groups various planning tools together as resources for local jurisdictions. This ordinance also supports the implementation of the RTIP and requires all TransNet funded projects to accommodate bicycle and pedestrian facilities where it is reasonable to do so.

Grants and Related Programs

SANDAG has partnered with the County of San Diego Health and Human Services Agency to leverage Federal grants to fund a number of health-related project and programs in the region. These include the Caltrans Transportation Planning Grant, a grant from the CDC Communities Putting Prevention to Work program and the CDC Community Transformation Grant. These grants, and SANDAG's role in the funded projects, are described below in more detail.

Caltrans Transportation Planning Grant

HHSA's Public Health Services (PHS) and WalkSanDiego received $250,000 through the FY2008-2009 Environmental Justice Program of the Caltrans Transportation Planning Grant Program. The "Health Equity by Design" project aimed to reduce health disparities in San Diego's City Heights neighborhood, a disadvantaged community, through community-driven, transit-oriented development strategies. The project created a roadmap to help community members identify barriers to health equity, develop solutions to reduce disparities, and identify steps for implementation. The grant was administered by SANDAG on behalf of HHSA and helped establish the first formal partnership between the two agencies, laying the groundwork for future collaboration.

Communities Putting Prevention to Work

In 2010, HHSA received a Communities Putting Prevention to Work (CPPW) grant of $16.1 million, the largest CPPW grant in the country to address obesity. The grant project, known as Healthy Works in the San Diego region, intended to improve levels of daily physical activity and access to fresh and healthy food and nutrition through policy, systems and environmental change. Healthy Works is part of the County of San Diego's Live Well, San Diego! Initiative, which is a 10-year vision and plan for creating "healthy, safe, and thriving communities." HHSA partnered with SANDAG in applying to the grant to identify ways in which health could inform, enhance, and expand upon existing SANDAG projects to improve health outcomes through built environment strategies.

Through the CPPW grant, HHSA contracted with SANDAG for approximately $3 million to implement transportation-related projects and programs at the local and regional levels that could improve opportunities for physical activity. SANDAG integrated these initiatives into its Overall Work Program (OWP), the Federally required summary of all transportation planning work funded through the MPO, was amended to include these projects. This integration aligned these activities with SANDAG's overall regional transportation planning process and establishing the relevance and importance of these health initiatives.

The CPPW project allowed SANDAG to hire three new staff as well as fund existing staff to promote health in the region. One of the new positions created was for a Public Health Planning Specialist who has experience in both planning and public health, as well as in project management, and community engagement. A number of existing SANDAG staff from planning, engineering, technical services and communications divisions were also involved in the project.

SANDAG formed a Public Health Stakeholder Group (PHSG) to develop recommendations and provide feedback on grant-funded activities. This group consisted of about 30 representatives from local jurisdictions, professional organizations, advocacy groups, community-based organizations, HHSA, other public health professionals, and medical providers. The PHSG made recommendations to the Regional Planning Technical Working Group, consisting of the planning directors from all 19 jurisdictions, which reported to the Regional Planning Committee, consisting of elected officials, which in turn reported to the SANDAG Board of Directors.

SANDAG completed the following initiatives through CPPW, grouped into three categories:

Incentives
Regional Policies and Programs
Tools and Technical Assistance
Community Transformation Grant

In 2011, HHSA received $15 million over five years from the CDC's Community Transformation Grant (CTG) program to continue the "Healthy Works" initiative, which concluded in March 2012. Work on the CTG is anticipated to begin in July 2012 and will continue through September 2016. The grant program will promote tobacco-free and active living, healthy eating, and improved clinical management of risk factors of high blood pressure and high cholesterol in the San Diego region. The grant will be implemented in collaboration with a number of partners including SANDAG, which will receive approximately $2.5 million of the funding. Of the five strategy areas of the CTG, SANDAG will implement projects under the "healthy and safe physical environments" area to increase physical activity in the community and workplace, establish community design standards to make streets safe for all users, and develop tools and protocols for assessing the impacts of proposed projects and plans on community health and wellbeing. To this extent, SANDAG plans to implement four projects:

Partners

SANDAG partnered with a number of agencies and organizations to implement the CPPW projects and programs. In addition to securing funding for the project, HHSA supported SANDAG with technical data and information, developing recommendations and implementing programs. The two agencies have partnered to implement various components of the CPPW project related to regional planning, active transportation, and SRTS. SANDAG also partnered with the San Diego County Air Pollution Control District and the California Department of Public Health for developing the health module for the ABM and CommunityViz. SANDAG's other partners on related initiatives include the University of California at San Diego (UCSD), San Diego State University (SDSU), and Active Living Research (ALR), a national program of the Robert Wood Johnson Foundation administered by UCSD. Finally, Caltrans participated in the PHSG, attended two SANDAG training workshops on HIAs, and partnered with SANDAG, HHSA, and other partners to apply for a Caltrans internal research grant to fund the application of HIAs for access improvement studies at all port of entries. The project would allow SANDAG to conduct a second pilot HIA project at the US-Mexico San Ysidro border site within the county, focusing on nonmotorized access and equity, as well as support Caltrans at the other sites.

Evolution of Activities

SANDAG is still in the process of integrating health considerations into its transportation planning and implementation activities. The MPO is pursuing several strategies to build capacity and support for these initiatives among internal and external stakeholders both at the local and regional level. Integration of health into formal planning efforts began in 2007, when the Board of Directors approved the 2030 RTP, which recognized the link between public health and air quality and physical activity. Since then, SANDAG has been able to leverage and expand much of its public health work due to its partnership with the San Diego County HHSA, established in 2008 through the Health Equity by Design project in the City Heights neighborhood of San Diego.

As part of the 2010 Healthy Works Project, SANDAG was able to hire additional staff to focus on public health initiatives and was also able to engage existing staff in the new work. For example, the health module for the ABM required the involvement of technical staff and the pilot HIA project was managed by the transit planning division. This staffing arrangement helped others in the organization to recognize the connection between SANDAG's on-going transportation planning process and public health, and to develop the capacity to more effectively implement transportation-related health initiatives in the future.

This work will be continued through the CTG, awarded to HHSA by the CDC in 2011. Also in 2011, SANDAG approved its 2050 RTP/SCS, and although the document did not include full results of the Healthy Works project (due to timing), it acknowledges key public health principles that promote healthy communities. According to SANDAG staff, these activities will be more fully incorporated in the next RTP/SCS update.

Healthy Works. Paths to Healty Living logo.
Photo of multiple people at tables in a meeting. Building capacity at local governments can broaden the MPO's ability to promote health in transportation, in particular in connection to land use.Photo of six produce baskets.

Photos (From top to bottom of page): Healthy Works logo; Health Impact Assessment training, Source: SANDAG; Food at convenience stores through the “Cilantro to Stores” program, Source: City of Chula Vista.

Although SANDAG has benefited in the short-term from external grants that support its health initiatives, the MPO is actively looking for ways to sustain these projects in the future and to mainstream health consideration as part of its work. For example, due to the success of the CPPW grant program, SANDAG has made health-related projects eligible for funding under the TransNet Smart Growth Incentive Program, which awards funds for public improvements that support transit-oriented development projects. As a result, now more local jurisdictions are encouraged to consider health in the projects, or even include a HIA.

Moving forward, SANDAG has identified a number of next steps to continue integrating health considerations into its activities. In addition to the CTG projects described above, staff will continue to engage policymakers and stakeholders to raise awareness, develop recommendations, and build support for health-related initiatives. In addition, SANDAG will continue to build capacity in the region to address health in land use and transportation planning.

Observations and Conclusions

  1. Collaborating with public health partners to achieve common goals can lead to new resources and project opportunities. SANDAG's ability to partner with the San Diego County's HHSA has been integral to its success in leveraging new resources and implementing public health initiatives successfully. Due to this partnership, SANDAG has been able to receive funding from a number of competitive grants, such as the CPPW and the CTG, that provide resources necessary to create health and transportation programs. Partnership with HHSA has also been critical in engaging local and regional stakeholders.
  2. Allocating grant funds and other resources towards building internal staff capacity can lay the foundation for addressing health throughout the MPO. The ability to hire additional staff has been instrumental in SANDAG's ability to pursue public health initiatives. In particular, having a professional on the team who can help leverage public health initiatives through prior experience has been very important. In addition, additional staff has helped SANDAG focus on internal buy-in, promoting health initiatives within the organization, building staff capacity for the long term, and engaging elected officials and Board members on health-related transportation issues.
  3. Building capacity at local governments can broaden the MPO's ability to promote health in transportation, in particular in connection to land use. Since SANDAG does not have land use authority, it needs to build support and leverage participation from local governments to influence local and region-wide land use decisions in coordination with transportation to improve health outcomes. Providing best practices, models, tools, and incentives has been useful in helping to build support among other agencies, elected officials, and the broader community. SANDAG allocated grant funds to support partners in implementing projects and programs, and build their capacity to conduct health assessments to ensure that the region will continue to advance public health objectives through transportation planning in a sustainable manner, beyond the grant period.

Timeline

Year

Health-related Activity

2004

  • Regional Comprehensive Plan adopted; based on smart growth principles
  • Voters approved extension of one-half cent sales tax for transportation projects through 2048; included designated funding for smart growth and bicycle and pedestrian initiatives and required accommodation of bicycle/pedestrian facilities

2005

2006

  • California Global Warming Solutions Act of 2006 passed

2007

  • 2030 San Diego Regional Transportation Plan: Pathways to the Future was adopted, with public health acknowledgement

2008

  • The Sustainable Communities and Climate Protection Act of 2008 (SB375) passed
  • The California Complete Streets Act of 2008 passed
  • San Diego County's Health and Human Services Agency (HHSA) received grant from Caltrans Transportation Planning Grant Program for "Health Equity by Design" project, via SANDAG

2009

2010

  • HHSA awarded CDC Communities Putting Prevention to Work (CPPW) grant and contracted with SANDAG ($3 million) to implement part of the grant to address obesity prevention, physical inactivity and poor nutrition resulting from transportation infrastructure investments and land use patterns

2011

  • SANDAG implemented many "Healthy Works" components, including grants, tools, and a Health Impact Assessment
  • HHSA awarded a CDC Community Transformation Grant (CTG) to continue work of the CPPW grant
  • SANDAG Board of Directors approved $6.5 million to fund the initial implementation of the Regional Bicycle Program
  • SANDAG updated the RTP and met the requirements of SB375 with the approval of the 2050 RTP/Sustainable Communities Strategy (SCS).

2012

  • HHSA to contract with SANDAG ($2.5-3 million) to work on CTG

 

Updated: 01/07/2014
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