At the Intersection of Health, Health Care and Policy Cite this article as: Bethany Rogerson, Ruth Lindberg, Marjory Givens and Aaron Wernham A Simplified Framework For Incorporating Health Into Community Development Initiatives Health Affairs, 33, no.11 (2014):1939-1947 doi: 10.1377/hlthaff.2014.0632
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Measuring Community Health By Bethany Rogerson, Ruth Lindberg, Marjory Givens, and Aaron Wernham 10.1377/hlthaff.2014.0632 HEALTH AFFAIRS 33, NO. 11 (2014): 1939–1947 ©2014 Project HOPE— The People-to-People Health Foundation, Inc.
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A Simplified Framework For Incorporating Health Into Community Development Initiatives
Bethany Rogerson is a senior associate with the Health Impact Project, a collaboration of the Robert Wood Johnson Foundation and the Pew Charitable Trusts, in Washington, D.C.
Community development seeks to address the consequences of poverty through initiatives that improve housing, economic opportunity, service availability, and community capacity. There is growing recognition that the fields of community development and public health have much in common with regard to target populations, objectives, and challenges. Individual and neighborhood-level poverty are well-documented risk factors for illness and premature death. But relatively few developers systematically analyze how their projects could affect the health of the target community. Tools and metrics that facilitate incorporating health into planning, financing, and implementing new community development projects and programs will foster more widespread and productive collaboration between these two fields. We propose a simple framework to facilitate the identification and measurement of potential health effects, actions to optimize anticipated positive impacts, and strategies to mitigate potential negative impacts. The framework is drawn from an analysis of health impact assessments and includes four elements: identifying the health status of the population served, considering neighborhood-level influences on health, building design features important to health, and incorporating community engagement and capacity-building activities into the initiative. ABSTRACT
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growing body of research documents the connections between low income, inadequate housing, and concentrated neighborhood poverty, on the one hand, and rates of mortality and illnesses such as coronary artery disease, diabetes, asthma, and many cancers, on the other hand.1–6 The mechanisms through which economic hardship acts on health are complex. Food insecurity and stress in early childhood, poor educational outcomes, and exposure to violence are more common in low-income neighborhoods than elsewhere and increase the risk of many illnesses.3,7,8 Low-income families face barriers to health such as housing with lead paint,
Ruth Lindberg is a senior associate with the Health Impact Project. Marjory Givens is an officer with the Health Impact Project. Aaron Wernham (aawernham@ gmail.com) was director of the Health Impact Project at the time of this research. He has since left the project.
mold, and dangerous structural problems; fewer places to exercise safely and purchase nutritious food; and greater exposure to air pollution.7,9–11 Moreover, given their limited budgets, low-income households often must choose between nutritious food, medical care, housing, and adequate home heating and cooling—and all of those choices have implications for health and well-being.8 Community developers and community development finance institutions address many of these challenges. For example, they provide financing for small business development; build affordable housing; and support infrastructure and programming that increase access to child care, social services, medical care, healthful N ov e m b e r 201 4
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Measuring Community Health food, safe places to exercise, and public transit.12–14 By involving communities in leading, planning, implementing, and managing these initiatives, community developers also support the development of stronger social infrastructure.14,15 Greater collaboration between the fields of community development and public health offers opportunities for both fields and the communities they serve. Incorporating public health data and responding to the health needs and concerns of communities gives developers another way to achieve their objectives, offers a new approach to building stakeholder consensus in support of a well-planned initiative, and provides new metrics to use in measuring and demonstrating the value of developers’ work. For people in the field of public health, community developers represent a dynamic new ally in the challenging work of improving economic, environmental, and social influences on health. Interest in collaboration between the fields has grown recently, catalyzed by the efforts of the Healthy Communities Initiative that was created by the Federal Reserve System and the Robert Wood Johnson Foundation.16 Recent conferences and publications have highlighted the common ground between these fields in regard to target populations, objectives, and challenges.17,18 Early examples from partnerships between the fields have yielded benefits for the public’s health, but explicit cross-sector coordination is still relatively rare.14 Consequently, the many health benefits of community development initiatives have seldom been systematically identified, measured, or optimized. There are practical challenges to the implementation of partnerships between the fields— as is the case with the implementation of any new partnership. Community developers face hurdles in planning, financing, obtaining permits, addressing stakeholders’ interests and concerns, and designing and building new projects. Given the omnipresent barriers of tight budgets and challenging timelines, it may be impractical to add detailed public health investigations to an already burdensome planning process. Realizing the full promise of collaboration between community development and public health, therefore, will require health partners to work within developers’ time and budget constraints and to simplify the task of incorporating health concerns into their initiatives.
Health Impact Assessments One tool that is commonly used to incorporate health in decisions made outside the health sector is a health impact assessment. Such an as1940
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sessment is “a systematic process that uses an array of data sources and analytic methods and considers input from stakeholders to determine the potential effects of a proposed policy, plan, program, or project on the health of a population and the distribution of those effects within the population. [Health impact assessments] provide recommendations on monitoring and managing those effects.”19(p5) The assessments have proved to be an effective tool for building and strengthening cross-sector collaborations because they facilitate sharing data, engaging stakeholders, and identifying common goals and practical approaches to achieving them.20 It commonly takes six weeks to a year to prepare a health impact assessment, and according to one estimate, the process can cost between $10,000 and $200,000.21 Relatively few developers undertake health impact assessments when planning new initiatives. A recent national evaluation found that the time and resources required to complete an assessment can sometimes create a barrier to the more common use of this tool, particularly for those new to the process.20 To help developers incorporate health into their work, this article offers a framework that makes it easier to build health into the planning and implementation of community development initiatives and that assists developers in measuring and demonstrating the health benefits of their work. This simplified framework is derived from a sample of completed health impact assessments. It is not intended to replace a more in-depth assessment; it draws upon and is consistent with core elements of health impact assessments and can facilitate the process by providing an overview of potential health effects, data sources, and indicators, as well as actions that can be taken to optimize a project’s health impacts. Developers considering whether to conduct a health impact assessment should refer to the screening criteria described in guidance from the National Research Council.19(p47–52) The criteria include consideration both of the ways that development decisions could influence health and of the time and resources available to complete the assessment. Even when developers choose not to undertake a health impact assessment, it is still possible for them to address important health issues. In this case, our simplified framework can be used as a starting point and a guide for identifying important health considerations and practical ways to maximize the health benefits of community development. Our framework is described in detail below. It has four elements: identifying the health status
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It may be challenging to find data that accurately represent smaller populations or specific neighborhoods.
of the population served; considering neighborhood-level influences on health; building design features important to health into the project; and incorporating community engagement and capacity-building activities into the project.
Study Data And Methods We reviewed a purposeful sample of thirty-four US health impact assessments contained in a public database maintained by the Health Impact Project, a collaboration of the Robert Wood Johnson Foundation and the Pew Charitable Trusts.22 This database was developed in 2010 in conjunction with the Centers for Disease Control and Prevention’s (CDC’s) Healthy Community Design Initiative.23 It includes assessments that are reported by their authors to either the Health Impact Project or the CDC.24 To select the thirty-four assessments, we read the titles and short descriptions of 224 completed assessments in the database as of March 31, 2014. Thirty-two of the selected assessments have been completed. They all addressed decisions that involved community developers or topics relevant to activities often undertaken by developers, such as the siting of housing; neighborhood revitalization plans; redeveloping and building new affordable housing; constructing parks, trails, and open spaces; and developing transit-oriented and mixed-use projects. We included two in-progress assessments to describe important examples related to policies for funding community development activities. Selected assessments are presented in online Appendix Exhibit A. For each of the thirty-four assessments, we identified the main health impacts they addressed, the indicators they used to measure health, their analytical tools, their assessment findings, and the actions they recommended to improve health.25 Exhibit 1 outlines the influences on health that these assessments common-
ly addressed and gives examples of the types of changes they recommended to optimize health.
Framework Based on our review, we propose a framework with four elements that should be taken into account to incorporate health considerations in development decisions. Identify Population Health Status And Needs Developers can maximize the health benefits of their projects—and understand the value of investments in health—by identifying which illnesses are most prevalent in and important to the population that their projects serve. For example, in New Haven, Connecticut, a health impact assessment found high rates of diabetes, obesity, and motor vehicle–related pedestrian injuries among residents of a corridor targeted for redevelopment (Appendix Exhibit A, row 28).25 The assessment provided a series of evidence-based recommendations to increase physical activity and improve safety through modifications to sidewalks and lighting, and through the introduction of new traffic signals and other traffic-calming features. An assessment in South Los Angeles, California, found that people living near a redevelopment site suffered from high rates of heart disease, diabetes, obesity, and hypertension (Appendix Exhibit A, row 32).25 The surrounding neighborhood contained numerous fast food outlets, convenience stores, and restaurants— but no retail source for fruit and vegetables. The assessment recommended including a farmers market and commercial space at the site to improve residents’ access to healthy food. Baseline health information is often accessible through publicly available sources. Exhibit 2 lists some of these data sources that were commonly used in assessments to characterize the health status of a target community. In some cases, it may be challenging to find data that accurately represent smaller populations or specific neighborhoods. Here, assessments sometimes extrapolated from data for a larger area if the populations had similar demographic characteristics. Assessments also commonly used surveys or added questions to existing needs assessments or other studies. For example, to inform plans for a new affordable housing development, the South Los Angeles assessment included a survey to identify the prevalence of illnesses such as obesity and asthma and to characterize health influences such as air quality, diet, and exercise (Appendix Exhibit A, row 32).25 In Phoenix, Arizona, an assessment for a public housing redevelopment used deidentified November 2014
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Measuring Community Health Exhibit 1 Examples Of Influences On Health And Actions To Optimize Health Sample influences on health and sample health issues
Sample actions to optimize health
Housing structure Old carpet and mold can trigger asthma Structural problems increase risk of falls and burns Stairway design can promote exercise
Install smooth flooring or remove carpeting Include safety features such as safe railings and grab rails Include wide, well-lit stairways
Access to public transit, parks, and open spaces Public transit, pedestrian, and bike infrastructure promote physical activity Unsafe pedestrian crossings increase pedestrians’ risk of injury by motor vehicles
Include sidewalks, bicycle lanes, and open spaces Locate projects near open spaces Add bus or light rail stops in walking distance of projects
Air quality Major outdoor pollution sources may degrade indoor air quality and increase the risk of asthma, heart disease, and other illnesses Crime Neighborhood design can promote social interaction and reduce crime, improving well-being and reducing violent injury Noise Noise from roadways and industry can lead to stress and sleep disturbance and exacerbate high blood pressure Access to goods, services, and employment Density of liquor outlets may increase use Distance to grocery stores may affect quality of diet and increase risk of obesity and diabetes Access to child care, clinics, and jobs has multifaceted health benefits
Install central air filtration and seal windows near emission sources Locate buildings in less polluted areas Include lighting, mixed-use design elements, and common social areas Design buildings that allow residents to view common areas and have more social interaction with neighbors Include sound insulation and barriers for housing near major noise sources Locate buildings in quieter areas Include health-promoting amenities such as farmers markets and community gardens Locate projects to maximize access to existing amenities
Housing affordability and stability Housing costs affect residents’ ability to afford other essentials important to health (food, heat, and medications) Displacement of current residents leads to stress and homelessness and creates multiple health risks Education, employment, and personal income Education, employment, and income improve general health and reduce mortality Ability to pay for essentials (food, heat, and housing) reduce risk of heat and cold injury and improve general health
Build affordable housing Revitalize housing in phases to minimize the displacement of current residents
Include capacity building and job training in development initiatives Implement initiatives to hire local people Support programming and infrastructure for early childhood education and child care
Social cohesion and social capital Neighborhood cohesion and civic engagement can improve mental health, lower crime rates, and improve residents’ overall health
Include capacity building and community engagement Design neighborhoods to maximize safe social interaction
SOURCE Authors’ review of the health impact assessments listed in the online Appendix (see Note 25 in text).
health information from a nearby school because 75 percent of the students lived in the housing units (Appendix Exhibit A, row 5).25 The data helped the researchers better understand residents’ concerns about asthma, air quality, and housing conditions. Although countywide statistics showed relatively low asthma rates, the school reported that more than half of its students suffered from asthma. Having identified this important health concern, the developer included new heating and cooling systems to improve indoor air quality and reduce asthma triggers. Consider Neighborhood Features That Influence Health In the assessments we reviewed, the presence and location of neighbor1942
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hood features such as grocery stores, public transit, and child care were identified as important influences on health (Exhibit 1). Developers can maximize health benefits by considering access to these features in project siting decisions and in the planning and design of communityscale initiatives. Exhibit 3 shows examples of tools used to identify and analyze neighborhood features that are important to health. For example, the Pedestrian Environmental Quality Index, developed by the San Francisco (California) Department of Public Health, measures aspects of roadways that can affect both people’s ability to exercise and their safety while doing so. Maps derived from geographical or geospatial
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Exhibit 2 Data Sources Commonly Used To Measure Baseline Health In Health Impact Assessments Data source
Description
Behavioral Risk Factor Surveillance Surveya
An annual state-by-state telephone survey of self-reported health outcomes (for example, diabetes, high blood pressure, and asthma) whose results are used to determine national and state disease rates.
WONDERb
An online statistical tool that draws on a number of health statistical databases and allows the calculation of rates of certain illnesses for states or regions.
County Health Rankingsc
County-by-county statistics on length of life, self-reported general health, and a subset of health influences.
National Environmental Public Health Tracking Networkd
A program that provides funds for twenty-three states and one city to collect and report data on rates of illnesses that can have environmental triggers and environmental data such as air pollution and drinking water quality.
State and local departments of public health
Departments that track and report rates of a range of illnesses; the departments’ websites can be a good source for vital statistics (mortality rates and causes, and birth rates, all of which are commonly available), data on specific illnesses (varies by state), and some data at the city or county level (varies by state). Door-to-door or telephone surveys of residents in a project area, often used to collect data on self-reported health status (such as general health, mental health, and medical diagnoses including asthma and diabetes) and on influences on health (such as neighborhood safety, access to fruits and vegetables, diet, and exercise).
Surveys conducted during project planning
SOURCE Authors’ review of the health impact assessments listed in the online Appendix (see Note 25 in text). NOTES The exhibit is not intended to provide a complete list of health data sources but instead lists sources that can provide some health statistics for small geographic regions, are publicly available, and were commonly used in the health impact assessments reviewed for this study. aCenters for Disease Control and Prevention. Behavioral Risk Factor Surveillance System [home page on the Internet]. Atlanta (GA): CDC; [last reviewed 2014 Sep 2; cited 2014 Sep 12]. Available from: http://www.cdc.gov/brfss/. bCDC.gov. CDC WONDER [home page on the Internet]. Atlanta (GA): Centers for Disease Control and Prevention; [last reviewed 2014 Jul 28; cited 2014 Sep 12]. Available from: http://wonder.cdc.gov/. cCounty Health Rankings and Roadmaps [home page on the Internet]. Madison (WI): County Health Rankings and Roadmaps; [cited 2014 Sep 12]. Available from: http://www.countyhealthrankings.org/. d Centers for Disease Control and Prevention. State and local tracking portals [Internet]. Atlanta (GA): CDC; [last updated 2014 Jul 1; cited 2014 Sep 12]. Available from: http://ephtracking.cdc.gov/showStateTracking.action.
Exhibit 3 Examples Of Analytic Tools Used To Gauge Health Implications Of Community Development Proposals Tool
Description
Galveston Housing Siting Toola
Developed to guide choices regarding where to build or redevelop public housing, the tool consists of a list of twenty-three publicly available or readily measurable indicators of features at the neighborhood, block, and building level that can affect health, weighted according to importance to health and strength of evidence. The tool estimates the health-related economic benefits of walking or cycling that are associated with transportation infrastructure changes.
Health Economic Assessment Toolb Meridian Township development checklistc
This simple checklist is used by planners to review proposed projects and suggest design features that might support health.
Pedestrian Environmental Quality Indexd
This list of street characteristics can be used to guide a street-by-street walking audit of sidewalks, street crossings, bicycle lanes, and other roadway features that can affect traffic safety and people’s ability to get adequate exercise.
Bicycle Environmental Quality Indexe
This quantitative survey tool uses twenty-one indicators to assess bicycle safety and can be used to identify actions to encourage safe bicycling.
Sustainable Communities Indexf (formerly the Healthy Development Measurement Tool)
This comprehensive, open-source index contains more than a hundred measures of community features such as transportation, housing, services, and economy, with data on their links to health.
SOURCE Authors’ review of the health impact assessments listed in the online Appendix (see Note 25 in text). aNolen LB, Prochaska JD, Dills J, Fuller E, Rushing M, Buschmann R, et al. A health impact assessment for improving healthy housing and neighborhoods in Galveston, Texas: technical report. Galveston (TX): Center to Eliminate Health Disparities at the University of Texas Medical Branch; 2014. bHealth Economic Assessment Tool [home page on the Internet]. Copenhagen: World Health Organization; 2014 Aug 19 [cited 2014 Sep 12]. Available from: http://www.heatwalkingcycling.org/. cIngham County Health Department and Charter Township of Meridian. Charter Township of Meridian health impact assessment [Internet]. Meridian (MI): Charter Township of Meridian; [cited 2014 Sep 19]. Available from: http://hd.ingham.org/Portals/HD/Home/Documents/CHA/HIA%20Checklist.pdf. dUniversity of California, Los Angeles, Center for Occupational and Environmental Health. Pedestrian environmental quality index [Internet]. Los Angeles (CA): University of California; [cited 2014 Sep 12]. Available from: http:// www.peqiwalkability.appspot.com/about.jsp. eSan Francisco Department of Public Health, Program on Health, Equity, and Sustainability. Bicycle Environmental Quality Index [home page on the Internet]. San Francisco (CA): The Department; [cited 2014 Sep 12]. Available from: http://www.sfhealthequity.org/elements/24elements/tools/102-bicycle-environmental-quality-index. fSustainable Communities Index (see Note 26 in text).
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Measuring Community Health information systems (GIS) are also commonly used to determine neighborhood characteristics. For example, a food price and food outlet survey conducted to inform a public housing redevelopment in Denver, Colorado, uncovered the need for healthy food retailers within a shorter and safer walk from the housing units than had been the case. The assessment proposed road safety improvements and the addition of community gardens to increase access to healthy food (Appendix Exhibit A, row 30).25 Similarly, another assessment used maps to show how alternative affordable housing sites would affect residents’ access to neighborhood resources such as community centers, schools, and parks and their exposure to varying levels of noise and air pollution (Appendix Exhibit A, row 29).25 Checklists, indicator sets, and evidence-based standards or benchmarks can also be used to assess neighborhood-level influences on health. The Sustainable Communities Index (Exhibit 3), developed by the San Francisco Department of Public Health, includes more than a hundred indicators that measure how transportation, education, economic, housing, and other community characteristics affect health.26 The index was created in San Francisco, but it has been adapted and implemented by other communities around the country. In Meridian Township, Michigan, planners and developers designed a simple checklist (Exhibit 3) to evaluate and improve proposed development projects according to nine healthrelated domains, including water and air quality, noise, social capital, and health equity (Appendix Exhibit A, row 14).25 During its ten years of use, this checklist has helped increase elderly residents’ access to public transportation, mitigate environmental effects on wetlands while adding open space near housing, and incorporate farmers markets into development plans. Based on the success of this tool, university and government partners are now collaborating to build a more comprehensive GIS-based and online version for regional use.27,28 Developers can also prioritize project sites located in areas with health-supportive resources. An assessment in Texas—conducted by the Georgia Health Policy Center and the University of Texas Medical Branch—used a list of twentythree health-related indicators at the neighborhood, block, and unit levels to help identify optimal sites for rebuilding public housing destroyed by Hurricane Ike. Drawn from publicly available sources, the indicators were weighted by importance to health and strength of evidence (Appendix Exhibit A, row 27).25 Identify And Implement Building Design 1944
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Developers can prioritize project sites located in areas with health-supportive resources.
Features That Support Health Many assessments addressed the influence of a building’s structure and design on health (Exhibit 1). For example, installing smooth flooring and air filtration can reduce asthma triggers, and reinforcing walls for grab rails or building entrances with no steps can reduce the risk of injury from falls (Appendix Exhibit A, row 33).25 In the Denver redevelopment mentioned above, the assessment recommended wider, well-lit stairways to encourage walking and the incorporation of a bike-sharing station to promote biking (Appendix Exhibit A, row 30).25 In another example, community organizations had expressed concerns about air quality and noise impacts on residents at a proposed low-income senior housing facility near a congested freeway. In response to a request by the city’s design review committee, the developer and public health experts identified ways to mitigate related issues such as respiratory illnesses, sleep disturbance, and stress. The developer implemented several evidence-based modifications, including particulate air filtration and sealed bay windows to minimize indoor air pollution, and a building entrance sited to reduce noise (Appendix Exhibit A, row 17).25 Engage The Community To Build Capacity And Respond To Health Concerns And Needs Involving communities in planning and decision making is central to both community development and health impact assessment. Incorporating health into community engagement efforts can help developers plan and implement projects that better serve the needs of the target population, build community support for a proposed project, ensure that developers understand and attend to community priorities, and build community capacity and agency (Exhibit 1). During an assessment of a neighborhood revitalization plan in Missouri, residents identified dangerous road intersections. This led to specific interventions, such as sidewalk improvements and the installation of elevated medians and traffic signals (Appendix Exhibit A, row 25).25 Stake-
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Incorporating health into community engagement efforts can help developers plan and implement projects that better serve the needs of the target population.
holders engaged in an assessment of a proposed walking and biking trail voiced concerns about crime and safety issues that would likely limit use of the trail. Further consultation led the developer to include lighting and other design features to reduce the risk of crime and maximize the chance that people would use the trail (Appendix Exhibit A, row 9).25 Community engagement can also give residents a stronger voice in project planning. Based on residents’ input, one city health department provided comments to the planning department on a proposal to demolish and replace rentcontrolled apartments with market-rate condominiums. The health department documented how the displacement of low-income residents could exacerbate mental illness, food insecurity resulting from increased rent burden, and infection risks associated with overcrowding. A public health analysis, paired with strong community engagement, contributed to the developer’s decision to adopt an alternative that did not displace current residents.29 Addressing health-related community concerns can also build support for a project. In the low-income senior housing development example above, the developer’s inclusion of healthrelated modifications garnered support from neighborhood leaders and recognition for the company as an innovator committed to creating healthy neighborhoods.30 Finally, community engagement and capacity building can contribute to community cohesion, which has strong links to reducing violence and improving general health and well-being.31 Using health metrics can help developers strengthen and better demonstrate this dimension of their work. In the Missouri example above, the assessment highlighted the health benefits of
continued engagement with community members and recommended education and training programs to augment these benefits (Appendix Exhibit A, row 25).25
Considerations When Implementing The Framework Several practical considerations must be addressed when implementing this framework and in any effort to more intentionally build health into community development initiatives. Given the challenges inherent in planning, financing, and getting permits for community development projects, it will be important to find ways to integrate health into new initiatives with a minimum of time. There are hopeful indications from health impact assessments that health can be readily integrated into routine project planning activities. Doing so can also build community support, which can help expedite project approvals. In some instances, for example, completing a health impact assessment has helped secure funds for required environmental reviews or for fast-tracking the implementation of healthrelated recommendations (Appendix Exhibit A, rows 1 and 9).25 Health impact assessments can offer a way to engage community members more actively in the decisions that affect them, but conducting the assessments may also save developers time and money by accomplishing common development practices such as a market analysis. Assessment teams can identify ways to avoid duplication of efforts and maximize the health benefits of engaging community members. In one case, a developer decided not to do a market analysis because the assessment had already collected similar information, assessed community needs, and augmented community engagement in the process (Debarati Majumdar Narayan, Catalyze Research, personal communication, May 21, 2014). Some enhancements to improve health might add to project costs. At the same time, incorporating health through conducting an assessment or simply relying on this framework offers developers an opportunity to identify health metrics that help make a stronger economic case for the value of such investments. For example, an assessment in North Carolina found that full implementation of a plan to revitalize a small neighborhood would support higher-density mixed-use development, and that better pedestrian and bicyclist infrastructure would increase residents’ daily physical activity. The assessment estimated that this investment would offset the costs of the infrastructure through avoiding November 2014
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Measuring Community Health cases of diabetes, coronary heart disease, stroke, hypertension, and premature mortality, which collectively would cost $313 million over twenty years (Appendix Exhibit A, row 2).25 As policy makers, health care providers, and insurance carriers search for effective ways to contain costs, providing solid evidence of healthrelated economic benefits may help create new opportunities for developers to secure funding from sources within the health care system.13 For example, New York State allocated more than $160 million of state Medicaid funding to support housing coordinated with on-site services for high-risk homeless people. The state provided the funds because of evidence that making supportive housing available to such people, who may use hospital services frequently, can improve their health outcomes and reduce associated costs.32 Similarly, a supportive housing project in San Francisco that helped fifty residents move from a city-run nursing home to a community-based setting saved the city about $1.45 million annually.14 Health metrics may also provide a useful way to inform the allocation of financial resources for community development projects. An assessment in Massachusetts, for example, examined how funding criteria for a new state tax grant program for community development corporations could be drafted to support community health (Appendix Exhibit A, row 21).25 And in Georgia an assessment is under way to inform the state’s plan for distributing low-income housing tax credits to developers, based in part on health needs.33 Finally, although our proposed framework can guide developers’ efforts, fully integrating health considerations into community development initiatives will likely require close collaboration with public health experts. Fortunately, there are a growing number of ready partners. Appendix Exhibit B lists some organizations that are working at the intersection of community development and public health.25 One important example is the recently launched Build Healthy Places Network, which will build on the collaboration between the Federal Reserve System and the Robert Wood Johnson Foundation and provide leadership, data, metrics, and other resources.34 The preparation of this article was supported by a grant from the Robert Wood Johnson Foundation. The views expressed are those of the authors and
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Partnerships between community development and public health hold potential as a way to realize measurable and critically needed improvements for people in low-income communities.
Conclusion This article offers a simplified framework to facilitate greater collaboration between the fields of community development and public health. Taking advantage of the increasing expertise and resources available to facilitate partnerships, developers and public health professionals can create shared objectives, identify metrics to demonstrate the value of their investments, and optimize the health benefits of their initiatives. Such partnerships hold tremendous potential as a way to realize measurable and critically needed improvements in the lives, health, and well-being of people in low-income communities. In practice, any such framework is only a starting point and will need to be adapted to each developer’s unique community contexts, resources, and goals. Systematic efforts to evaluate whether implementing more health-based recommendations is achieving the desired outcomes and to identify the most effective practices will be essential to advancing and strengthening this work as collaboration becomes more common. ▪
do not necessarily reflect the views of the Pew Charitable Trusts or the Robert Wood Johnson Foundation. The authors thank Amber Lenhart for her
contributions in editing and assistance with document preparation.
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NOTES 1 Banks J, Marmot M, Oldfield Z, Smith JP. Disease and disadvantage in the United States and in England. JAMA. 2006;295(17):2037–45. 2 Bashinskaya B, Nahed BV, Walcott BP, Coumans JCE, Onuma OK. Socioeconomic status correlates with the prevalence of advanced coronary artery disease in the United States. PLoS One. 2012;7(9):e46314. 3 Braveman PA, Cubbin C, Egerter S, Williams DR, Pamuk E. Socioeconomic disparities in health in the United States: what the patterns tell us. Am J Public Health. 2010; 100(Suppl 1):S186–96. 4 Martinson ML. Income inequality in health at all ages: a comparison of the United States and England. Am J Public Health. 2012;102(11): 2049–56. 5 Muennig P, Fiscella K, Tancredi D, Franks P. The relative health burden of selected social and behavioral risk factors in the United States: implications for policy. Am J Public Health. 2010;100(9):1758–64. 6 Kawachi I, Adler NE, Dow WH. Money, schooling, and health: mechanisms and causal evidence. Ann N Y Acad Sci. 2010;1186:56–68. 7 Diez Roux AV, Mair C. Neighborhoods and health. Ann N Y Acad Sci. 2010;1186:125–45. 8 Health Impact Project. Health impact assessment of proposed changes to the Supplemental Nutrition Assistance Program [Internet]. Washington (DC): The Project; 2013 Jul [cited 2014 Sep 12]. Available from: http://www.rwjf.org/content/ dam/farm/reports/reports/2013/ rwjf407284 9 Bell ML, Ebisu K. Environmental inequality in exposures to airborne particulate matter components in the United States. Environ Health Perspect. 2012;120(12):1699–704. 10 Drewnowski A, Rehm CD, Solet D. Disparities in obesity rates: analysis by ZIP code area. Soc Sci Med. 2007;65(12):2458–63. 11 Jacobs DE. Environmental health disparities in housing. Am J Public Health. 2011;101(Suppl 1):S115–22. 12 Williams DR, Marks J. Community development efforts offer a major opportunity to advance Americans’ health. Health Aff (Millwood). 2011;30(11):2052–5. 13 Braunstein S, Lavizzo-Mourey R. How the health and community development sectors are combining forces to improve health and wellbeing. Health Aff (Millwood). 2011;30(11):2042–51. 14 Erickson D, Andrews N. Partnerships among community develop-
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ment, public health, and health care could improve the well-being of lowincome people. Health Aff (Millwood). 2011;30(11):2056–63. Sportiche N, Wood B, Chen B, James P, Ito K, Banay R, et al. Community development and health: a health impact assessment to inform the community investment tax credit program. Boston (MA): Health Resources in Action; 2014. Federal Reserve Bank of San Francisco. Community development: Healthy Communities [Internet]. San Francisco (CA): The Bank; c2014 [cited 2014 Sep 19]. Available from: http://www.frbsf.org/communitydevelopment/initiatives/healthycommunities Linking community development and health. Health Aff (Millwood). 2011;30(11). Special Issue. Andrews NO, Erickson DJ, Galloway IJ, Seidman ES, editors. Investing in what works for America’s communities. San Francisco (CA): Federal Reserve Bank of San Francisco and Low Income Investment Fund; 2012. National Research Council. Improving health in the United States: the role of health impact assessment. Washington (DC): National Academies Press; 2011. Bourcier E, Charbonneau D, Cahill C, Dannenberg A. Do health impact assessments make a difference? A national evaluation of HIAs in the United States [Internet]. Seattle (WA): Center for Community Health and Evaluation; 2014 Apr [cited 2014 Sep 12]. Available from: http://www .rwjf.org/content/dam/farm/ reports/issue_briefs/2014/ rwjf409204 Health Impact Project. Health impact assessment: bringing public health data to decision making [Internet]. Washington (DC): The Project; 2010 Dec [cited 2014 Sep 12]. Available from: http:// www.pewtrusts.org/en/~/media/ Assets/External-Sites/HealthImpact-Project/healthimpact assessmentbringingpublichealth datatodecisionmaking.pdf Health Impact Project. HIA in the United States [Internet]. Washington (DC): The Project; [cited 2014 Sep 12]. Available from: http:// www.pewtrusts.org/en/multimedia/ data-visualizations/2014/hia-in-theunited-states Centers for Disease Control and Prevention. Designing and building healthy places [Internet]. Atlanta (GA): CDC; [last updated 2014 Sep 10; cited 2014 Sep 12]. Available from: http://www.cdc.gov/healthy
places 24 Health Impact Project. Data sources for the HIA map and list [Internet]. Washington (DC): The Project; 2014 [cited 2014 Oct 6]. Available from: http://www.pewtrusts.org/en/ multimedia/data-visualizations/ 2014/hia-in-the-united-states/hiamap-data-sources 25 To access the Appendix, click on the Appendix link in the box to the right of the article online. 26 Sustainable Communities Index [home page on the Internet]. San Francisco (CA): Sustainable Communities Collective; [cited 2014 Sep 19]. Available from: http://www .sustainablecommunitiesindex.org/ 27 Roof K, Glandon R. Tool created to assess health impacts of development decisions in Ingham County, Michigan. J Environ Health. 2008; 71(1):35–8. 28 Health Impact Project. HIA programs and HIA based tools and approaches [Internet]. Washington (DC): The Project; [cited 2014 Sep 19]. Available from: http:// www.pewtrusts.org/en/projects/ health-impact-project/about/ funding-opportunities/hiaprograms-and-hia-based-tools-andapproaches 29 Corburn J. Toward the healthy city: people, places, and the politics of urban planning. Cambridge (MA): MIT Press; 2009. 30 Federal Reserve Bank of San Francisco, Urban Institute. What counts: harnessing data for America’s communities. San Francisco (CA): The Bank; forthcoming. 31 Kawachi I, Berkman LF. Social cohesion, social capital, and health. In: Berkman LF, Kawachi I, editors. Social epidemiology. New York (NY): Oxford University Press; 2000. p. 174–90. 32 Doran KM, Misa EJ, Shah NR. Housing as health care—New York’s boundary-crossing experiment. N Engl J Med. 2013;369(25):2374–7. 33 Georgia State University, Georgia Health Policy Center. Study to inform housing tax credit allocations [Internet]. 2014. Atlanta (GA): Georgia State University; 2014 Jan 14 [cited 2014 Sep 12]. Available from: http://ghpc.gsu.edu/2014/01/ 14/georgia-health-policy-centerconducting-study-inform-housingtax-credit-allocations/ 34 Build Healthy Places Network [home page on the Internet]. Oakland (CA): Public Health Institute; [cited 2014 Sep 19]. Available from: http://www .buildhealthyplaces.org/
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Measuring Community Health By Bethany Rogerson, Ruth Lindberg, Marjory Givens, and Aaron Wernham 10.1377/hlthaff.2014.0632 HEALTH AFFAIRS 33, NO. 11 (2014): 1939–1947 ©2014 Project HOPE— The People-to-People Health Foundation, Inc.
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A Simplified Framework For Incorporating Health Into Community Development Initiatives
Bethany Rogerson is a senior associate with the Health Impact Project, a collaboration of the Robert Wood Johnson Foundation and the Pew Charitable Trusts, in Washington, D.C.
Community development seeks to address the consequences of poverty through initiatives that improve housing, economic opportunity, service availability, and community capacity. There is growing recognition that the fields of community development and public health have much in common with regard to target populations, objectives, and challenges. Individual and neighborhood-level poverty are well-documented risk factors for illness and premature death. But relatively few developers systematically analyze how their projects could affect the health of the target community. Tools and metrics that facilitate incorporating health into planning, financing, and implementing new community development projects and programs will foster more widespread and productive collaboration between these two fields. We propose a simple framework to facilitate the identification and measurement of potential health effects, actions to optimize anticipated positive impacts, and strategies to mitigate potential negative impacts. The framework is drawn from an analysis of health impact assessments and includes four elements: identifying the health status of the population served, considering neighborhood-level influences on health, building design features important to health, and incorporating community engagement and capacity-building activities into the initiative. ABSTRACT
A
growing body of research documents the connections between low income, inadequate housing, and concentrated neighborhood poverty, on the one hand, and rates of mortality and illnesses such as coronary artery disease, diabetes, asthma, and many cancers, on the other hand.1–6 The mechanisms through which economic hardship acts on health are complex. Food insecurity and stress in early childhood, poor educational outcomes, and exposure to violence are more common in low-income neighborhoods than elsewhere and increase the risk of many illnesses.3,7,8 Low-income families face barriers to health such as housing with lead paint,
Ruth Lindberg is a senior associate with the Health Impact Project. Marjory Givens is an officer with the Health Impact Project. Aaron Wernham (aawernham@ gmail.com) was director of the Health Impact Project at the time of this research. He has since left the project.
mold, and dangerous structural problems; fewer places to exercise safely and purchase nutritious food; and greater exposure to air pollution.7,9–11 Moreover, given their limited budgets, low-income households often must choose between nutritious food, medical care, housing, and adequate home heating and cooling—and all of those choices have implications for health and well-being.8 Community developers and community development finance institutions address many of these challenges. For example, they provide financing for small business development; build affordable housing; and support infrastructure and programming that increase access to child care, social services, medical care, healthful N ov e m b e r 201 4
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Measuring Community Health food, safe places to exercise, and public transit.12–14 By involving communities in leading, planning, implementing, and managing these initiatives, community developers also support the development of stronger social infrastructure.14,15 Greater collaboration between the fields of community development and public health offers opportunities for both fields and the communities they serve. Incorporating public health data and responding to the health needs and concerns of communities gives developers another way to achieve their objectives, offers a new approach to building stakeholder consensus in support of a well-planned initiative, and provides new metrics to use in measuring and demonstrating the value of developers’ work. For people in the field of public health, community developers represent a dynamic new ally in the challenging work of improving economic, environmental, and social influences on health. Interest in collaboration between the fields has grown recently, catalyzed by the efforts of the Healthy Communities Initiative that was created by the Federal Reserve System and the Robert Wood Johnson Foundation.16 Recent conferences and publications have highlighted the common ground between these fields in regard to target populations, objectives, and challenges.17,18 Early examples from partnerships between the fields have yielded benefits for the public’s health, but explicit cross-sector coordination is still relatively rare.14 Consequently, the many health benefits of community development initiatives have seldom been systematically identified, measured, or optimized. There are practical challenges to the implementation of partnerships between the fields— as is the case with the implementation of any new partnership. Community developers face hurdles in planning, financing, obtaining permits, addressing stakeholders’ interests and concerns, and designing and building new projects. Given the omnipresent barriers of tight budgets and challenging timelines, it may be impractical to add detailed public health investigations to an already burdensome planning process. Realizing the full promise of collaboration between community development and public health, therefore, will require health partners to work within developers’ time and budget constraints and to simplify the task of incorporating health concerns into their initiatives.
Health Impact Assessments One tool that is commonly used to incorporate health in decisions made outside the health sector is a health impact assessment. Such an as1940
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sessment is “a systematic process that uses an array of data sources and analytic methods and considers input from stakeholders to determine the potential effects of a proposed policy, plan, program, or project on the health of a population and the distribution of those effects within the population. [Health impact assessments] provide recommendations on monitoring and managing those effects.”19(p5) The assessments have proved to be an effective tool for building and strengthening cross-sector collaborations because they facilitate sharing data, engaging stakeholders, and identifying common goals and practical approaches to achieving them.20 It commonly takes six weeks to a year to prepare a health impact assessment, and according to one estimate, the process can cost between $10,000 and $200,000.21 Relatively few developers undertake health impact assessments when planning new initiatives. A recent national evaluation found that the time and resources required to complete an assessment can sometimes create a barrier to the more common use of this tool, particularly for those new to the process.20 To help developers incorporate health into their work, this article offers a framework that makes it easier to build health into the planning and implementation of community development initiatives and that assists developers in measuring and demonstrating the health benefits of their work. This simplified framework is derived from a sample of completed health impact assessments. It is not intended to replace a more in-depth assessment; it draws upon and is consistent with core elements of health impact assessments and can facilitate the process by providing an overview of potential health effects, data sources, and indicators, as well as actions that can be taken to optimize a project’s health impacts. Developers considering whether to conduct a health impact assessment should refer to the screening criteria described in guidance from the National Research Council.19(p47–52) The criteria include consideration both of the ways that development decisions could influence health and of the time and resources available to complete the assessment. Even when developers choose not to undertake a health impact assessment, it is still possible for them to address important health issues. In this case, our simplified framework can be used as a starting point and a guide for identifying important health considerations and practical ways to maximize the health benefits of community development. Our framework is described in detail below. It has four elements: identifying the health status
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It may be challenging to find data that accurately represent smaller populations or specific neighborhoods.
of the population served; considering neighborhood-level influences on health; building design features important to health into the project; and incorporating community engagement and capacity-building activities into the project.
Study Data And Methods We reviewed a purposeful sample of thirty-four US health impact assessments contained in a public database maintained by the Health Impact Project, a collaboration of the Robert Wood Johnson Foundation and the Pew Charitable Trusts.22 This database was developed in 2010 in conjunction with the Centers for Disease Control and Prevention’s (CDC’s) Healthy Community Design Initiative.23 It includes assessments that are reported by their authors to either the Health Impact Project or the CDC.24 To select the thirty-four assessments, we read the titles and short descriptions of 224 completed assessments in the database as of March 31, 2014. Thirty-two of the selected assessments have been completed. They all addressed decisions that involved community developers or topics relevant to activities often undertaken by developers, such as the siting of housing; neighborhood revitalization plans; redeveloping and building new affordable housing; constructing parks, trails, and open spaces; and developing transit-oriented and mixed-use projects. We included two in-progress assessments to describe important examples related to policies for funding community development activities. Selected assessments are presented in online Appendix Exhibit A. For each of the thirty-four assessments, we identified the main health impacts they addressed, the indicators they used to measure health, their analytical tools, their assessment findings, and the actions they recommended to improve health.25 Exhibit 1 outlines the influences on health that these assessments common-
ly addressed and gives examples of the types of changes they recommended to optimize health.
Framework Based on our review, we propose a framework with four elements that should be taken into account to incorporate health considerations in development decisions. Identify Population Health Status And Needs Developers can maximize the health benefits of their projects—and understand the value of investments in health—by identifying which illnesses are most prevalent in and important to the population that their projects serve. For example, in New Haven, Connecticut, a health impact assessment found high rates of diabetes, obesity, and motor vehicle–related pedestrian injuries among residents of a corridor targeted for redevelopment (Appendix Exhibit A, row 28).25 The assessment provided a series of evidence-based recommendations to increase physical activity and improve safety through modifications to sidewalks and lighting, and through the introduction of new traffic signals and other traffic-calming features. An assessment in South Los Angeles, California, found that people living near a redevelopment site suffered from high rates of heart disease, diabetes, obesity, and hypertension (Appendix Exhibit A, row 32).25 The surrounding neighborhood contained numerous fast food outlets, convenience stores, and restaurants— but no retail source for fruit and vegetables. The assessment recommended including a farmers market and commercial space at the site to improve residents’ access to healthy food. Baseline health information is often accessible through publicly available sources. Exhibit 2 lists some of these data sources that were commonly used in assessments to characterize the health status of a target community. In some cases, it may be challenging to find data that accurately represent smaller populations or specific neighborhoods. Here, assessments sometimes extrapolated from data for a larger area if the populations had similar demographic characteristics. Assessments also commonly used surveys or added questions to existing needs assessments or other studies. For example, to inform plans for a new affordable housing development, the South Los Angeles assessment included a survey to identify the prevalence of illnesses such as obesity and asthma and to characterize health influences such as air quality, diet, and exercise (Appendix Exhibit A, row 32).25 In Phoenix, Arizona, an assessment for a public housing redevelopment used deidentified November 2014
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Measuring Community Health Exhibit 1 Examples Of Influences On Health And Actions To Optimize Health Sample influences on health and sample health issues
Sample actions to optimize health
Housing structure Old carpet and mold can trigger asthma Structural problems increase risk of falls and burns Stairway design can promote exercise
Install smooth flooring or remove carpeting Include safety features such as safe railings and grab rails Include wide, well-lit stairways
Access to public transit, parks, and open spaces Public transit, pedestrian, and bike infrastructure promote physical activity Unsafe pedestrian crossings increase pedestrians’ risk of injury by motor vehicles
Include sidewalks, bicycle lanes, and open spaces Locate projects near open spaces Add bus or light rail stops in walking distance of projects
Air quality Major outdoor pollution sources may degrade indoor air quality and increase the risk of asthma, heart disease, and other illnesses Crime Neighborhood design can promote social interaction and reduce crime, improving well-being and reducing violent injury Noise Noise from roadways and industry can lead to stress and sleep disturbance and exacerbate high blood pressure Access to goods, services, and employment Density of liquor outlets may increase use Distance to grocery stores may affect quality of diet and increase risk of obesity and diabetes Access to child care, clinics, and jobs has multifaceted health benefits
Install central air filtration and seal windows near emission sources Locate buildings in less polluted areas Include lighting, mixed-use design elements, and common social areas Design buildings that allow residents to view common areas and have more social interaction with neighbors Include sound insulation and barriers for housing near major noise sources Locate buildings in quieter areas Include health-promoting amenities such as farmers markets and community gardens Locate projects to maximize access to existing amenities
Housing affordability and stability Housing costs affect residents’ ability to afford other essentials important to health (food, heat, and medications) Displacement of current residents leads to stress and homelessness and creates multiple health risks Education, employment, and personal income Education, employment, and income improve general health and reduce mortality Ability to pay for essentials (food, heat, and housing) reduce risk of heat and cold injury and improve general health
Build affordable housing Revitalize housing in phases to minimize the displacement of current residents
Include capacity building and job training in development initiatives Implement initiatives to hire local people Support programming and infrastructure for early childhood education and child care
Social cohesion and social capital Neighborhood cohesion and civic engagement can improve mental health, lower crime rates, and improve residents’ overall health
Include capacity building and community engagement Design neighborhoods to maximize safe social interaction
SOURCE Authors’ review of the health impact assessments listed in the online Appendix (see Note 25 in text).
health information from a nearby school because 75 percent of the students lived in the housing units (Appendix Exhibit A, row 5).25 The data helped the researchers better understand residents’ concerns about asthma, air quality, and housing conditions. Although countywide statistics showed relatively low asthma rates, the school reported that more than half of its students suffered from asthma. Having identified this important health concern, the developer included new heating and cooling systems to improve indoor air quality and reduce asthma triggers. Consider Neighborhood Features That Influence Health In the assessments we reviewed, the presence and location of neighbor1942
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hood features such as grocery stores, public transit, and child care were identified as important influences on health (Exhibit 1). Developers can maximize health benefits by considering access to these features in project siting decisions and in the planning and design of communityscale initiatives. Exhibit 3 shows examples of tools used to identify and analyze neighborhood features that are important to health. For example, the Pedestrian Environmental Quality Index, developed by the San Francisco (California) Department of Public Health, measures aspects of roadways that can affect both people’s ability to exercise and their safety while doing so. Maps derived from geographical or geospatial
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Exhibit 2 Data Sources Commonly Used To Measure Baseline Health In Health Impact Assessments Data source
Description
Behavioral Risk Factor Surveillance Surveya
An annual state-by-state telephone survey of self-reported health outcomes (for example, diabetes, high blood pressure, and asthma) whose results are used to determine national and state disease rates.
WONDERb
An online statistical tool that draws on a number of health statistical databases and allows the calculation of rates of certain illnesses for states or regions.
County Health Rankingsc
County-by-county statistics on length of life, self-reported general health, and a subset of health influences.
National Environmental Public Health Tracking Networkd
A program that provides funds for twenty-three states and one city to collect and report data on rates of illnesses that can have environmental triggers and environmental data such as air pollution and drinking water quality.
State and local departments of public health
Departments that track and report rates of a range of illnesses; the departments’ websites can be a good source for vital statistics (mortality rates and causes, and birth rates, all of which are commonly available), data on specific illnesses (varies by state), and some data at the city or county level (varies by state). Door-to-door or telephone surveys of residents in a project area, often used to collect data on self-reported health status (such as general health, mental health, and medical diagnoses including asthma and diabetes) and on influences on health (such as neighborhood safety, access to fruits and vegetables, diet, and exercise).
Surveys conducted during project planning
SOURCE Authors’ review of the health impact assessments listed in the online Appendix (see Note 25 in text). NOTES The exhibit is not intended to provide a complete list of health data sources but instead lists sources that can provide some health statistics for small geographic regions, are publicly available, and were commonly used in the health impact assessments reviewed for this study. aCenters for Disease Control and Prevention. Behavioral Risk Factor Surveillance System [home page on the Internet]. Atlanta (GA): CDC; [last reviewed 2014 Sep 2; cited 2014 Sep 12]. Available from: http://www.cdc.gov/brfss/. bCDC.gov. CDC WONDER [home page on the Internet]. Atlanta (GA): Centers for Disease Control and Prevention; [last reviewed 2014 Jul 28; cited 2014 Sep 12]. Available from: http://wonder.cdc.gov/. cCounty Health Rankings and Roadmaps [home page on the Internet]. Madison (WI): County Health Rankings and Roadmaps; [cited 2014 Sep 12]. Available from: http://www.countyhealthrankings.org/. d Centers for Disease Control and Prevention. State and local tracking portals [Internet]. Atlanta (GA): CDC; [last updated 2014 Jul 1; cited 2014 Sep 12]. Available from: http://ephtracking.cdc.gov/showStateTracking.action.
Exhibit 3 Examples Of Analytic Tools Used To Gauge Health Implications Of Community Development Proposals Tool
Description
Galveston Housing Siting Toola
Developed to guide choices regarding where to build or redevelop public housing, the tool consists of a list of twenty-three publicly available or readily measurable indicators of features at the neighborhood, block, and building level that can affect health, weighted according to importance to health and strength of evidence. The tool estimates the health-related economic benefits of walking or cycling that are associated with transportation infrastructure changes.
Health Economic Assessment Toolb Meridian Township development checklistc
This simple checklist is used by planners to review proposed projects and suggest design features that might support health.
Pedestrian Environmental Quality Indexd
This list of street characteristics can be used to guide a street-by-street walking audit of sidewalks, street crossings, bicycle lanes, and other roadway features that can affect traffic safety and people’s ability to get adequate exercise.
Bicycle Environmental Quality Indexe
This quantitative survey tool uses twenty-one indicators to assess bicycle safety and can be used to identify actions to encourage safe bicycling.
Sustainable Communities Indexf (formerly the Healthy Development Measurement Tool)
This comprehensive, open-source index contains more than a hundred measures of community features such as transportation, housing, services, and economy, with data on their links to health.
SOURCE Authors’ review of the health impact assessments listed in the online Appendix (see Note 25 in text). aNolen LB, Prochaska JD, Dills J, Fuller E, Rushing M, Buschmann R, et al. A health impact assessment for improving healthy housing and neighborhoods in Galveston, Texas: technical report. Galveston (TX): Center to Eliminate Health Disparities at the University of Texas Medical Branch; 2014. bHealth Economic Assessment Tool [home page on the Internet]. Copenhagen: World Health Organization; 2014 Aug 19 [cited 2014 Sep 12]. Available from: http://www.heatwalkingcycling.org/. cIngham County Health Department and Charter Township of Meridian. Charter Township of Meridian health impact assessment [Internet]. Meridian (MI): Charter Township of Meridian; [cited 2014 Sep 19]. Available from: http://hd.ingham.org/Portals/HD/Home/Documents/CHA/HIA%20Checklist.pdf. dUniversity of California, Los Angeles, Center for Occupational and Environmental Health. Pedestrian environmental quality index [Internet]. Los Angeles (CA): University of California; [cited 2014 Sep 12]. Available from: http:// www.peqiwalkability.appspot.com/about.jsp. eSan Francisco Department of Public Health, Program on Health, Equity, and Sustainability. Bicycle Environmental Quality Index [home page on the Internet]. San Francisco (CA): The Department; [cited 2014 Sep 12]. Available from: http://www.sfhealthequity.org/elements/24elements/tools/102-bicycle-environmental-quality-index. fSustainable Communities Index (see Note 26 in text).
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Measuring Community Health information systems (GIS) are also commonly used to determine neighborhood characteristics. For example, a food price and food outlet survey conducted to inform a public housing redevelopment in Denver, Colorado, uncovered the need for healthy food retailers within a shorter and safer walk from the housing units than had been the case. The assessment proposed road safety improvements and the addition of community gardens to increase access to healthy food (Appendix Exhibit A, row 30).25 Similarly, another assessment used maps to show how alternative affordable housing sites would affect residents’ access to neighborhood resources such as community centers, schools, and parks and their exposure to varying levels of noise and air pollution (Appendix Exhibit A, row 29).25 Checklists, indicator sets, and evidence-based standards or benchmarks can also be used to assess neighborhood-level influences on health. The Sustainable Communities Index (Exhibit 3), developed by the San Francisco Department of Public Health, includes more than a hundred indicators that measure how transportation, education, economic, housing, and other community characteristics affect health.26 The index was created in San Francisco, but it has been adapted and implemented by other communities around the country. In Meridian Township, Michigan, planners and developers designed a simple checklist (Exhibit 3) to evaluate and improve proposed development projects according to nine healthrelated domains, including water and air quality, noise, social capital, and health equity (Appendix Exhibit A, row 14).25 During its ten years of use, this checklist has helped increase elderly residents’ access to public transportation, mitigate environmental effects on wetlands while adding open space near housing, and incorporate farmers markets into development plans. Based on the success of this tool, university and government partners are now collaborating to build a more comprehensive GIS-based and online version for regional use.27,28 Developers can also prioritize project sites located in areas with health-supportive resources. An assessment in Texas—conducted by the Georgia Health Policy Center and the University of Texas Medical Branch—used a list of twentythree health-related indicators at the neighborhood, block, and unit levels to help identify optimal sites for rebuilding public housing destroyed by Hurricane Ike. Drawn from publicly available sources, the indicators were weighted by importance to health and strength of evidence (Appendix Exhibit A, row 27).25 Identify And Implement Building Design 1944
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Developers can prioritize project sites located in areas with health-supportive resources.
Features That Support Health Many assessments addressed the influence of a building’s structure and design on health (Exhibit 1). For example, installing smooth flooring and air filtration can reduce asthma triggers, and reinforcing walls for grab rails or building entrances with no steps can reduce the risk of injury from falls (Appendix Exhibit A, row 33).25 In the Denver redevelopment mentioned above, the assessment recommended wider, well-lit stairways to encourage walking and the incorporation of a bike-sharing station to promote biking (Appendix Exhibit A, row 30).25 In another example, community organizations had expressed concerns about air quality and noise impacts on residents at a proposed low-income senior housing facility near a congested freeway. In response to a request by the city’s design review committee, the developer and public health experts identified ways to mitigate related issues such as respiratory illnesses, sleep disturbance, and stress. The developer implemented several evidence-based modifications, including particulate air filtration and sealed bay windows to minimize indoor air pollution, and a building entrance sited to reduce noise (Appendix Exhibit A, row 17).25 Engage The Community To Build Capacity And Respond To Health Concerns And Needs Involving communities in planning and decision making is central to both community development and health impact assessment. Incorporating health into community engagement efforts can help developers plan and implement projects that better serve the needs of the target population, build community support for a proposed project, ensure that developers understand and attend to community priorities, and build community capacity and agency (Exhibit 1). During an assessment of a neighborhood revitalization plan in Missouri, residents identified dangerous road intersections. This led to specific interventions, such as sidewalk improvements and the installation of elevated medians and traffic signals (Appendix Exhibit A, row 25).25 Stake-
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Incorporating health into community engagement efforts can help developers plan and implement projects that better serve the needs of the target population.
holders engaged in an assessment of a proposed walking and biking trail voiced concerns about crime and safety issues that would likely limit use of the trail. Further consultation led the developer to include lighting and other design features to reduce the risk of crime and maximize the chance that people would use the trail (Appendix Exhibit A, row 9).25 Community engagement can also give residents a stronger voice in project planning. Based on residents’ input, one city health department provided comments to the planning department on a proposal to demolish and replace rentcontrolled apartments with market-rate condominiums. The health department documented how the displacement of low-income residents could exacerbate mental illness, food insecurity resulting from increased rent burden, and infection risks associated with overcrowding. A public health analysis, paired with strong community engagement, contributed to the developer’s decision to adopt an alternative that did not displace current residents.29 Addressing health-related community concerns can also build support for a project. In the low-income senior housing development example above, the developer’s inclusion of healthrelated modifications garnered support from neighborhood leaders and recognition for the company as an innovator committed to creating healthy neighborhoods.30 Finally, community engagement and capacity building can contribute to community cohesion, which has strong links to reducing violence and improving general health and well-being.31 Using health metrics can help developers strengthen and better demonstrate this dimension of their work. In the Missouri example above, the assessment highlighted the health benefits of
continued engagement with community members and recommended education and training programs to augment these benefits (Appendix Exhibit A, row 25).25
Considerations When Implementing The Framework Several practical considerations must be addressed when implementing this framework and in any effort to more intentionally build health into community development initiatives. Given the challenges inherent in planning, financing, and getting permits for community development projects, it will be important to find ways to integrate health into new initiatives with a minimum of time. There are hopeful indications from health impact assessments that health can be readily integrated into routine project planning activities. Doing so can also build community support, which can help expedite project approvals. In some instances, for example, completing a health impact assessment has helped secure funds for required environmental reviews or for fast-tracking the implementation of healthrelated recommendations (Appendix Exhibit A, rows 1 and 9).25 Health impact assessments can offer a way to engage community members more actively in the decisions that affect them, but conducting the assessments may also save developers time and money by accomplishing common development practices such as a market analysis. Assessment teams can identify ways to avoid duplication of efforts and maximize the health benefits of engaging community members. In one case, a developer decided not to do a market analysis because the assessment had already collected similar information, assessed community needs, and augmented community engagement in the process (Debarati Majumdar Narayan, Catalyze Research, personal communication, May 21, 2014). Some enhancements to improve health might add to project costs. At the same time, incorporating health through conducting an assessment or simply relying on this framework offers developers an opportunity to identify health metrics that help make a stronger economic case for the value of such investments. For example, an assessment in North Carolina found that full implementation of a plan to revitalize a small neighborhood would support higher-density mixed-use development, and that better pedestrian and bicyclist infrastructure would increase residents’ daily physical activity. The assessment estimated that this investment would offset the costs of the infrastructure through avoiding November 2014
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Measuring Community Health cases of diabetes, coronary heart disease, stroke, hypertension, and premature mortality, which collectively would cost $313 million over twenty years (Appendix Exhibit A, row 2).25 As policy makers, health care providers, and insurance carriers search for effective ways to contain costs, providing solid evidence of healthrelated economic benefits may help create new opportunities for developers to secure funding from sources within the health care system.13 For example, New York State allocated more than $160 million of state Medicaid funding to support housing coordinated with on-site services for high-risk homeless people. The state provided the funds because of evidence that making supportive housing available to such people, who may use hospital services frequently, can improve their health outcomes and reduce associated costs.32 Similarly, a supportive housing project in San Francisco that helped fifty residents move from a city-run nursing home to a community-based setting saved the city about $1.45 million annually.14 Health metrics may also provide a useful way to inform the allocation of financial resources for community development projects. An assessment in Massachusetts, for example, examined how funding criteria for a new state tax grant program for community development corporations could be drafted to support community health (Appendix Exhibit A, row 21).25 And in Georgia an assessment is under way to inform the state’s plan for distributing low-income housing tax credits to developers, based in part on health needs.33 Finally, although our proposed framework can guide developers’ efforts, fully integrating health considerations into community development initiatives will likely require close collaboration with public health experts. Fortunately, there are a growing number of ready partners. Appendix Exhibit B lists some organizations that are working at the intersection of community development and public health.25 One important example is the recently launched Build Healthy Places Network, which will build on the collaboration between the Federal Reserve System and the Robert Wood Johnson Foundation and provide leadership, data, metrics, and other resources.34 The preparation of this article was supported by a grant from the Robert Wood Johnson Foundation. The views expressed are those of the authors and
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Partnerships between community development and public health hold potential as a way to realize measurable and critically needed improvements for people in low-income communities.
Conclusion This article offers a simplified framework to facilitate greater collaboration between the fields of community development and public health. Taking advantage of the increasing expertise and resources available to facilitate partnerships, developers and public health professionals can create shared objectives, identify metrics to demonstrate the value of their investments, and optimize the health benefits of their initiatives. Such partnerships hold tremendous potential as a way to realize measurable and critically needed improvements in the lives, health, and well-being of people in low-income communities. In practice, any such framework is only a starting point and will need to be adapted to each developer’s unique community contexts, resources, and goals. Systematic efforts to evaluate whether implementing more health-based recommendations is achieving the desired outcomes and to identify the most effective practices will be essential to advancing and strengthening this work as collaboration becomes more common. ▪
do not necessarily reflect the views of the Pew Charitable Trusts or the Robert Wood Johnson Foundation. The authors thank Amber Lenhart for her
contributions in editing and assistance with document preparation.
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NOTES 1 Banks J, Marmot M, Oldfield Z, Smith JP. Disease and disadvantage in the United States and in England. JAMA. 2006;295(17):2037–45. 2 Bashinskaya B, Nahed BV, Walcott BP, Coumans JCE, Onuma OK. Socioeconomic status correlates with the prevalence of advanced coronary artery disease in the United States. PLoS One. 2012;7(9):e46314. 3 Braveman PA, Cubbin C, Egerter S, Williams DR, Pamuk E. Socioeconomic disparities in health in the United States: what the patterns tell us. Am J Public Health. 2010; 100(Suppl 1):S186–96. 4 Martinson ML. Income inequality in health at all ages: a comparison of the United States and England. Am J Public Health. 2012;102(11): 2049–56. 5 Muennig P, Fiscella K, Tancredi D, Franks P. The relative health burden of selected social and behavioral risk factors in the United States: implications for policy. Am J Public Health. 2010;100(9):1758–64. 6 Kawachi I, Adler NE, Dow WH. Money, schooling, and health: mechanisms and causal evidence. Ann N Y Acad Sci. 2010;1186:56–68. 7 Diez Roux AV, Mair C. Neighborhoods and health. Ann N Y Acad Sci. 2010;1186:125–45. 8 Health Impact Project. Health impact assessment of proposed changes to the Supplemental Nutrition Assistance Program [Internet]. Washington (DC): The Project; 2013 Jul [cited 2014 Sep 12]. Available from: http://www.rwjf.org/content/ dam/farm/reports/reports/2013/ rwjf407284 9 Bell ML, Ebisu K. Environmental inequality in exposures to airborne particulate matter components in the United States. Environ Health Perspect. 2012;120(12):1699–704. 10 Drewnowski A, Rehm CD, Solet D. Disparities in obesity rates: analysis by ZIP code area. Soc Sci Med. 2007;65(12):2458–63. 11 Jacobs DE. Environmental health disparities in housing. Am J Public Health. 2011;101(Suppl 1):S115–22. 12 Williams DR, Marks J. Community development efforts offer a major opportunity to advance Americans’ health. Health Aff (Millwood). 2011;30(11):2052–5. 13 Braunstein S, Lavizzo-Mourey R. How the health and community development sectors are combining forces to improve health and wellbeing. Health Aff (Millwood). 2011;30(11):2042–51. 14 Erickson D, Andrews N. Partnerships among community develop-
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ment, public health, and health care could improve the well-being of lowincome people. Health Aff (Millwood). 2011;30(11):2056–63. Sportiche N, Wood B, Chen B, James P, Ito K, Banay R, et al. Community development and health: a health impact assessment to inform the community investment tax credit program. Boston (MA): Health Resources in Action; 2014. Federal Reserve Bank of San Francisco. Community development: Healthy Communities [Internet]. San Francisco (CA): The Bank; c2014 [cited 2014 Sep 19]. Available from: http://www.frbsf.org/communitydevelopment/initiatives/healthycommunities Linking community development and health. Health Aff (Millwood). 2011;30(11). Special Issue. Andrews NO, Erickson DJ, Galloway IJ, Seidman ES, editors. Investing in what works for America’s communities. San Francisco (CA): Federal Reserve Bank of San Francisco and Low Income Investment Fund; 2012. National Research Council. Improving health in the United States: the role of health impact assessment. Washington (DC): National Academies Press; 2011. Bourcier E, Charbonneau D, Cahill C, Dannenberg A. Do health impact assessments make a difference? A national evaluation of HIAs in the United States [Internet]. Seattle (WA): Center for Community Health and Evaluation; 2014 Apr [cited 2014 Sep 12]. Available from: http://www .rwjf.org/content/dam/farm/ reports/issue_briefs/2014/ rwjf409204 Health Impact Project. Health impact assessment: bringing public health data to decision making [Internet]. Washington (DC): The Project; 2010 Dec [cited 2014 Sep 12]. Available from: http:// www.pewtrusts.org/en/~/media/ Assets/External-Sites/HealthImpact-Project/healthimpact assessmentbringingpublichealth datatodecisionmaking.pdf Health Impact Project. HIA in the United States [Internet]. Washington (DC): The Project; [cited 2014 Sep 12]. Available from: http:// www.pewtrusts.org/en/multimedia/ data-visualizations/2014/hia-in-theunited-states Centers for Disease Control and Prevention. Designing and building healthy places [Internet]. Atlanta (GA): CDC; [last updated 2014 Sep 10; cited 2014 Sep 12]. Available from: http://www.cdc.gov/healthy
places 24 Health Impact Project. Data sources for the HIA map and list [Internet]. Washington (DC): The Project; 2014 [cited 2014 Oct 6]. Available from: http://www.pewtrusts.org/en/ multimedia/data-visualizations/ 2014/hia-in-the-united-states/hiamap-data-sources 25 To access the Appendix, click on the Appendix link in the box to the right of the article online. 26 Sustainable Communities Index [home page on the Internet]. San Francisco (CA): Sustainable Communities Collective; [cited 2014 Sep 19]. Available from: http://www .sustainablecommunitiesindex.org/ 27 Roof K, Glandon R. Tool created to assess health impacts of development decisions in Ingham County, Michigan. J Environ Health. 2008; 71(1):35–8. 28 Health Impact Project. HIA programs and HIA based tools and approaches [Internet]. Washington (DC): The Project; [cited 2014 Sep 19]. Available from: http:// www.pewtrusts.org/en/projects/ health-impact-project/about/ funding-opportunities/hiaprograms-and-hia-based-tools-andapproaches 29 Corburn J. Toward the healthy city: people, places, and the politics of urban planning. Cambridge (MA): MIT Press; 2009. 30 Federal Reserve Bank of San Francisco, Urban Institute. What counts: harnessing data for America’s communities. San Francisco (CA): The Bank; forthcoming. 31 Kawachi I, Berkman LF. Social cohesion, social capital, and health. In: Berkman LF, Kawachi I, editors. Social epidemiology. New York (NY): Oxford University Press; 2000. p. 174–90. 32 Doran KM, Misa EJ, Shah NR. Housing as health care—New York’s boundary-crossing experiment. N Engl J Med. 2013;369(25):2374–7. 33 Georgia State University, Georgia Health Policy Center. Study to inform housing tax credit allocations [Internet]. 2014. Atlanta (GA): Georgia State University; 2014 Jan 14 [cited 2014 Sep 12]. Available from: http://ghpc.gsu.edu/2014/01/ 14/georgia-health-policy-centerconducting-study-inform-housingtax-credit-allocations/ 34 Build Healthy Places Network [home page on the Internet]. Oakland (CA): Public Health Institute; [cited 2014 Sep 19]. Available from: http://www .buildhealthyplaces.org/
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