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Developing Built Environment Programs in Local Health Departments: Lessons Learned From a Nationwide Mentoring Program Kate Rube, MCP, Maggie Veatch, MPH, Katy Huang, RN, MMSc, MSc, Rachel Sacks, MPH, Megan Lent, MPH, Gail P. Goldstein, MPH, and Karen K. Lee, MD, MHSc

Local health departments (LHDs) have a key role to play in developing built environment policies and programs to encourage physical activity and combat obesity and related chronic diseases. However, information to guide LHDs’ effective engagement in this arena is lacking. During 2011–2012, the New York City Department of Health and Mental Hygiene (DOHMH) facilitated a built environment peer mentoring program for 14 LHDs nationwide. Program objectives included supporting LHDs in their efforts to achieve built environment goals, offering examples from DOHMH’s built environment work to guide LHDs, and building a healthy built environment learning network. We share lessons learned that can guide LHDs in developing successful healthy built environment agendas. (Am J Public Health. 2014;104:e10–e18. doi:10.2105/ AJPH.2013.301863)

Obesity is the second leading cause of preventable death in the United States.1 Nationally, 66% of adults and 30% of children are overweight or obese, placing them at risk for cardiovascular disease, diabetes, and related conditions.2 Cross-sectional research suggests that improving the built environment (BE) may be an essential component of a comprehensive public health strategy to curtail the epidemics of obesity and related chronic diseases.3---6 Typically, the BE is defined as comprising buildings, streets, and neighborhoods, including parks and other amenities. As prospective research is developed to further explore this topic, US public health authorities including the Centers for Disease Control and Prevention (CDC),7 the Institute of Medicine,8 and the US surgeon general9 concur that sufficient evidence exists to support designing communities to encourage walking, bicycling, and active recreation and to enhance access to healthy foods and beverages as a means of supporting healthier behaviors and improving health outcomes.3---5 Local health departments (LHDs) can play a key role in the development and implementation of BE policies and programs in the communities they serve.10,11 In the late 19th and early 20th centuries, public health leaders overcame the most urgent threat of that era— infectious disease—by working with urban

planning professionals to improve living conditions, overcrowded housing, and hospital environments.12,13 Similarly, today LHDs can collaborate with other agencies to improve building design, land use patterns, and other aspects of the BE as a means of combating obesity and obesity-related noncommunicable diseases. Since the mid-20th century in the United States, infrastructure that prioritizes passive movement such as use of automobiles, elevators, and escalators has engineered physical activity out of many residents’ daily lives.14 Collaboration between LHDs, other governmental agencies, community-based organizations, and private institutions with roles in BE design could help to reverse this trend by influencing policy and promoting practice-level change.5 There is great potential for interagency collaboration to improve health outcomes through BE initiatives; however, coalition building among different entities, each with its own unique mission and some with complex bureaucracies, can by stymied by institutional and jurisdictional challenges. For example, although municipal governments are responsible for most land use decision-making in the United States, regional bodies and state governments often control transportation planning and other areas that influence BE issues. Thus,

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fostering walkable, active local communities requires agreement among all 3 governmental levels. As another example, LHDs, although expert in health promotion and disease prevention, may lack expertise in land use, transportation, and design issues, rendering LHD staff unprepared to offer feasible project alternatives to BE-oriented organizations or agencies that could prove to be valuable partners if goals are aligned. Conversely, local parks or transportation departments may lack awareness of how urban design affects health. Enhancing communication across these sectors to illuminate common goals is essential to breaking down barriers between these municipal agencies and developing strong coalitions to improve the local BE. Perhaps the most important challenge facing LHDs is that, despite the emphasis that health organizations and funders place on the importance of BE research, policy, and program development,15,16 few guidelines exist to direct LHDs’ engagement in this area. Recently, Kuiper et al.10 advocated that increased technical support and resources be allocated to strong, transformational leaders within LHDs to help them define, manage, and market a healthy community design vision with measurable goals. With sustained funding for public health agencies in decline both nationally and locally,11 developing innovative, affordable technical assistance packages for LHDs is critical. We describe lessons learned about healthy BE work from the experiences of the New York City Department of Health and Mental Hygiene (DOHMH) and 14 other LHDs from across the country. We also discuss the Built Environment Mentoring Program, a 2011---2012 initiative led by DOHMH and implemented with support from the CDC’s Communities Putting Prevention to Work initiative (CPPW). This initiative provided technical assistance, tools,

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and coaching for 14 LHDs across the country working on healthy BE initiatives.17 The key challenges encountered and successes achieved by participating LHDs, as well as the critical lessons learned, can help LHDs nationwide in their efforts to facilitate successful BE work.

HEALTHY BUILT ENVIRONMENT WORK IN NEW YORK CITY Supportive and strong leadership at DOHMH, spearheaded by then commissioner of health and current CDC director Thomas R. Frieden and the assistant commissioner of what was then the Bureau of Chronic Disease Prevention and Control, was critical to its BE initiative. The health department’s leaders understood the importance of BE in combating obesity and related diseases, particularly in the areas of the city most affected by health disparities (East and Central Harlem, North Brooklyn, and the South Bronx); furthermore, they were willing to change departmental structures to address this issue, and they provided funding to hire and empower staff to oversee the effort.

DOHMH initiated its work by hiring a director to develop a BE program and to organize a half-day “Fit City” conference jointly with the New York chapter of the American Institute of Architects, bringing health, design, planning, and construction professionals together to discuss potential BE solutions. Since then, Fit City conferences have been held each year.18 After the second conference, the New York City Department of Design and Construction announced that it would partner with DOHMH to create evidence-based healthy BE design guidelines, building on previous city guidelines addressing environmental sustainability and universal accessibility. The Active Design Guidelines were published in January 2010, the product of a collaboration between DOHMH and the Departments of Design and Construction, Transportation, and City Planning, with input from 8 additional city agencies and mayoral offices.19 DOHMH’s built environment director and staff provided project management and coordination support for this effort, as well as funding for an academic-led literature review.

Since then, DOHMH’s built environment program has worked with other city agencies to create policies and programs aimed at implementing the Active Design Guidelines. Results include developing and launching a training program for architects, planners, and other BE professionals in the private and public sectors; engaging in outreach to building managers, schools, and community groups to encourage uptake of active design strategies such as use of stair prompts; and creating additional active play spaces for children and families in underserved communities through the Play Streets program (Table 1).18

BUILT ENVIRONMENT MENTORING PROGRAM The CDC selected DOHMH to lead the Built Environment Mentoring Program because of the department’s history of successful interagency collaboration on healthy BE issues in New York City. Launched in January 2011 with CPPW funding, the Built Environment Mentoring Program was a peer mentoring

TABLE 1—Examples of Healthy Built Environment Work Developed and Implemented by New York City (NYC) Government Agencies: 2007–2013 Domain

Activity

Buildings

The NYC Department of Buildings “greened” the building codes while improving the infrastructure for health; plumbing code changes were made to improve

City administration

The NYC Department of City Administrative Services unlocked and enabled access to stairwells in city-operated buildings and posted “Burn Calories,

tap water drinking facilities in buildings through the addition of water bottle refilling stations at required water fountains Not Electricity. Take the Stairs!” prompt signs in elevator call areas and outside accessible stairwells; it is also working to create healthier work environments for city employees Economic development

The NYC Economic Development Corporation included active design language and strategies in the agency’s requests for proposals for real estate

Education

The NYC School Construction Authority integrated active design strategies by creating a green schools credit, intended to encourage new schools to

development in the city; it also created tax incentives for supermarket development in underserved neighborhoods incorporate outdoor and indoor design features to promote physical activity in the daily lives and school routines of students and staff; it also built “gymatoriums” (rather than auditoriums), auxiliary gymnasiums, and outdoor and rooftop playgrounds to increase spaces for physical activity Housing

The NYC Department of Housing Preservation and Development referenced the Active Design Guidelines in its new supportive housing guidelines as well

Parks and recreation

as in its requests for proposals for new construction The NYC Department of Parks and Recreation worked with the Department of Education to convert hundreds of schoolyards to community playgrounds

Public works

The NYC Department of Design and Construction integrated active design strategies into all of its new construction and major renovation projects, where applicable (including city office and institutional buildings, public libraries, and street construction); it also integrated these strategies into the design consultant guide used by all of its project teams

Transportation

The NYC Department of Transportation created and expanded bicycle lanes, street bicycle parking, pedestrian plazas, and a bike share program; it also

Urban planning

The NYC Department of City Planning introduced zoning requirements for secure bicycle parking in buildings, as well as zoning incentives for supermarket

established programs such as Summer Streets and Weekend Walks that temporarily close streets to vehicles to promote active recreation development in underserved neighborhoods; it also promoted walkable neighborhoods by encouraging density and a mix of land uses around transit stations and stops, along with safe and well-designed public space destinations

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and training initiative in 14 communities across the country that had also received CPPW funding for BE work (Table 2). Typically, a municipal or county health department was the funding recipient (referred to here as an LHD or mentee). Each LHD partnered with local entities, including government agencies, community organizations, and academic institutions, to accomplish its goals. The 14 LHDs were located in rural, suburban, or urban settings. The extent of their BE experience ranged from no experience to more than 10 years of experience. DOHMH’s built environment program partnered with the American Institute of Architects’ New York chapter and the Departments of Design and Construction, City Planning, and Transportation to implement the BE mentoring program.18 The program’s goals were to support mentees in achieving CPPW goals, to offer lessons learned and examples from DOHMH’s built environment work to guide mentees, and to build a learning network among the mentees related to healthy BE

and actors at different levels of government that influence BE issues. Generally, LHDs did not have close working relationships or contacts at agencies conducting planning, transportation, and building design work. For example, the County of San Diego Health and Human Services Agency invested significant staff time initially navigating complex and unfamiliar agency processes to find the appropriate contacts to establish a successful collaboration with the region’s transportation authority, the Metropolitan Planning Organization (MPO). Communicating with professionals in various sectors, given the differences in technical language and terminology, presents a challenge that can require significant time and dedicated staff to address. Third, LHDs confronted policy-related and institutional barriers. For instance, zoning codes requiring segregated land uses have led to a reliance on automobiles, as housing is located in zones that are separate from commercial or office properties. In addition, street design standards often promote vehicle use

issues. Program components consisted of monthly group calls, periodic individual calls, quarterly webinars, and 2 in-person “Fit Nation” conferences. DOHMH also developed resources and tools to support mentees’ work. Table 3 provides a summary of mentees’ activities and achievements.

CHALLENGES OF HEALTHY BUILT ENVIRONMENT WORK Although specific programmatic choices and implementation strategies varied among mentees, all faced similar challenges. First, garnering high-level support and leadership within LHDs for BE initiatives was sometimes difficult, given competing demands for public health resources. Mentees cited a lack of awareness regarding their role relative to BE issues, a difficulty compounded by reliance on traditional strategies to combat obesity, such as public education and physical activity programming. A second common barrier was establishing relationships with the multitude of agencies

TABLE 2—Communities Participating in the Built Environment Mentoring Program: 2011–2012 Community

Local Health Department/Mentee

Other Participating Partner(s)

Boston, MA

Boston Public Health Commission

Transportation Department, Redevelopment Authority

Cherokee Nation, OK

Healthy Nation Rogers County

Planning and Development Department

Chicago, IL

Consortium to Lower Obesity in Chicago Children

Department of Public Health, Department of Housing and

(nonprofit organization)

Economic Development, Department of Transportation

Cook County, IL

Cook County Department of Public Health

Department of Transportation and Highways, Active Transportation Alliance (nonprofit

Davidson County, TN (Nashville) Douglas County, NE (Omaha)

Nashville Metro Public Health Department Douglas County Health Department

Planning Department Planning Department, Omaha by Design (nonprofit organization)

Jefferson County, AL (Birmingham)

United Way of Central Alabama (nonprofit

Conservation Alabama Foundation (nonprofit organization), Freshwater Land Trust

organization), Public Health Institute of Metropolitan Chicago (nonprofit organization)

organization), Jefferson County Department of Health

(nonprofit organization), Jefferson County Land Planning and Development Services, YMCA of Greater Birmingham (nonprofit organization)

King County, WA (Seattle)

King County Public Health

City of Federal Way, Puget Sound Regional Council (Metropolitan Planning Organization)

Louisville, KY

Louisville Metro Department of Health and Wellness

Louisville Metro Planning and Design Services, Louisville Metro Parks, Transit

Miami–Dade County, FL Multnomah County, OR (Portland)

Miami–Dade County Health Department Multnomah County Health Department

Park and Recreation Department, Miami–Dade County Bureau of Planning and Sustainability

Philadelphia, PA

Philadelphia Department of Public Health

Mayor’s Office of Transportation and Utilities, Planning Department

Pima County, AZ (Tucson)

Pima County Health Department

Department of Transportation, Planning and Development Department, Drachman Institute

Authority of River City

at the University of Arizona College of Architecture and Landscape Architecture, Activate Tucson (nonprofit organization) San Diego County, CA

County of San Diego Health and Human Services Agency

San Diego Association of Governments (Metropolitan Planning Organization), New School of Architecture and Design

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TABLE 3—Mentees’ Healthy Built Environment Activities and Outcomes: 2011–2012 Domain Planning

Components Comprehensive and local plans, zoning code requirements and

No. of Mentees Engaged in Domain 14

Examples of Successful Strategies Louisville, KY, created a healthy development

incentives, design guidelines, incorporation of health-related

checklist for use in evaluating proposed

checklists or evaluations

planning projects; Jefferson County, AL, established the SmartCode Overlay Zone, which allows for mixed-use development and other design flexibility to promote walking and other physical activity

Transportation

Regional and local transportation plans, bicycle and pedestrian

13

Cook County, IL, and Birmingham, AL, adopted

plans, street design guidelines, project prioritization processes

complete streets policies that recognize the

with an emphasis on active transportation and health, active

need to balance the road needs of

transportation programs such as Summer Streets and

automobiles, bicyclists, and pedestrians

PlayStreets, wayfinding signage to encourage walking

to serve all modes of travel well; in Multnomah

or bicycling

County, Portland, OR, transportation planners developed health equity criteria to prioritize projects within their transportation system plan that increase opportunities for walking and biking, especially in underserved communities; Nashville’s Metropolitan Planning Organization (TN) will include questions on health and physical activity in its next household travel survey

Education and schools

School design guidelines, recess and gym requirements, Safe Routes to Schools programs, inclusion of active recreation spaces and

11

A school district in suburban Cook County, IL, adopted a comprehensive travel plan that

vegetable/fruit gardens, joint use policies to encourage use of

supports Safe Routes to School programs

active recreation facilities outside of school hours

through walking and bicycling, created a school garden and a “Fresh from the Farm Fridays” event at one of the district’s schools, and instituted new playground equipment that encourages children to

Parks and recreation

Park and recreation facility design guidelines, active recreation

11

be more active The Miami–Dade County Parks, Recreation and

programming, project prioritization processes with an emphasis

Open Spaces Department (FL) implemented a

on health and physical activity, bicycle and pedestrian plans and

healthy vending machine policy and

infrastructure to support access to parks and recreation facilities

developed criteria to improve bicycle and pedestrian access to county parks

Housing development and management

Housing design guidelines, location requirements for new projects,

5

The Philadelphia Redevelopment Authority (PA),

requirements for inclusion of stair prompts or other healthy built

in partnership with the Department of Public

environment elements in public housing, identification and redevelopment of vacant properties to promote physical activity

Property and the Housing Development Corporation, made maps and information

and health

about the city’s vacant properties publicly available; these resources can be used to identify potential locations for redevelopment, community gardens, play space, and urban agriculture

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over walking and bicycling. Changing these policies is no simple matter and may require addressing related agency philosophies. Such a shift requires significant political and public support, as well as the establishment of good interagency relationships.

TRANSFORMING CHALLENGES INTO SUCCESS Recognizing the importance of addressing these challenges, we encouraged participating LHDs to share their strategies for overcoming obstacles and to seek and receive guidance from DOHMH and their peers regarding specific technical questions throughout the course of the BE mentoring program. In addition, throughout the implementation, DOHMH recorded and analyzed mentees’ experiences to develop a list of essential lessons learned. These lessons were intended to guide LHDs’ future efforts to develop BE initiatives and to address common challenges in BE work.

Conducting Internal Planning and Assessments Addressing health through BE issues typically requires restructuring LHD staff time and programs; thus, high-level departmental support, complemented by dedicated leadership and staff time, is critical.10 Initial compilation of information on chronic disease epidemiology, health disparities, risk factors, and evidencebased interventions and identification of connections between these issues and BE design can both inform strategy options and garner leadership support for BE work within and beyond the LHD. An important part of the initial planning process by many of the LHDs was to identify the geography of health disparities related to obesity in local communities so that they could prioritize BE work in these areas. An official senior-level project head must have an interest in and dedicated time committed to BE issues, the ability to garner resources and assign staff to projects, strong interpersonal skills, and experience working within and across the LHD. Once senior-level support is secured, dedication of additional staff, typically at a more junior level, ensures that the LHD can plan and conduct work and develop and nurture partnerships necessary for

success. According to the 14 LHD mentees, dedicated staff should have experience in public health, planning, architecture, and transportation issues (recognizing that experience across the different fields is often not currently available in the form of any single staff member and must be attained by having 2 or more staff people with complementary backgrounds assigned to the project), as well as strong communication and facilitation skills and experience working with data. In Chicago, Illinois, and Boston, Massachusetts, LHD staff with these skills added BE projects to their job duties until sufficient resources were assembled to permit full-time staffing of BE work. Mentees reported that BE staff and programs were housed within various LHD divisions and bureaus, including chronic disease, physical activity and nutrition, environmental health, and obesity prevention. In New York City, the BE program was instituted within the Bureau of Chronic Disease Prevention and Control because of the program’s goal to address physical inactivity, obesity, and related chronic diseases including diabetes, cardiovascular disease, and cancer. Some mentee LHDs contracted out portions of their healthy BE work to nongovernmental agencies and partners, whereas others hired staff internally. As one LHD representative noted: It’s really important that this isn’t just something that the health department is doing, but that it is a broad community effort. . .. If everything [is] seen as government intervention, it doesn’t play well in our community.

By contracting work outside of the LHD, mentees shared greater ownership and increased involvement with their partners. However, mentees agreed that maintaining some staffing within the LHD was important to ensure prioritization of public health issues, coordination of the health agenda, and project sustainability. After the initial assessment process of defining the local obesity and BE context, 2 additional steps taken by the DOHMH BE program were paralleled by a number of the mentees. The first was engagement of local government agencies, nongovernmental organizations, and other entities that play important roles in the BE sector, including institutions responsible for the planning, design, and construction of BE features such as transportation

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systems, land use, housing, public buildings, private buildings, parks, and schools. For most LHDs, this group included local departments of planning, transportation, education or school construction, and parks and recreation (Table 3). LHDs also commonly engaged communitybased and environmental organizations in BE work, and several mentees were able to engage local chapters of the American Planning Association, the American Institute of Architects, the US Green Building Council, and the American Society of Landscape Architects. The second step was identifying allies already working in support of healthy BE goals, including those that did not explicitly have prevention of obesity and chronic disease as an objective. Other such entities may prioritize environmental protection, economic development, accessibility, safety, or aesthetics.

Building Working Relationships LHDs, as health-focused organizations, cannot directly affect the BE on their own. To develop successful healthy BE initiatives, LHDs must form partnerships with BE-focused agencies and institutions such as the local transportation department. After an assessment phase to identify relevant agencies and organizations, LHDs should work to understand their missions, goals, and operational characteristics to facilitate effective engagement. As one of the LHD representatives stated: “[Health departments] need to become more aware of how city departments work in order to have the leverage they need, so they know how to interject their goals.” For instance, understanding the priority that the local department of transportation places on safety issues in road design, an LHD may discover common ground related to walking and bicycling. Conversely, LHDs must also note how the missions and goals of other agencies may pose barriers to healthy BE work. For example, some transportation agencies may prioritize movement of vehicles, leading to the development of wider vehicle lanes and streets that encourage high-speed vehicles while jeopardizing safe walking and bicycling.20,21 Developing opportunities for the exchange of ideas is critical. In San Diego, California, the LHD invited the MPO and city planners to make presentations to LHD staff; in return, the LHD presented its work to those agencies.

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These meetings, along with the workshops that followed, generated an opportunity for the LHD to participate in a regional transportation plan working group coordinated by the MPO. Participation helped the LHD better understand the MPO’s priorities and decision-making processes, establish contacts, and identify opportunities for collaboration. Most BE-oriented organizations do not identify public health improvements as one of their explicit goals. Therefore, LHDs learned to frame the discussion to highlight ways in which healthy BE strategies improve economic development, environmental sustainability, safety, and universal accessibility outcomes. In so doing, LHDs created synergies that proved helpful in amassing support for multisectoral initiatives. Holding an initial interagency meeting or conference was a key way that LHDs brought people from different sectors together to build momentum and establish a common health and BE foundation. LHDs in San Diego; Douglas County, Nebraska; Jefferson County, Alabama; Louisville, Kentucky; Chicago; and Miami--Dade County, Florida—some of them inspired by the Fit City conferences in New York City— held interagency meetings early in their work to forge partnerships and elicit interest from BE agencies and professionals. The most successful forums created opportunities for speakers from different sectors to share their expertise, knowledge, and ideas. The LHDs took multiple approaches to organizing their partnerships with other agencies and organizations. Some LHDs formalized working groups on obesity prevention or health that included BE subcommittees. Others, including DOHMH, began with informal working groups of city agencies and other relevant partners, and these collaborations later developed into more formal, structured relationships. Having a more informal working group at the start of an initiative facilitates participation by public agencies and creates a decision-making structure that can be flexible and allow quick action, if needed; over time, formalizing this coalition allows for greater transparency, growth, and management of a large group of partners. Creating a structure wherein the need for quick action—and successful outcomes—was balanced with the need for broad input and support from the coalition

allowed LHDs to maintain small working groups to carry out core work with a larger network of partners reviewing and providing feedback on specific initiatives. A concrete initiative with a specific set of short-term objectives and actions can help a group start working together with a common purpose, and accomplishments achieved relatively quickly can inspire greater commitment and support for longer-term work. In San Diego, the LHD worked with the MPO to create a healthy communities atlas that mapped existing regional data on the social and physical determinants of health. In addition to serving as an educational tool and resource to help transportation and land use planners, the document creation process helped strengthen the relationship between the LHD and MPO, paving the way for greater collaboration. Several LHDs cited the importance of funding in catalyzing BE work and interagency partnerships. As noted by one LHD representative regarding the CPPW grant: Health is a new player to this game, so it helped that it was the health department . . . funding many of the built environment projects because then the other city departments had to play nice with us. . . . Each agency is very busy managing its immediate projects and, therefore, without this forced collaboration, [the partnership] might not have evolved to the extent it did.

A multilevel approach to assessing the mission, needs, and strengths of each potential partner organization helps lay the foundation for success.

Planning for Sustainability To ensure the sustainability of the coalition and the BE work it undertakes, the LHD and its partners must articulate the roles and responsibilities that each will assume (Figure 1). Appropriate roles for LHDs may include providing data and the evidence base for work, using data on health disparities and other epidemiological information to identify populations and neighborhoods of interest, acting as a liaison to or convener of partners, educating the public, seeking funding support, helping develop policies, assisting with health-related evaluations and assessments (including health impact assessments), and conducting media outreach. BE agencies can assess their opportunities to update internal processes, programs, design guidelines, codes, plans, and other

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measures to synergistically support obesity prevention and improved health outcomes in their work. In addition, ensuring access to technical assistance is essential. Opportunities for this type of support can be found through national organizations providing guidance on healthy BE issues and through networks of public health and BE professionals; however, additional sources of affordable technical assistance must be developed. As shrinking budgets and growing demands challenge LHDs, articulating the populationwide effects of BE programs can help convey the importance of sustaining this work. According to many mentees, working toward solutions and strategies that fundamentally change the way agencies, institutions, and the private sector do business is essential so that health goals are not an additional layer in their work but are interwoven into day-to-day processes.

Building Political and Public Support Changing the BE to address obesity and related diseases often requires action by elected officials and political bodies. In an initial survey of mentees, 77% ranked garnering public support and 82% ranked building political support among the highest-priority areas for technical assistance. Nongovernmental entities often proved excellent partners in developing and disseminating information to build political and public support. For example, in Omaha, Nebraska, a nonprofit organization, Omaha by Design, bolstered the healthy BE efforts of the LHD and its institutional partners by facilitating partnerships among the public, private, and philanthropic sectors; monitoring local policies; developing and disseminating information; and helping fund and organize specific projects such as the development of a streetscape handbook promoting multimodal transportation. Although much progress can be made through interagency and cross-sector partnerships, LHDs also cited the importance of support for healthy BE work on the part of mayors and elected officials. Louisville’s Healthy Hometown Movement, an intersectoral group coordinated by the LHD, was initiated by former mayor Jerry Abramson and embraced by current mayor Greg Fischer.

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• Act as convener/liaison with partners; Provide data and evidence base; Health Department

Educate the public; Seek health grants; Help develop policy; Conduct evaluation and media outreach

• Assess opportunities to change internal processes, programs, codes, design guidelines, plans, construction bids and contracts, and other measures; Train staff and identify staff for trainings; Conduct outreach to professional associations and other partners; Garner available nonhealth grants and funding such as those available for sustainable urban development and transportation

Built Environment Agencies

• Conduct outreach to and education with members; Host trainings and

Built Environment Associations/ Private Sector

events; Conduct media outreach and education of policymakers; Integrate strategies in design projects

• Conduct outreach to and education with members, the public, and Community Organizations

policymakers; Host trainings and events; Seek grants and other funding; Advocacy

• Provide literature reviews and research; Conduct evaluation of built

Academic Institutions

environment strategies and projects; Integrate topics in curricula

• Act as convener for partners; Educate grantees and policymakers; Provide

Foundations

funding for work

FIGURE 1—Potential departmental and organizational roles in healthy built environment work.

Compelling data on the city’s high rates of obesity and related diseases, coupled with the efforts of a charismatic health department director, helped garner mayoral support. Forums such as the Healthy Hometown program’s Built Environment Committee and the Bike Summit created additional opportunities to garner the support of the mayor, key agencies, and stakeholders. Mentees also found that developing a simple, compelling message that resonated with the public and decision-makers was instrumental to success. Nashville, Tennesee’s healthy BE work, branded “NashVitality,” was framed in terms of improving the quality of life of the region’s residents. An excerpt from the initiative’s Web site explains: Our quality of life is largely determined by our communities—where we live, work, learn, worship and play. We eat better when healthy food is

more available than junk food and sugary beverages. We move more when we have safe, inviting places nearby to be active. We live longer, healthier lives in these communities.22

Mentees also found success by adjusting their messages to specific audiences or emphasizing the shared benefits of healthy BE work. In New York City, where the environmental sustainability movement had high traction within the architecture and design communities, DOHMH integrated messaging about the energy and environmental benefits of alternatives to motor vehicle use, sedentary activities, and use of escalators and elevators. By working directly with the US Green Building Council, DOHMH’s built environment program and its partners helped create a new “Design for Active Occupants” pilot credit within the Leadership in Energy and

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Environmental Design (LEED) system to encourage real estate project developers to incorporate strategies that promote physical activity.23 This credit counts as 1 point toward LEED certification (a national and international rating system for green real estate development used by architects, developers, and designers).18,24

Evaluating Outcomes Finally, as with any public health initiative, evaluation of BE work is essential. Whereas LHDs are uniquely positioned to conduct health-related evaluations of programs, policies, and projects, other partners involved in healthy BE work, such as architecture and planning agencies, may not be equipped for such analyses. To evaluate their success, most participating LHDs assessed effects on

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individuals and characteristics of the BE within their jurisdictions, including identifying whether the populations most vulnerable to obesity and related health disparities were being affected. In Nashville, a health impact assessment of a transit commuter benefits program evaluated the effects on participants’ weekly levels of physical activity (i.e., walking and bicycling). Other evaluations focused on BE indicators connected to obesity levels. For example, to track progress over time, the Multnomah County, Oregon, health department developed built environment rankings for each of the region’s neighborhoods on a wide range of indicators, including number of residents living within a quarter mile of a park or trail, the density of recreation facilities and grocery stores, and the extent of mixed-use residential zoning.

CONCLUSIONS Over the past decade, research on the health impact of the BE has produced an evolving set of policy, programmatic, and institutional best practices. The next decade will present opportunities to use these findings to expand the number of LHDs engaged in BE work as an evidence-based and effective means of combating obesity and related chronic diseases. National and local funders, nonprofit organizations, and academic institutions have important roles to play in supporting LHDs as they pursue BE work. Key areas for future research and action include instituting and expanding healthy BE training for public health as well as other governmental and nongovernmental personnel, dedicating additional resources to localized data collection on obesity and physical activity levels, and developing a set of standard indicators to measure a healthy BE and track improvements over time. Systematically examining the BE policy approaches and programmatic methods that have proven most effective in addressing physical activity and obesity is also recommended. Finally, although exploring the role of transformational leaders in spearheading innovative, intersectoral collaboration was beyond the scope of our program design, we recommend that future research focus on identifying the characteristics of such leaders and determining

how strong BE leadership can be fostered among LHD staff. Even as these areas continue to be explored and finessed, LHDs can and should embark on healthy BE work. In communities such as New York City and Philadelphia, Pennsylvania, where BE work is part of a comprehensive approach to obesity prevention and control, early reversals in childhood obesity trends have been documented.25,26 Through DOHMH’s built environment mentoring program, LHDs have uncovered strategies for success that should resonate with public health professionals in all disciplines and that can be implemented across LHDs in diverse settings, both domestically and internationally: identifying leaders with the clout needed to embark on a new direction and the ability to inspire others; dedicating staffing resources to BE work; engaging a diverse, multisectoral network of partners; developing short- and long-term measurable and specific goals that keep partners, policymakers, and the public energized and supportive of BE work; using local data and evaluation methods regularly to illustrate local effects; and applying existing evidence and best practices to local BE needs, policies, and practices. Although some of these strategies are not unfamiliar, their application in addressing the new challenges of BE work will require LHDs to be creative and to learn from other health departments with experience in the field. j

About the Authors At the time this article was written, Kate Rube, Maggie Veatch, Rachel Sacks, Megan Lent, Gail P. Goldstein, and Karen K. Lee were with the Bureau of Chronic Disease Prevention and Tobacco Control, New York City Department of Health and Mental Hygiene, Queens, NY. Katy Huang is with the Division of Health Care Access and Improvement, New York City Department of Health and Mental Hygiene. Correspondence should be sent to Rachel Sacks, MPH, 252 Richardson St, Suite 3L, Brooklyn, NY 11222 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted December 21, 2013.

Contributors K. Rube contributed to the data collection and analysis, wrote the initial draft, and edited the final version of the article. M. Veatch coordinated the data collection and analysis, assisted in the development of the original draft, and edited the final version. K. Huang conducted the literature review and contributed to the original draft. R. Sacks revised the original draft, coordinated the

May 2014, Vol 104, No. 5 | American Journal of Public Health

editing process, and edited the final version. M. Lent contributed to the literature review, the data analysis, and the writing and editing of the original draft. G. P. Goldstein contributed to developing the original draft and editing the final version. K. K. Lee worked with K. Rube to frame the original draft, provided supervision over content and direction throughout, and edited the final version.

Acknowledgments This project was supported in part by cooperative agreement 3U58DP002419-01S1 from the Centers for Disease Control and Prevention. We thank the Built Environment Mentoring Program partners, including the leadership and staff of the Boston Public Health Commission, Healthy Nation Rogers County, the Consortium to Lower Obesity in Chicago Children, the Cook County Department of Public Health, the Nashville Metro Public Health Department, the Douglas County Health Department, United Way of Central Alabama, the Jefferson County Department of Health, King County Public Health, the Louisville Metro Department of Health and Wellness, the Miami---Dade County Health Department, the Multnomah County Health Department, the Philadelphia Department of Public Health, the Pima County Health Department, and the County of San Diego Health and Human Services Agency. We also thank the partner institutions and agencies acknowledged in Tables 1 and 2. Note. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention.

Human Participant Protection No protocol approval was needed because we analyzed data collected as part of a program evaluation.

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