U.S. Department of Transportation Federal Highway Administration Federal Transit Administration

Annotated Bibliography on
Health and Physical Activity in Transportation Planning

Prepared for
The Federal Highway Administration and Federal Transit Administration
Offices of Planning

April 2004

Ben Rasmussen
William M. Lyons
John A. Volpe National Transportation Systems Center
Research and Special Programs Administration
U.S. Department of Transportation

Prepared for:
The Federal Highway Administration and Federal Transit Administration
Offices of Planning
U.S. Department of Transportation

Prepared by:
Volpe National Transportation Systems Center
Cambridge, Massachusetts
Research and Special Programs Administration
U.S. Department of Transportation

April 2004

Acknowledgements

This report was prepared for the Federal Highway Administration (FHWA) and Federal Transit Administration of the U.S. Department of Transportation (USDOT) by the USDOT's Volpe National Transportation Systems Center (Volpe Center). Sherry Ways of the FHWA and Effie Stallsmith of the FTA provided overall guidance for the report.

The report authors are Ben Rasmussen, lead analyst, and William M. Lyons, Volpe Center project manager of the Health and Physical Activity Project. The project team received helpful assistance, including suggestions on research studies and programs to review, from Andrew Dannenberg and Tom Schmid of the Centers for Disease Control and Prevention; Marya Morris of the American Planning Association; Nan Humphrey, program officer for the National Academy of Science's Physical Activity, Health, Transportation, and Land Use project; Kate Kraft and Richard Killingsworth of the Robert Wood Johnson Foundation; and representatives from other organizations working in the combined fields of public health and community design, including the National Coalition for Promoting Physical Activity, the National Association of County and City Health Officials, the Association of State and Territorial Health Officials; and the Prevention Institute. Wendy Klancher from the Metropolitan Washington Council of Governments, Joe Curley from the Metropolitan Transportation Commission, Kathleen Reavis from the City of Fort Collins, and Hannah Twaddell from Renaissance Planning Group (formerly Thomas Jefferson Planning District Commission, VA) also provided useful assistance. Dr. David A. Belluck, John Fegan, and David Kuehn of FHWA provided valuable comments on this report.

The USDOT, the FHWA, the FTA, and the organizations providing information are not responsible for the accuracy of the report, which is solely the responsibility of the authors.

This report is available on the FHWA and FTA's Transportation Planning Capacity Building web site at http://www.planning.dot.gov/ or in hard copy by e-mail to William Lyons at lyons@volpe.dot.gov or by fax to (617) 494-3260.

Table of Contents

1. INTRODUCTION
1. Transportation Planning
2. Capacity Building
3. Health and Physical Activity
4. The Transportation Planning, Capacity Building, and Health Connection
5. Structure of the Bibliography

 
2. REVIEW OF SOURCES

  Table One: Methods Covered By Sources
 
3. SYNTHESIS OF THE LITERATURE
1. Scenario and Long-Range Planning
2. Performance Measures and Indicators
3. Community Impact Assessments
4. Planning for Safety
5. Assessments of Alternatives
6. Level of Service Assessments
7. Participation, Outreach, and Communication
8. General Sources on Health and Activity and/or Planning
9. Overlap in Methods Considered

 
4. SUMMARY AND CONCLUSION

Executive Summary

The Transportation Planning Capacity Building Program (TPCB), supported by the Federal Highway Administration (FHWA) and Federal Transit Administration of the U.S. Department of Transportation (USDOT), is one mechanism to encourage state, metropolitan, rural, and Tribal transportation planning agencies to plan for and achieve health goals. To assist these agencies and public health agencies and organizations, the FHWA and FTA have developed this annotated bibliography on health and physical activity in transportation planning. This report was prepared for the FHWA and FTA by the USDOT's Volpe National Transportation Systems Center (Volpe Center).

This bibliography is the first of two parts of the Health and Activity Project. The second part of the initiative is a Transportation Planning and Physical Activity Experts Peer Roundtable in January 2004 at the third annual New Partners for Smart Growth Conference in Portland, Oregon. The bibliography and proceedings of the roundtable will provide useful resources to transportation planners interested in incorporating opportunities for physical activity into their planning processes and to public health officials interested in understanding and contributing to the transportation planning process.

Numerous studies have looked at the relationship between public health and the built environment, but limited attention has been given to the transportation planning process, which can result in decisions that can promote health through physical activity. To address this gap, this annotated bibliography examines studies and programs that evaluate or demonstrate how health and physical activity concerns can be incorporated into transportation planning processes.

Transportation planning is typically undertaken by state Departments of Transportation (DOTs); federally designated metropolitan planning organizations (MPOs); city and county transportation agencies; and transportation providers. Similar to state and local agencies with energy, environment, economic development, and land use responsibilities, public health agencies can also consider transportation trends, issues, and strategies in their planning. Research and programs both of public health and transportation planning agencies and organizations are important sources of information for this initiative and the bibliography.

To improve the understanding of potential linkages between the fields of transportation planning and public health, this bibliography has two critical focuses:

1. Transportation planning and decision making in contrast to a broader focus on the health impacts of transportation decisions themselves. Rather than considering the implications for physical activity of specific decisions, including investments, coordination of multi-modal systems, or strategies, the focus is on the transportation planning process that leads to these decisions. This process is developed at the statewide, metropolitan area, or local level and follows the broad framework defined in the federal legislation under the Transportation Equity Act for the 21st Century (TEA-21). For the purposes of this report, transportation planning also includes planning that includes transportation considerations by agencies responsible for public health, as well as for energy, the environment, or economic development.
2. Physical activity from daily activities in contrast to more general research and programs that look at broad aspects of public health, including respiratory and other diseases related to air or water pollution, and safety. Physical activity is one specific focus among many under the broad heading of public health.

With these two focuses in mind, the report reviews each source based on:

1. Impetus or reason for the study or program;
2. Description of what the study or program is about and its findings, prospective findings, or message; and
3. Contribution or the role of the study in literature regarding the consideration of health and physical activity in transportation planning processes.

To assist in reviewing the research and programs included in this report, this report identifies seven potential methods for incorporating health and activity concerns into the transportation planning process. These methods are:

• Scenario and long-range planning;
• Performance measures and indicators;
• Community impact assessments;
• Planning for safety, especially for the elderly and routes to school for children;
• Assessments of alternatives;
• Level of service assessments; and
• Participation, outreach, and communication.

The following summary observations were reached from compiling the bibliography and completing the synthesis of how the sources reviewed approach the integration of physical activity and health goals into the transportation planning process.

• Consideration of the overall transportation planning process. In general, the sources reviewed do not explicitly consider how physical activity goals might be integrated within the overall transportation planning process. This indicates that the sources are not focusing on the holistic process through which transportation is planned at statewide, metropolitan area, and local levels, including the broad general framework for transportation planning by states and metropolitan areas described in the federal Transportation Equity Act for the 21st Century.
• Consideration of key methods of the transportation planning process. The sources reviewed do consider the integration of physical activity within transportation planning when it is considered from the perspective of the seven methods identified rather than as a holistic process. The bibliography describes important examples of research completed and current programs focusing on key aspects of transportation planning, including vision or scenario planning, public participation, and use of performance measures are underway.
• Overlap among transportation planning methods. The review of sources, synthesis, and summary in Table One demonstrate that there are numerous overlaps in the methods addressed in the research and programs reviewed. For example, some research considers planning for safety of pedestrians and cyclists and performance measures as part of health impact assessments. Some implications seem clear:
1. There may not be a single best way to incorporate physical activity concerns into the transportation planning process. Transportation planners and public health practitioners might effectively borrow from the range of methods and applications documented in the research depending on local circumstances and priorities.
2. The prevalence of overlaps in the methods might indicate progress toward a more holistic approach to transportation planning.
3. Transportation planners and researchers might consider expanding overlaps between methods or investigate new overlaps. For example, additional performance measures that allow health and activity impacts to be considered alongside traditional transportation goals of reduced congestion or improved accessibility might strengthen vision or scenario planning. Transportation planners might be interested in expanding public participation by introducing safety, physical activity, or health performance measures to bolster public interest.
• Documenting practical applications. Transportation planning agencies considering whether to include physical activity dimensions require analytical methods and data to determine the significance of relationships between transportation, activity, and health, and relevance to their jurisdictions. Planners will benefit from documentation of experiences of peers incorporating health and activity goals into planning processes.
• Expanding mutual awareness between transportation planners and public health practitioners. The incorporation of physical activity and health goals into transportation planning is a new and evolving area of interest. This integrated approach is certainly the exception rather than the rule. Public health researchers may not have a strong awareness of the overall transportation planning process as practiced at statewide, metropolitan area, and local levels, as encouraged by TEA-21 and adapted in each jurisdiction. Hopefully this bibliography will be a useful tool for expanding understanding from both perspectives.
• A role for future capacity building. This brief bibliography can help document the range of research completed and programs underway. It can also help determine where further research in the field is needed. It might be useful to develop guides, courses, or other materials that describe the overall transportation planning process for public health researchers and practitioners. It might also be helpful to develop special summaries of the transportation planning processes targeted to health practitioners and of physical activity and health research targeted to transportation planners.
• Importance of partnerships. To succeed, future capacity building will require partnerships between transportation planners and public health practitioners and their agencies and organizations at national, state, and local levels.

I. INTRODUCTION

In recent years, numerous planning and public health programs and studies have examined the effects of policy and changes to both the human and natural environment on public health. These changes, known in the public health field as interventions, include changes in transportation systems, urban design, company policies, and recreation opportunities. Though a number of studies have found that various interventions are associated with improved public health, relatively little attention has been given to how these interventions can be supported by considering health concerns in regional, state, or local transportation planning processes.

This annotated bibliography focuses on the extent to which documented research has considered how the transportation planning process can incorporate health and physical activity goals into transportation decisions that promote health alongside other transportation goals. The bibliography also reviews several programs of public and non-profit organizations with interest in related fields. The studies that result from these programs may help encourage the incorporation of health and activity concerns into the transportation planning process and may direct further discussion on the topic in the future.

To improve the understanding of potential linkages between the fields of transportation planning and public health, this bibliography has two important focuses on the research reviewed:

1. Transportation planning and decision making in contrast to a broader focus on the health impacts of transportation decisions themselves. Rather than considering the physical activity implications of specific investments (e.g., a new road project, bus route, or bikeway); multi-modal systems (e.g., a coordinated network of roads, park-and-ride lots, bus routes, sidewalks, etc.); or strategies (e.g., congestion pricing or coordinated management of parking), the focus is on the transportation planning process that leads to these decisions. State Departments of Transportation (DOTs), Metropolitan Planning Organizations (MPOs), counties, cities, or transportation providers conduct this planning process at the statewide, metropolitan area, or local level. This process corresponds to the framework for statewide and metropolitan transportation planning defined in the federal legislation under the Intermodal Surface Transportation Efficiency Act (ISTEA) in 1991 and continued in 1996 under the Transportation Equity Act for the 21st Century (TEA-21). For the purposes of this report, transportation planning also includes planning that incorporates transportation considerations by agencies responsible for public health, as well as for energy, the environment, or economic development.
2. Physical activity from daily activities in contrast to a broader focus on public health. Physical activity is one specific focus among many under the broad heading of public health, including respiratory and other diseases related to air or water pollution, and safety, particularly accidents involving pedestrians or cyclists. This report focuses on physical activity from routine daily activities (i.e., travel to work, school, shopping, etc.) as opposed to that under the related topic of recreation. Transportation planners usually refer to these activities as non-motorized travel, which includes walking and bicycling as well as other activities such as in-line skating and using scooters. Because this study focuses on the overlap between transportation planning and public health research, this bibliography concentrates on walking and bicycling.

This report will be a useful reference and tool both for transportation planners and public health officials interested in transportation planning and health/activity issues. To clarify the focus of this bibliography, the following terms are defined below:

• Transportation planning
• Capacity building
• Health and physical activity

Based on these definitions, this report provides a list of candidate methods for incorporating health and activity considerations into the transportation planning process. The report then provides a synthesis of how the sources and programs reviewed apply these methods and concludes with observations on the extent to which the research documented considers how to incorporate health and activity goals as part of transportation planning.

Transportation Planning

According to the Transportation Planning Capacity Building Program¹ of the Federal Highway Administration (FHWA and Federal Transit Administration (FTA), transportation planning is the process used to identify priorities within the field of transportation and determine how transportation funds are allocated to different projects and areas. This process involves:

• Establishing a community or regional vision and identifying how transportation fits into this vision.
• Developing and utilizing a cooperative and inclusive transportation vision and operations concept for the region.
• Understanding the types of decisions needed to achieve this vision.
• Assessing the opportunities and limitations of the future in relation to goals and desired system performance measures.
• Identifying near- and long-term consequences of alternative choices.
• Relating alternative decisions to goals, objectives, and system performance measures and presenting this information to decision-makers.
• Helping decision-makers establish priorities and develop an investment program.

Additionally, public involvement is an important and necessary aspect of the transportation planning process, and is required as part of the comprehensive framework for statewide and metropolitan transportation planning defined in the federal TEA-21 legislation. For example, in long-range transportation planning, public involvement is important in gaining a better understanding of the historical context and baseline conditions; articulating the community's, region's, or state's needs, vision, and goals; identifying a variety of transportation priorities and concerns; and promoting an understanding of the planning process.

Transportation planning is typically undertaken by state DOTs; federally designated MPOs; city and county transportation agencies; public transit, port, rail, and airport authorities; and other public and private sector transportation operators. Similar to state and local agencies with energy, environment, economic development, and land use responsibilities, public health agencies also can consider transportation trends, issues, and strategies in their planning. Indeed, health agencies are sometimes involved in the programming and operation of health-related transportation with U.S. Department of Health and Human Services funds that sometimes exceed highway and transit federal aid programs. Research and programs both of public health and transportation planning agencies and organizations are important sources of information for this initiative and the bibliography.

Capacity Building

Capacity building is the continuing process of helping and improving upon the ability and capability of people and organizations to efficiently deliver services that fall within their mandate, such as transportation planning. Capacity building increases the ability of people and organizations to access, understand, and apply information and knowledge in ways that contribute to the organization reaching its goals or fulfilling its stated mission. Capacity building is gradual and can happen through a variety of activities and projects including interventions, workshops, and the distribution of information.

Health and Physical Activity

The CDC states that more than 60% of American adults do not get enough physical activity to provide health benefits.² Together, unhealthy eating and the lack of physical activity account for over 300,000 preventable deaths a year, which is second in preventable deaths only to tobacco. To counter these trends, changes in diet and more opportunities for physical activity need to be created.

While starting a physical activity regimen can be difficult, incorporating physical activity into daily routines can be relatively easy. For example, instead of driving to work or shopping, it might be feasible to walk or bicycle to work, perhaps combined with transit. Strategies to improve opportunities for these alternatives might also contribute to promotion of complementary transportation goals such as reduced congestion or improved accessibility, and broader goals, such as more livable communities or improved air quality. To make such activity feasible, however, local, regional, and state transportation planning organizations need to consider how plans could include expanded opportunities for everyday physical activity, such as constructing sidewalks and bike lanes, throughout transportation planning processes.

The Transportation Planning, Capacity Building, and Health Connection

As part of the Transportation Planning Capacity Building Program, the U.S. Department of Transportation, Federal Highway Administration, and Federal Transit Administration are involved in building capacity in organizations responsible for statewide, metropolitan, rural, and Tribal transportation planning. Health and physical activity concerns can potentially be considered via capacity building as part of these transportation planning processes.

To explore this possibility, this annotated bibliography will examine research that considers health and physical activity goals in transportation planning processes. The bibliography will also consider several related programs of public and non-profit organizations with interests in related topics. Because this is a topic of growing interest, those programs may be considered the starting point for future research. Additionally, the bibliography will reference other literature reviews that have more broadly covered relationships between transportation, land use, and health and activity. The scope of this review will be limited to a specific focus on a sub-set of these broader topics - the transportation planning and decision making process.

The bibliography will be useful for transportation planners interested in incorporating opportunities for physical activity into their planning processes and for public health officials interested in understanding and contributing to the transportation planning process.

Structure of the Bibliography

The following list of sources is not intended to be exhaustive on the topic. Instead, the sources selected should be considered to represent and illustrate the range of literature in the field that discusses the incorporation of health and physical activity concerns into the transportation planning process. Experts working on the topic suggested the sources reviewed. This bibliography is not intended to evaluate the various sources on or related to the topic. Instead, this report describes each of the selected sources and identifies trends in research and programs and how they relate to the topic.

To understand how a source relates to the topic, each source is reviewed in a consistent manner based on:

1. Impetus - impetus or reason for the study or program;
2. Description - description of what the study or program is about and its findings, prospective findings, or message; and
3. Contribution - role of the study in the literature regarding the consideration of health and physical activity in transportation planning processes.

With respect to this last point, there are a number of potential methods for incorporating health considerations into the transportation planning process. However, some methods have greater potential than others for widespread adoption and are more directly related to the transportation planning process defined above. These methods include:

• Scenario and long-range planning;
• Performance measures and indicators;
• Community impact assessments;
• Planning for safety, especially for the elderly and routes to school for children;
• Assessments of alternatives;
• Level of service assessments; and
• Participation, outreach, and communication.

Table One summarizes the methods that each source mentions or examines. If the source was not classifiable, then it was deemed "General Source on Health and Activity and/or Planning," meaning its focus is broader than any of the methods mentioned above. Much of the activities performed by the programs that are reviewed in this document fall into this category. A synthesis of the trends identified in this document follows the review of the sources.

II. REVIEW OF SOURCES

British Medical Association. Road Transport and Health. British Medical Association, 1997, 94 pages.

1. Impetus - To describe ways transport impacts health and to recommend ways to increase health through transport decision making.
2. Description - The report discusses patterns of transport use in Great Britain, the health benefits (i.e., the potential for physical activity) and impacts (i.e., accidents, air pollution, noise pollution, and community severance) of road transport, ways to reduce health risks and increase health benefits through transport policy, and then makes general recommendations and more specific recommendations for action for specific departments and divisions of the government. The report also looks at how different segments of the population (e.g., children and the elderly) are impacted differently by transport decisions.
3. Contribution - To increase walking and bicycling, the authors recommend investing in measures to increase pedestrian and bicyclist safety and ways to collaborate with government officials.

Brownson R., E. Baker, R. Housemann, L. Brennan, and S. Bacak. "Environmental and policy determinants of physical activity in the United States." American Journal of Public Health. December 2001, Vol. 91, No. 12, pages 1995-2003. Available on-line at: http://www.ajph.org/cgi/reprint/91/12/1995.pdf

1. Impetus - To examine descriptive patterns in perceived environmental and policy determinants of physical activity and to look at associations between these factors and behavior. This study over-samples individuals at lower income levels.
2. Description - According to their study, public support is greatest for changes in school physical education requirements and for local funding for areas in which people can engage in physical activity, such as walking and jogging trails.
3. Contribution - This study takes a quantitative approach to the issue and is therefore helpful in illustrating where there is the most support for policies and practices that have the potential for increasing physical activity. However, this study focuses on the end result of the process, namely the creation of more means for people to engage in physical activity, and does not focus on a prospective approach to the policy-making process itself.

Centers for Disease Control and Prevention (CDC).
The CDC has two sites that are reviewed separately:

• "The Community Guide." Site: http://www.thecommunityguide.org/pa/
1. Impetus - To provide leadership in the evaluation of community, population, and health care system strategies to address a variety of public health and health promotion topics.
2. Description - The Community Guide is being put together by a non-federal Task Force on Community Preventive Services that was convened in 1996 by the Director of the Centers for Disease Control and Prevention. As part of its study of environmental and policy approaches to increasing physical activity, the Task Force is currently looking at how transportation policy and infrastructure changes can promote non-motorized transit. Their findings should be released in the near future.
3. Contribution - Provided that there is sufficient literature on the topic for the Task Force to examine, this study should at least have indirect findings that are pertinent to how physical activity considerations can be incorporated into transportation planning processes.
• Division of Nutrition and Physical Activity (DNPA). Site: http://www.cdc.gov/nccdphp/dnpa/index.htm
1. Impetus - To be involved in epidemiological and behavioral research, surveillance, training and education, intervention development, health promotion and leadership, policy and environmental change, communication and social marketing, and partnership development. With respect to the work the DNPA is doing in these areas, their web-site hosts a section of resources available to the health professional: http://www.cdc.gov/nccdphp/dnpa/physical/health_professionals/index.htm
2. Description - The CDC is attempting to increase the prevalence of physical activity nation-wide by making information available to the public and by providing funds, advocacy, and collaboration. While the DNPA looks at well-being more broadly, the Active Community Environments Initiative (http://www.cdc.gov/nccdphp/dnpa/aces.htm, a subsidiary of the DNPA) focuses on promoting physical activity at the community level and works with a number of organizations to this end.
3. Contribution - The CDC is involved in two projects that are closely related to incorporating health considerations into the transportation planning process: how health might be reflected in New York metropolitan area's long range planning and how health and physical activity concerns can be incorporated into New Jersey's state development plan.

City of Fort Collins, Colorado. "Multimodal Transportation Level of Service Manual." March 1997, 29 pages. Available on-line at: http://www.co.larimer.co.us/engineering/GMARdStds/ApdxH%2010-01-02.pdf

1. Impetus - In accordance with other city documents and plans and as a result of public and elected officials input, this manual is a component of the City of Fort Collins' Transportation Master Plan that devises level of service standards for pedestrians, bicyclists, and public transit in addition to the more traditional standards for motor vehicles.
2. Description - Pedestrian level of service standards are based on directness, continuity, street crossings, visual interest and amenity, and security. Minimum levels of service (LOS) across these categories are determined for the following types of pedestrian facilities: pedestrian district, activity corridor/center, transit corridor, school walking area, and other. While it is hoped that existing locations will be brought up to the minimum level of service standards by 2015, all new developments must meet the minimum level of service standards. Bicycle LOS standards are based on the connectivity to the following bicycle facilities in connecting corridors: on-street lanes, off-street paths, and on-street routes. Minimum LOS standard of C must be attained citywide, A for public school sites, B for recreation sites, and B for community/neighborhood commercial centers. The manual also outlines the procedure for applying the LOS standards for development review and provides attendant worksheets.
3. Contribution - This document does not directly examine the incorporation of health concerns into the transportation planning process. However, it follows that if transportation planners endeavor to attain high levels of service for pedestrians and bicyclists in their decision making processes for locations that necessitate such actions, then more people will be physically active.

City of Tucson. "The Livable Tucson Vision Program." Available on-line at: http://www.ci.tucson.az.us/livable2.html

1. Impetus - To identify a long-term, community-driven vision for Tucson that would help shape the city's budget and provide a framework for developing programs and services that address the concerns of the community.
2. Description - This indicator-based program is in-line with the federal Livability Agenda for the 21st Century. Over 1,200 community members, business people, and city employees have participated in the program and bulletin boards and an internet site were set up for further public comment. Based on these comments, seventeen key goals emerged. One of these goals is to provide better alternatives to automobile transportation through an improved public transportation system, bicycle and pedestrian friendly streets, improved roadways (landscape, lighting, sidewalks, bus stops), and promotion of alternatives to the automobile. The indicators for this goal are use of alternative means of travel, ratio of miles of quality pedestrian and bike paths and bus routes to total lane miles of roads, number of days you can see Rincon Peak from Tumamoc Hill, and number of pedestrians in neighborhood. A featured project/example for each goal is then provided in addition to a list of actions an individual can take to help the community realize the goal.
3. Contribution - This program is tied to national policy, involves the public, and suggests and uses performance measures for the promotion of alternative modes of transportation. Though health and physical activity is not a direct goal, it is an indirect benefit of the goal to promote alternative modes of transportation.

Department for Regional Development. "Pilot Health Impact Assessment: Regional Transportation Strategy for Northern Ireland 2002 - 2012." 2002, 21 pages. Available on-line at: http://www.drdni.gov.uk/rts/pdf_files/final_pdfs/Health_impact.pdf

1. Impetus - This document is a health impact assessment for the 2002-2012 regional transportation strategy for Northern Ireland.
2. Description - The study evaluates the strategy's impact on air pollution, road traffic injuries, physical activity, community severance, noise, access/mobility, and inequalities. The evaluation is mainly qualitative and finds that while the strategy will be beneficial for the health of the overall population, some additional items need to be considered.
3. Contribution - Though this document considers overall public health rather than focusing on physical activity, it is an example of how a health impact assessment can be incorporated into the planning stage of a region's transportation strategy. Additionally, this report also develops several specific recommendations that, if followed, would further benefit the health of the population.

District Department of Transportation. "1997 Strategic Transportation Plan for District of Columbia."

1. Impetus - The strategic transportation plan for the District of Columbia DOT presents a vision for the District's future transportation system and an action plan for fulfilling it. Table One of the plan presents the Department of Public Works' document on the scenario planning process and its application in the District.
2. Description - The District of Columbia DOT was one of the first agencies to use the process of scenario planning in the development of its transportation plan. This document presents five broad end-states (a tourism and entertainment scenario, a free market model city scenario, a federal/city partnership scenario, a regional scenario, and world capital scenario) that were developed after more than 50 interviews with civic and business leaders in the community. The development of these five potential future outcomes was followed by a process of identifying and examining the events and decisions that would lead to each of these end-states. For each end-state, a transportation emphasis is summarized. While all five scenarios call for transit improvements, two explicitly call for improvements to pedestrian and bicycle facilities. Citizens and business representatives were asked which would be the most likely and most desirable end-states and the Plan then incorporated the steps necessary for having the District reach the most desirable outcome.
3. Contribution - Though the District DOT's long-range transportation planning process does not account for the changes in health over the years, it is an example of how scenario planning can be used in the long-range transportation planning process.

Dixon, L. "Bicycle and Pedestrian Level-of-Service Performance Measures and Standards for Congestion Management Systems." Transportation Research Record 1538: 1995, pages 1-9.

1. Impetus - To look at the level of service measures for bicycle and pedestrian facilities that were created for the city of Gainesville, Florida.
2. Description - The level of service measures are point based and weighted. Bicycle level of service measures rate the provision of basic facilities, conflicts, speed differential, motor vehicle level of service, maintenance, and transportation demand management programs or multimodal links to transit. Pedestrian level of service measures rate the provision of basic facilities, conflicts, amenities, motor vehicle level of service, maintenance and transportation demand management programs or multimodal links to transit. Each of these components is described in some detail. The author recommends that all projects attain level of service D at the minimum with level of service A or B existing around schools, central city districts, and other activity centers.
3. Contribution - Though the article makes no mention of public health or physical activity, it is logical that more pedestrians and bicyclists will exist in areas with high levels of bike and pedestrian service (depending on location) and people will therefore be more physically active these areas.

Dora, C. "A different route to health: implications of transport policies." British Medical Journal. June 1999, Vol. 318, pages 1686-1689. Available on-line at: http://bmj.bmjjournals.com/cgi/content/full/318/7199/1686

1. Impetus - To examine why physical activity and non-motorized modes of transportation are beneficial to society and how policy is a good way to affect change in this regard.
2. Description - The author states that two ways to increase non-motorized modes of transportation are to increase safety provisions for bicyclists and pedestrians and to involve the public health community in policy-making.
3. Contribution - The author recommends ways in which the public health community should become involved in policy-making. These include assisting with the implementation of health impact assessments and the evaluation of the health costs of transport projects, taking into account the values and priorities of the affected communities, identifying gaps in knowledge and helping to fill these gaps, and providing access to information to facilitate community involvement. The article mentions these briefly and does not go into detail about how these steps can be taken.

Douglas, M. J., L. Conway, D. Gorman, S. Gavin, and P. Hanlon. "Developing Principles for Health Impact Assessment." Journal of Public Health Medicine. 2001, Vol. 23, No. 2, pages 148-154.

1. Impetus - To review the process and findings of the Health Impact Assessment of the City of Edinburgh Council's Urban Transport Strategy and a HIA of housing investment, also in Scotland.
2. Description - The authors talk about the impetus for HIA in the United Kingdom, the reasons for the HIA in Edinburgh, how they performed the HIAs, the findings of the HIAs, and recommendations for how future HIAs should be performed.
3. Contribution - Though physical activity is considered as a component of the HIA for the transport strategy, this article gives insight into how a HIA was and should be performed prospectively for broad transportation policies. Specific recommendations for HIAs are that they should be systematic, involve decision-makers and affected communities, take into account local factors, use evidence and methods appropriate to the impacts identified and the importance and scope of the policy, and that they should make practical recommendations. Three scenarios were analyzed as part of the HIA in Edinburgh based on low, medium, and high levels of spending.

European Conference of Ministers of Transport, Masatoshi, M. "Draft Report on National Cycling Policies" developed as part of Sustainable Urban Travel project. Available when final at: http://www1.oecd.org/cem/topics/urban/index.htm

1. Impetus - To describe the state of bicycle planning in Europe, the United States, and Japan.
2. Description - As part of this description, this report looks at the trends, benefits, barriers, institutional framework, policies, plans, and the role of the national government with respect to planning for bicycling in these various countries. The report provides examples of what different countries are doing with respect to promoting bicycling nationwide.
3. Contribution - Instead of discussing how health concerns can be incorporated into the transportation planning process, this report documents how current plans and policies attempt to encourage bicycling throughout Europe, Japan, and the United States and examines how these countries can better promote bicycling as a viable form of transportation. The report discusses planning for bicyclist safety, avenues for collaboration between planning and health officials, and other more general aspects of bicycling.

Federal Highway Administration (FHWA).
The FHWA has three sources that are reviewed separately:

• "Community Impact Assessment: A Quick Reference for Transportation." Publication No. FHWA-PD-96-036, 1996
1. Impetus - To serve as an introduction to the community impact assessment process for transportation officials.
2. Description - In addition to providing definitions of key terms, this document lists policies that call for the use of community impact assessment. The bulk of the document, however, presents and describes each step of the process for conducting a community impact assessment for transportation projects. These steps are: define the project/study area, develop a community profile, collect data, analyze impacts, select analysis tools, identify solutions, use public involvement throughout, and document findings.
3. Contribution - Aside from tangentially relevant references to how pedestrian and bicycle access and safety may be impacted, there is no mention of health or physical activity in this concise yet informative document. However, health considerations could feasibly be integrated into a number of the steps related to transportation planning identified above.
• "Community Impact Assessment: Case Studies." Publication No. FHWA-PD-98-024, May 1998.
1. Impetus - To provide examples of how transportation projects have been planned, designed, and constructed to be neighborhood friendly; how projects have avoided, minimized, and mitigated impacts; and how projects have enhanced the livability of communities and neighborhoods.
2. Description - This document examines five case studies on community impact assessment, mitigation, and enhancement: Durham, NC; Oak Park, MI; Philadelphia, PA; Seattle, WA; and Prichard, AL. These cases involved the construction or expansion of major roadways that if left unmitigated could potentially sever community form, function, and cohesion.
3. Contribution - While neither health nor physical activity was an explicit component of the impact assessments, three of the five projects resulted in the creation of large park and recreation facilities.
• The FHWA Transportation and Community and System Preservation (TCSP) Program. "Resources: Land Use and Transportation Modeling Tools - CorPlan Model, Charlottesville, VA." 21 Nov. 2002. Available on-line at: http://www.fhwa.dot.gov/tcsp/corplan.html
1. Impetus - As a result of a TCSP grant, the Thomas Jefferson Planning District Commission (TJPDC) for the Charlottesville, Virginia, region developed the CorPlan Model, which can estimate various land use and transportation growth scenarios.
2. Description - The CorPlan model was developed for TJPDC to provide a community-level land-use model that can be easily understood by the public. TJPDC had a number of meetings and public workshops that served to articulate alternatives for growth over a 50-year period that were then incorporated into the model. The outputs of the model were then entered into a travel demand model for each scenario to not only estimate land use but transportation impacts as well. Transportation needs were then assessed to serve each of the land use scenarios, including light rail and bus rapid transit systems. The scenarios - Dispersed, Town Centers, and Urban Core - were then discussed and the most desirable scenario was chosen to be the basis for regional and local long-range plans. The model, which is an Excel-based application with optional connections to GIS, and guidebooks are downloadable on TJPDC's web site (http://www.tjpdc.org/community/epi.asp). A number of other regions and communities have begun using CorPlan (http://www.citiesthatwork.com/).
3. Contribution - The developers of CorPlan incorporated the work of experts to create elasticities for walking and bicycling trips,³ which allows this model to estimate the percentage of these trips made under each scenario. Therefore, this model helps incorporate health concerns into scenario planning and the transportation planning process.

Fleeman, N., and A. Scott-Samuel. "A prospective health impact assessment of the Merseyside Integrated Transport Strategy (MerITS)." Journal of Public Health Medicine. 2000, Vol. 22, pages 268-274.

1. Impetus - To review the health impact assessment (HIA) that was performed on the integrated transport strategy of the Merseyside region (Liverpool area) of the United Kingdom. This was one of the first HIAs conducted on transport policy.
2. Description - The HIA was broadly defined and focused on the four major policy areas of MerITS: establishing road hierarchies, economic viability, air quality, and public transport. A steering committee composed of commissioners, assessors, project/policy proponents, and other stakeholders, such as representatives of affected communities formulated the HIA. The steering committee recommended ways to mitigate the health impacts of MerITS.
3. Contribution - Though health impact assessments represent an explicit way in which health concerns are incorporated into the transportation planning process, physical activity was given a cursory amount of attention.

Frank, L.D., P. Engelke, and D. Hourigan. "How Land Use and Transportation Systems Impact Public Health: An Annotated Bibliography." ACES: Active Community Environments Initiative Working Paper #2. Last updated: December 2000. Available on-line at: http://www.cdc.gov/nccdphp/dnpa/pdf/aces-workingpaper2.pdf

1. Impetus - To begin to synthesize the literature on the effects of urban form and transportation system investments on physical activity, especially on walking and bicycling, and to guide the development of subsequent empirical research in the field.
2. Description - The sections of the bibliography review sources on travel and safety statistics, transportation system characteristics, land development patterns, and relationships between urban form and travel behavior.
3. Contribution - While useful in covering a number of the perspectives and issues in the field, this bibliography does not review sources that look at how physical activity considerations can be incorporated into transportation planning processes. However, the authors review a handful of studies that look at level of service standards for pedestrians and bicyclists.

Gorman, D., M.J. Douglas, L. Conway, P. Noble, and P. Hanlon. "Transport policy and health inequalities: a health impact assessment of Edinburgh's transport policy." Public Health. 2003, Vol. 117, No. 1, pages 15-24.

1. Impetus - To specifically review the process and findings of the Health Impact Assessment of the City of Edinburgh Council's Urban Transport Strategy.
2. Description - In addition to summarizing the HIA mentioned above, the authors provide information on Edinburgh, Scotland (population 450,000), why physical activity should be considered in a transport-related HIA (physical and mental health reasons), the creation of the group that crafted the HIA, shortcomings of the HIA process, and broad recommendations for transport policy changes.
3. Contribution - This article gives insight into how a group of people prospectively performed a HIA for the capital city of Scotland. Physical activity is considered as a component of the HIA for the transport strategy. The broad recommendations for how transportation policies can incorporate public health concerns are also useful. Three scenarios were analyzed as part of the HIA in Edinburgh, based on low, moderate, and high amounts of spending.

Hoehner, C.M., L.K. Brennan, R.C. Brownson, S.L. Handy, and R. Killingsworth. "Opportunities for Integrating Public Health and Urban Planning Approaches to Promote Active Community Environments." American Journal of Health Promotion. September/October 2003, Vol. 18, No. 1, pages 14-20.

1. Impetus - To suggest that planners and public health officials borrow methodologies from one another and collaborate with each other on their research.
2. Description - This article discusses how the fields of public health and urban planning can devise like methodological approaches when studying the impact of the environment on physical activity.
3. Contribution - The methodologies the authors discuss may impact and direct future research in the field.

Juslén, J. "Social Impact Assessment in Transportation System Planning." Paper for the International Association for Impact Assessment, New Orleans. 1997. Available on-line at: http://www.stakes.fi/sva/huia/publications/siaandtransport.html

1. Impetus - This paper is made up of two parts: part one investigates the social perspective in transportation planning and the second part looks at the social impact assessment of the Helsinki Metropolitan Area Transportation System.
2. Description - By way of interviews and a literature review, the author suggests that in order to undertake a social impact assessment of transportation systems, the planning culture needs to shift from a positivistic to a more hermeneutic (understanding) viewpoint, to include the idea of equity, include a broader range of values, and include the open formulation and assessment of alternatives into planning. In the second part of the paper, the author outlines the steps of the social impact assessment: planning the assessment and formulating alternatives, creating a baseline condition from the social perspective, organizing interaction between planners and the public, identifying and scoping the impacts, assessing alternatives, and reporting the assessment.
3. Contribution - This article looks at health impacts as a subset of social impacts. The author suggests ways that health concerns, defined broadly, can be incorporated into the transportation planning process by assessing alternatives and involving the public.

Killingsworth, R.E., A. de Nazelle, and R.H. Bell. "A New Role for Public Health in Transportation: Creating and Supporting Community Models for Active Transportation." Presented at the ITE 2003 Technical Conference and Exhibit, March 23-26, 2003. 28 pages. Available on-line at: http://www.ite.org/activeliving/files/Killingsworth_final.pdf

1. Impetus - To outline ways that communities can incorporate physical activity concerns into their planning processes.
2. Description - To increase rates of physical activity community-wide, the authors stress multidisciplinary action, public involvement, an improvement in the research that would strengthen the foundation for policy change, changes in planning policies, and physical improvements to the human environment.
3. Contribution - This document recommends that policy changes and planning process considerations be devised to focus on physical activity, such as creating a health impact statement for proposed developments and performance measures for built developments. Also, this document broadly recommends that transportation planners make physical improvements, such as traffic calming and streetscape improvements, to make walking and bicycling safer and more pleasant. The health impact statement and performance measures are ways that physical activity concerns can be incorporated into transportation planning processes.

King, A.C., R.W. Jeffery, et al. "Environmental and policy approaches to cardiovascular disease prevention through physical activity: issues and opportunities." Health Education Quarterly. November 1995, Vol. 22, No. 4, pages 499-511.

1. Impetus - To present an overview of existing and potential environmental and policy interventions for physical activity promotion.
2. Description - The authors discuss passive approaches to promoting physical activity through changes and improvements in communication networks, training mechanisms, liability legislation, zoning and land use policies, building construction and facilities development, community design, worksites, and schools.
3. Contribution - The article touches upon two pertinent methods for incorporating health concerns into the transportation planning process: collaboration and outreach and impact assessments for proposed projects. However, the authors do not go into much depth on these methods.

Laube, M.M., and R.W. Stout. "Grand Canyon National Park Assessment of Transportation Alternatives." Transportation Research Record 1735. 2000, pages 59-69.

1. Impetus - To review the transportation alternatives considered by the National Park Service for Grand Canyon National Park (GRCA).
2. Description - With respect to transportation system characteristics, impacts on the environment, and effects on development, the authors reviewed the GRCA transportation planning process that identified light-rail service as the preferred alternative for alleviating traffic growth and associated problems throughout the park. The authors found that light-rail service is, in fact, the most preferable option.
3. Contribution - Though the GRCA's transportation planning process does not incorporate health concerns, this article does demonstrate how alternatives can be assessed based on a number of considerations. The article mentions that pedestrian and bicycle paths will be an important part of the transportation network.

Litman, T. "Integrating Public Health Objectives in Transportation Decision-Making." American Journal of Health Promotion. September/October 2003, Volume 18, No. 1, pages 103-108.

1. Impetus - To make the case for expanding transportation planning and decision making processes to include health objectives.
2. Description - The author describes reasons for applying and ways to apply mobility management strategies broadly to increase public health.
3. Contribution - The author does not address the planning process itself but instead addresses the outcome of the process, with details on specific ways transportation decisions might consider and potentially improve health/activity.

Litman, T. "Quantifying the Benefits of Non-Motorized Travel for Achieving TDM Objectives." Victoria Transport Policy Institute. 1999, 24 pages. Available on-line at: http://www.vtpi.org/nmt-tdm.pdf

1. Impetus - To attempt to quantify - financially - the benefits of non-motorized travel, to examine the latent demand for non-motorized travel, and to identify the barriers to non-motorized travel, such as safety, and describe other strategies for encouraging more non-motorized travel.
2. Description - The article describes a number of reasons and ways to encourage walking and bicycling.
3. Contribution - Though the article does not explicitly consider health, the results can be useful in tandem with health benefits when considering non-motorized travel in transportation decision making processes.

London Health Commission.
The London Health Commission has two documents that are reviewed separately:

• Watkiss, P. et al. (NHS Executive). "On the move: informing transport health impact assessment in London." 2000. Available on-line at: http://www.londonshealth.gov.uk/pdf/onthemove.pdf (brief, 16 pages.), http://www.londonshealth.gov.uk/pdf/transhia.pdf (full report, 160 pages).
1. Impetus - To review the knowledge base and make recommendations with regard to how a transport health impact assessment (HIA) could be conducted for London.
2. Description - Five impacts are considered: accidents, air-pollution, noise, physical activity, and community severance. The authors examine each of these impacts in depth (in the full report) to gauge how much knowledge exists and to determine how quantifiable each impact is. For physical activity impacts, the authors conclude that though the certainty of an impact is medium to high, the certainty and approach for quantification is low. For accidents, the certainty of an impact and the certainty and approach for quantification are both high. The authors conclude by making recommendations with respect to how the certainty and approach for quantification can be improved.
3. Contribution - By considering the five impacts mentioned above, transportation planners take into account health concerns in the transportation planning process. However, the HIA has yet to be applied because of the difficulty of quantifying some aspects of some of the impacts.
• "A report of a health impact assessment of the Mayor's draft transport strategy." April 2001, 8 pages. Available on-line at: http://www.londonshealth.gov.uk/pdf/transprt.pdf
  1. Impetus - To outline the areas within the transport strategy that have significant effects on the health of Londoners.
  2. Description - The Commission summarizes and makes recommendations as to how the strategy can have a positive effect on health by promoting other modes of transport and reducing reliance on private cars; linking transport, economic development and spatial development to encourage the development of economically and socially sustainable communities; linking proposals for the greatest benefit to health; segregating modes of transport; involving the boroughs in the development and implementation of plans to improve transport; and by developing baseline statistics and targets for transport improvement and health gain. The Commission gives specific ways to attain each of these ends.
  3. Contribution - While the Commission's suggestions are broad and not quantitative, a number of the Commission's recommendations involve the incorporation of health concerns into the transportation planning process via public participation, planning for safety, and developing performance measures.

Mcintyre, L. and M. Petticrew. "Methods of Health Impact Assessment: A literature review." MRC Social & Public Health Sciences Unit Occasional Paper. December 1999, 110 pages. Available on-line at: http://www.phel.gov.uk/hiadocs/224_Petticrew-methods%20of%20hia%20review.pdf

1. Impetus - To look at the work that has been done on undertaking Health Impact Assessments.
2. Description - The authors group and review HIAs based on if the HIAs are prospective or retrospective and if they cover policies or projects.
3. Contribution - This document reviews a number of HIAs that have been conducted for transportation related policies and projects. However, several more such studies have been conducted since 1999. A few of the sources reviewed by the authors mention physical activity.

Merseyside Health Impact Assessment Steering Group - Scott-Samuel, A., M. Birley, and K. Ardern. "Merseyside Guidelines for Health Impact Assessment." Dec. 1999. Available on-line at: http://www.liv.ac.uk/~mhb/publicat/merseygui/

1. Impetus - To describe how to conduct a Health Impact Assessment.
2. Description - The authors describe the procedures and methods for undertaking HIA. Procedures for HIA involve: screening to select policies or projects for assessment; establishing a Steering Group and agreeing to Terms of Reference; carrying out the health impact assessment; negotiating the favored option(s) for achieving optimal health impact; and monitoring and evaluating processes and outcomes of the HIA and providing feedback to influence continuing review. Methods for undertaking HIA involve: policy analysis (where appropriate); profiling the areas and communities affected; involving stakeholders and key informants in predicting potential health impacts; using a predefined model of health; evaluating the importance, scale, and likelihood of predicted impacts; and considering alternative options and making recommendations for action to enhance or mitigate impacts.
3. Contribution - Though this framework is not specifically tailored for transportation planning, it can be applied to the transportation planning process. A list of considerations when assessing alternatives is provided under the methods section.

Metropolitan Washington Council of Governments (MWCOG), Washington DC. "Regional Mobility and Accessibility Study." Forthcoming.

1. Impetus - MWCOG is currently evaluating five scenarios as part of their Regional Mobility and Accessibility Study. The RMAS will be integrated into the next update of MWCOG's long-range transportation plan.
2. Description - The five scenarios are based on five different ways job and household growth may occur in the region over the next couple of decades: higher household growth in the region, more household growth in inner areas and clusters, more job growth in outer areas, uneven growth in the region, and transit-oriented development. Impacts on traffic/congestion, land use, safety, and water and air quality will be analyzed for each scenario and will be compared to the impacts of the baseline forecast. Citizen committees are one of the stakeholder groups in the study. Various elements from each of the scenarios will be incorporated into the overall scenario that will be used for long-range planning.
3. Contribution - This study incorporates health concerns into the transportation planning process by analyzing each scenario's impact on traffic safety and water and air quality. However, this study does not account for the how people's ability to be physically active will be impacted by each scenario.

Moscovich, J.L. "Designing Transportation Systems for Active Communities." Presented at the ITE 2003 Technical Conference and Exhibit, March 23-26, 2003. 19 pages. Available on-line at: http://www.ite.org/activeliving/files/Moscovich_final.pdf

1. Impetus - To look at ways that transportation systems in municipalities and regions can become less auto-oriented.
2. Description - The author states that a number of fields must be involved to make a community or region less auto-oriented. These fields include land use planners, educators, transportation planners, and business leaders. Ways to reduce dependence on the automobile include supporting high-density developments, especially around transit hubs; developing trunkline mass transit systems, such as Bus Rapid Transit; improving public transit through the provision of information to the user; employing context-sensitive and area-wide traffic calming techniques, such as roundabouts; improving pedestrian safety by widening sidewalks and using pedestrian countdown signals and leading pedestrian interval phases; increasing the acceptance of bicycling by providing bike lanes, secure bicycle parking, showers at work, and educating the public and bicyclists to the rules of the road; and creating transportation options that consider the elderly and children.
3. Contribution - While this paper does not address physical activity considerations as part of the transportation planning process, it does recommend that communities and regions provide more bike lanes; create transportation systems that combines and integrates walking, bicycling, and taking transit; and employ area-wide and context-sensitive traffic calming.

National Academies, project number SAIS-P-O2-04. "Physical Activity, Health, Transportation, and Land Use." Sponsors: the Robert Wood Johnson Foundation and Centers for Disease Control and Prevention's National Center for Environmental Health. Start date: November 2002. Site: http://www4.nas.edu/cp.nsf/Projects+_by+_PIN/SAIS-P-02-04-A?OpenDocument

1. Impetus - To bring together experts in the health and transportation fields.
2. Description - This project is a joint effort between the Institute of Medicine and the Transportation Research Board and is composed of a 13-member committee. The committee is examining the broad trends affecting the relationships among physical activity, health, land use, and transportation and will summarize what is known about these relationships; make suggestions for future policy decisions at the local, state, and federal levels; and identify priorities for future research. The committee has commissioned eight policy papers that will synthesize topics and will likely provide valuable insights related to transportation planning and health and activity. These papers are:
• "A Half Century of Change: Trends in Population, Land Use, Transportation, and Physical Activity."
• "Critical Assessment of Literature on the Relationships Among Transportation, Land Use, and Physical Activity."
• "Data and Data Analysis Issues."
• "Consumer Preferences, Marketing, and Social Marketing Approaches in Relation to Physical Activity Behavior and Travel and Location Choices."
• "Transportation, Land Use, and Physical Activity: Safety and Security Considerations."
• "Social Equity and Environmental Justice Issues Related to Physical Activity, Health, Transportation, and Land Use."
• "Institutional and Regulatory Factors Related to Non-motorized Travel and Walkable Communities."
• "Curriculum and Training in Transportation, Land Use, Physical Activity, and Health."
3. Contribution - As part of this project, a final report will be issued in September 2004 along with the policy papers. Though broad, this report may have topical information relating to how physical activity considerations can be incorporated into transportation planning processes.

National Alliance for Nutrition and Activity (NANA), a subsidiary of the Center for Science in the Public Interest. Site: http://cspinet.org/nutritionpolicy/nana.html

1. Impetus - To advocate for national policies and programs to promote healthy eating and physical activity.
2. Description - NANA is an alliance of over 250 national, state, and local organizations. NANA promotes within the legislative and executive branches of government and federal agencies to strengthen national and state nutrition, physical activity, and obesity programs; strengthen the national school lunch and other child nutrition programs; and support transportation policies that promote physical activity. Efforts include supporting effective education programs, advocating adequate funding for programs, and promoting environmental changes that help people improve their diets and be more active. NANA's web site also has general information on the policy and need for policy concerning nutrition and physical activity.
3. Contribution - While NANA's efforts do not focus on incorporating health concerns into transportation planning processes, NANA does support policy options for TEA-21 reauthorization and related transportation measures.

National Association of County and City Health Officials (NACCHO). Site: http://www.naccho.org/.

1. Impetus - According to their web site, "NACCHO provides education, information, research, and technical assistance to local health departments and facilitates partnerships among local, state, and federal agencies in order to promote and strengthen public health."
2. Description - NACCHO is a national nonprofit organization that represents local public health agencies, which serve 75% of the nation's population. NACCHO is primarily involved in securing funding, providing information and tools, and lobbying and advocating for its constituents. Regarding public health's role in local planning practices, NACCHO has a number of relevant resources that are mostly accessible from their "Integrating Public Health into Land Use Decision-making" web site (http://www.naccho.org/project84.cfm) that include:
• A fact sheet: "Public Health in Land Use Planning and Community Design," http://archive.naccho.org/Documents/Land-Use-Fact-Sheet6-19-03.pdf;
• A report based on the discussion of public health focus groups: "The Role for Local Public Health Agencies in Land Use Planning and Community Design," http://archive.naccho.org/Documents/LandUse-FocusGroupSummary-2002.pdf
• Notes from one of the focus groups: http://www.naccho.org/general516.cfm
3. Contribution - NACCHO's recommendations for incorporating health concerns into land use and transportation planning processes include: forging partnerships with planning officials, using data to inform decision-makers, regularly attending planning meetings, serving as information conduits to community members, and adopting local resolutions. The documents referred to above also mention barriers to public health that are inherent in planning processes and they make recommendations accordingly based on the lessons learned. In summary, NACCHO provides in depth guidance for public health practitioners to become involved in planning processes.

National Coalition for Promoting Physical Activity. Site: http://www.ncppa.org. 5-year strategic plan adopted in 2002: http://www.ncppa.org/Strategic%20Plan%20Web.pdf

1. Impetus - The National Coalition for Promoting Physical Activity's mission is "to unite the strengths of public, private, and industry efforts into collaborative partnerships that inspire and empower all Americans to lead more physically active lifestyles."
2. Description - The Coalition is composed of a number of public health, physical activity, and federal associations and organizations. This coalition intends to increase rates of physical activity by advocating policy changes at the local, state, and federal levels and by creating more advocates for physical activity by producing and distributing information, gaining media attention, and by holding meetings and conferences.
3. Contribution - The coalition works within the broader field of physical activity promotion and makes no specific reference to the incorporation of health concerns into the transportation planning process.

National Governors Association - Fierro, M. "The Obesity Epidemic - How States Can Trim the 'Fat.'" June 2002. Available on-line at: http://www.nga.org/center/divisions/1,1188,C_ISSUE_BRIEF^D_3878,00.html

1. Impetus - To provide the nation's governors and their senior staff with services that include lobbying, representation on Capitol Hill, developing policy reports, hosting networking seminars, and providing management and technical assistance to both new and incumbent governors.
2. Description - The report cited above mentions ways that states are using innovative food and physical activity policies and standards, healthy community design, public education, healthcare systems, and tax strategies to address public health concerns. The report includes an overview of the issue and recommendations for governors.
3. Contribution - though the report makes some specific policy recommendations, it does not suggest how transportation officials can be involved or how health concerns can be incorporated into transportation planning processes.

Pollard, T. "Policy Prescriptions for Healthier Communities." American Journal of Health Promotion. Sept./Oct. 2003, Vol. 18, No. 1, pages 109-113.

1. Impetus - To outline ways in which municipalities, states, and regions can increase public health levels.
2. Description - The author mentions a number of ways to increase public health (pollution abatement and increases in physical activity) in communities and stresses that they need to be done in concert with one another. While the author mentions that changes in transportation planning and policy need to occur, he mentions that they are only one piece of the solution. Other areas that need to change primarily include land use policies, design standards, and funding decisions. Regarding transportation planning, the author recommends that funds, laws, and policies need to be redirected from expanding roadways to investing in alternative means of transportation; "Safe Routes to School" programs should be supported; highway- and street-design standards need to be more flexible and sensitive to the natural and built environments; traffic-calming measures should be employed; and plans that promote interconnected streets should be adopted.
3. Contribution - The paper focuses on changes in land use and transportation equally and focuses on transportation funding within the transportation section but does not address the incorporation of health concerns into transportation planning process specifically.

Prevention Institute. "THRIVE: a Community Tool for Health & Resilience In Vulnerable Environments." Site: http://www.preventioninstitute.org/thrive.html

1. Impetus - To advocate for prevention across a range of issues and disciplines including fitness, nutrition, and related health issues; child and adolescent health; injury and violence prevention; and city and county initiatives.
2. Description - The Prevention Institute is a national non-profit organization that works with a variety of public and private organizations. The Prevention Institute advocates for prevention through a two-fold effort: building critical mass and advancing critical thinking. THRIVE is a tool that will assess a community's health to help the community identify ways in which it can eliminate health disparities and improve community health. The study is being piloted in three communities and will then be refined before being released.
3. Contribution - THRIVE will assess communities' transportation systems since they have been identified as one of the factors that influences the built environment, and by extension, a community's level of health. If THRIVE identifies a community's transportation system as having the potential for increasing the community's level of health, then it will suggest specific measures for implementation. These measures are likely to be interventions and changes in policy and not changes in the transportation policy-making process.

Pucher, J., and L. Dijkstra. "Promoting Safe Walking and Cycling to Improve Public Health: Lessons from The Netherlands and Germany." American Journal of Public Health. September 2003, Vol. 93, No. 9, 27 pages. Available on-line at: http://www.walkinginfo.org/pdf/AJPHArticle.pdf

1. Impetus - To describe how relatively unsafe walking and bicycling is in the United States compared to European nations. The authors then go on to recommend ways in which the United States can improve the conditions for walking and bicycling by implementing policies that have been adopted in The Netherlands and Germany.
2. Description - In addition to describing each policy, the authors recommend that the United States pursue six types of policies to make walking and bicycling more viable transportation alternatives relative to the automobile: create better facilities for walking and bicycling, implement area-wide traffic calming, devise restrictions on motor vehicle use in cities, make urban design sensitive to the needs of non-motorists, undertake rigorous traffic education of both motorists and non-motorists, and ensure strict enforcement of traffic regulations protecting pedestrians and bicyclists. The authors say that implementing these policies would not be expensive or difficult and would result in improved public health, via an increase in physical activity, would be considerable.
3. Contribution - This study does not address the incorporation of health considerations into the transportation planning process. Instead, this study describes ways that, if implemented, physical activity can result from the six transportation policies and measures described above. The authors go into detail by advocating various measures that have been successfully taken in The Netherlands and Germany.

Robert Wood Johnson Foundation (RWJF). Site: http://www.rwjf.org/ RWJF sponsors a number of national programs including:

• Active Living by Design, headed by Richard Killingsworth in Chapel Hill, NC. Site: http://www.activelivingbydesign.org/,
• Active Living Research, headed by James Sallis in San Diego, CA. Site: http://www.activelivingresearch.org/,

1. Impetus - Active Living by Design was created to establish and evaluate innovative approaches to increase physical activity through community design, public policies and communications strategies. Active Living Research was created to stimulate and support research that will identify environmental factors and policies that influence physical activity. These findings are expected to inform environmental and policy changes that will promote active living.
2. Description - The Robert Wood Johnson Foundation is the largest philanthropy devoted exclusively to health and health care in the United States. They concentrate grant-making in four areas, including the promotion of healthy communities and lifestyles. Both programs mentioned above promote the development and implementation of ways to make people more physically active within their community. Active Living, defined as a lifestyle that easily integrates physical activity into daily routines, is the means to this end.
3. Contribution - While neither of these programs focus specifically on the incorporation of health considerations into the transportation planning process, they do address each component (physical activity, public health, planning, and transportation) and some of the interactions between these components as well. Active Living by Design funds active living projects in communities across the nation, has an extensive literature review on relevant articles at http://www.activelivingbydesign.org/resources/publications.htm, and has a list of tools for city planning and public health professionals to assist them in making their community more active: http://www.activelivingbydesign.org/resources/toolkits.htm. Active Living Research funds research in the field and also has an extensive literature review at http://www.activelivingresearch.org/index.php/Literature%20Citations/129.

Sallis, J. F., A. Bauman, and M. Pratt. "Environmental and policy interventions to promote physical activity." American Journal of Preventive Medicine. Nov. 1998, Vol. 15, No. 4, pages 379-397. Available on-line at: http://www.cvhpinstitute.org/daniel/readings/env.pdf

1. Impetus - To review seven published evaluations of environmental and policy interventions and, based on this review, propose a model for the development of future physical activity interventions.
2. Description - The authors discuss important considerations when developing interventions. Notably, they state that environmental interventions should be in place before educational interventions are attempted, which means that there is pressure on implementing environmental changes so that educational interventions can then occur.
3. Contribution - The article states that there are few studies that look at the affect of interventions, and those that do exist serve to illustrate the challenges inherent in evaluating policy and environmental interventions. Subsequently, theories and models to guide the development of policy interventions are not well developed, and the empirical database is exceedingly limited. These shortcomings serve to inhibit the incorporation of health concerns into the transportation planning process since the impact of interventions has not been quantified reliably or consistently.

Sarkar, S. "Determination of Service Levels for Pedestrians, with European Examples." Transportation Research Record 1405. 1994, pages 35-42.

1. Impetus - To define various levels of service for pedestrians and bicyclists.
2. Description - The levels of service range from A (ideal) to F (least desirable). A streetscape is categorized at a certain service level based on safety, security, convenience and comfort, continuity, system coherence, and attractiveness. While service level A is ideal, the author states that that level is not realistic since it severely restricts vehicular traffic. Accordingly, the author recommends that all streetscapes be at service level B and service level A if possible and reasonable.
3. Contribution - While this article does not directly examine the incorporation of health concerns into the transportation planning process, if transportation planners endeavor to attain high levels of service for pedestrians and bicyclists in their decision making processes for locations that necessitate such actions, then more people will be physically active.

Schmid, T. L., M. Pratt, and E. Howze. "Policy as intervention: environmental and policy approaches to the prevention of cardiovascular disease." American Journal of Public Health. September 1995, Vol. 85, No. 9, pages 1207-1211.

1. Impetus - To discuss the importance of policy and environmental interventions and give examples of successful past interventions.
2. Description - While primarily advocating for preventive policy interventions, the authors state that policy interventions can only be successful if done in concert with other types of public health initiatives, such as education and environmental interventions.
3. Contribution - This article makes the case for why policy interventions are important in the public planning process when the goal is to improve public health. However, the authors do not provide details on these policy interventions and do not focus on physical activity or the transportation planning process. Nonetheless, the authors do mention ways that public health organizations can be involved in the planning process, i.e., through public involvement and empirical support.

Scottish Needs Assessment Programme - Gorman, D., L. Health, M. Douglas, and L. Conway. "Health Impact Assessment of the City of Edinburgh Council's Urban Transport Strategy." 2000, 63 pages. Available on-line at http://www.gla.ac.uk/Inter/OPHIS/PDF/hiatrans.PDF

1. Impetus - To use health impact assessment as a systematic approach that enables public health input at the planning stage of a transportation policy. This pilot study aims to identify both positive and negative health impacts of the City of Edinburgh Council's (CEC) Urban Transport Strategy.
2. Description - This study evaluates each of CEC's three scenarios based on future funding levels for their transportation system: scenario one, based on minimal funds; scenario two, based on the status quo/medium funds; and scenario three, based on increased funds. The study evaluates these scenarios based on the five main areas where transport is described as affecting health (adapted from the World Health Organization's charter): accidents; pollution; access to amenities, jobs, and social contacts; opportunities for healthy sustainable physical activity in walking and cycling; and impacts on community networks. The evaluation is performed with respect to two major population groups and their respective sub-groups: one, middle class/affluent/predominantly car owning; and two, disadvantaged/predominantly non-car owning. The study found that scenario three would be the most beneficial for the population's level of health.
3. Contribution - Though this document considers public health in sum and does not focus on just physical activity, it is an example of how a health impact assessment and scenario planning can be incorporated into the planning stage of a community's transportation policy. The study also puts forth a number of broad recommendations for further benefiting the health of the population.

Smart Growth America. Site: http://www.smartgrowthamerica.org

1. Impetus - To raise awareness of how metropolitan expansion affects the environment, quality of life, and economic sustainability.
2. Description - Smart Growth America (SGA) is a coalition of nearly 100 advocacy organizations. To protect the environment, raise the quality of life, and ensure economic sustainability, SGA works to protect farmland and open space, to revitalize neighborhoods, to ensure housing is affordable, and to provide transportation choices. To attain these ends, SGA builds coalitions, develops policy, translates and transmits information, and is involved in research on smart growth. Their web site has tools and information on the following elements of smart growth: housing, economy, children and schools, environment, preservation and revitalization, social equity, transportation, open space and farmland, and health.
3. Contribution - Though SGA does not specifically address the incorporation of health concerns into the transportation planning process, SGA is active in promoting neighborhoods and communities that support walking and bicycling and result in better public health for their citizens. One of their most notable recent studies is the report "Measuring the Health Effects of Sprawl" by Barbara McCann and Reid Ewing, published by the SGA and the Surface Transportation Policy Project. The report is available at http://www.smartgrowthamerica.org/healthreport.html. This report found a relationship between the degree of urban sprawl and obesity, with the most sprawling communities being associated with a higher degree of obesity. This study received significant media attention and similar studies by Ewing have been published in a number of planning and public health journals.

Surface Transportation Policy Project (STPP). Site: http://www.transact.org

1. Impetus - To ensure that transportation policy and investments help conserve energy, protect environmental and aesthetic quality, strengthen the economy, promote social equity, and make communities more livable.
2. Description - STPP is a non-profit funded by a number of foundations and individuals. STPP's web site hosts a multitude of informative documents that address transportation's relationship to health and safety, economic prosperity, equity and livability, and environment.
3. Contribution - In addition to advocating a number of other measures to increase physical activity in the context of transportation, STPP calls for the creation and use of performance measures that incorporate health outcomes (http://www.transact.org/news.asp?id=31), but does not provide details on how to accomplish this.

Transport and Health Study Group - Faculty of Public Health Medicine. "Carrying out a health impact assessment of a transport policy." 2000, 8 pages. Available on-line at: http://www.phel.gov.uk/hiadocs/hia_transport_policy_and_guidance.pdf

1. Impetus - To briefly describe the history of health impact assessments and how and why health impact assessments can be applied to transport policy.
2. Description - The authors recommend three steps for carrying out a health impact assessment: one, identify the impacts to be assessed; two, decide how the impacts will be measured; and three, recommend measures to minimize the adverse effects and maximize the beneficial effects of the policy. With respect to this second step, the authors recommend that HIAs use both quantitative and qualitative data.
3. Contribution - Though rudimentary, this document provides a framework for conducting HIAs for transport policies. The HIAs discussed by the authors consider all public health concerns, such as pollution and accidents, and do not focus solely on physical activity.

Wasatch Front Regional Council. "Chapter V. Long Range Plan Scenarios." 2030 Long Range Plan Report. December 2001. Available on-line at: http://www.wfrc.org/reports/lrp.htm

1. Impetus - To create a long-range transportation plan that considers and evaluates four different scenarios to determine what improvements need to be made to the greater Salt Lake City area's transportation system.
2. Description - Each scenario covers a different focus of the transportation system: freeways and highways, arterials and collectors, fixed guideway system, and bus transit only. Desired and necessary improvements were identified for each of these aspects of the transportation system and the scenarios were evaluated based on travel demand generated, impacts on the environment, and financial costs. Each scenario had its own advantages and disadvantages. Accordingly, the scenarios were presented to interested and involved organizations and members of the public who then determined which aspects of each scenario should be pursued.
3. Contribution - This plan quantitatively gauges, albeit broadly, each scenario's impact on three aspects of health: safety near schools, air quality, and noise, but does not consider physical activity. These health aspects are considered in the environmental impact portion of the analysis.

World Health Organization (WHO)
The WHO has two web sites on health impact assessment:

• "Health Impact Assessment," available at: http://www.who.int/hia/en/
• "HIA of Transport," available at: http://www.euro.who.int/transport/HIA/20021009_2

1. Impetus - To provide general information, international examples, and links to other resources regarding HIA.
2. Description - While the "Health Impact Assessment" web site is general and provides a broad understanding of HIA, the "HIA of Transport" web site provides information on how HIAs of transport consider the impacts of a project, like the building of roads, on public health, specifically on accidents and pollution. In addition to focusing on the impacts of a project instead of taking a prospective approach by suggesting policy changes, the "HIA of Transport" web site focuses on other aspects of health impact assessment, such as accidents, pollution, and noise, and not physical activity.
3. Contribution - The WHO is a prominent organization in the field of HIA development. These web sites are concerned with health in general and focus on the impacts instead of the policy prescription stage of the transportation planning process.

World Health Organization Healthy Cities project. "City planning for health and sustainable development." European Sustainable Development and Health Series: 2. 1997, 111 pages. Available on-line at: http://www.who.dk/healthy-cities/UrbanHealthTopics/20020114_4

1. Impetus - To describe how to create a city health plan.
2. Description - This document is composed of two parts: a background section on health and sustainable development and a section on city health planning. According to the second section of this document, the foundation for the successful development of the plan is composed of a vision, effectively managing the project, collecting data, determining priority issues, developing strategies, drafting the city health plan, implementing the plan, and monitoring and evaluating the outcomes. Each of these aspects is explained in detail and example plans are described at the end of the report.
3. Contribution - As part of the creation of a city health plan, this document calls for collaboration across disciplines and for the involvement of the public (a separate document on this topic - "Community participation in local health and sustainable development: Approaches and techniques" - has a tool box for getting the public involved as well as case studies and is available on-line at http://www.euro.who.int/document/e78652.pdf). This document also suggests that the steering group for the plan collect data on health to create a city health profile. The report lists the types of data that can be compiled to create such a profile. Using this data, priorities and objective are then formulated. After implementation, the impact of the plan is monitored to see if the objectives are attained. Accordingly, in addition to generally being about the incorporation of health considerations into planning processes, this document discusses performance measures, collaboration, and community involvement as ways to integrate health into the planning process. However, this document is not specifically concerned with transportation planning and does not mention physical activity explicitly in the report.

III. SYNTHESIS OF THE LITERATURE

The sources reviewed above touch upon a number of methods for incorporating health concerns into the transportation planning process:

• Scenario and long-range planning;
• Performance measures and indicators;
• Community impact assessments;
• Planning for safety, especially for the elderly and routes to school for children;
• Assessments of alternatives;
• Level of service assessments; and
• Participation, outreach, and communication.

While some sources consider both transportation planning and physical activity specifically, other sources consider one and not the other. Some sources are more concerned with broader planning and health issues, rather than the more specific focuses on this report - transportation planning and the activity sub-set of health. To understand where the research is focused, a summary of how thoroughly the research addresses each method follows.

Scenario and Long-Range Planning

A number of studies, such as Pollard (2003), broadly discuss scenario planning by making recommendations as to what policies will result in healthier communities in the long run. However, these studies do not actually employ scenarios and the recommendations are more anecdotal than objective.

As part of the HIA of the City of Edinburgh Council's Urban Transport Strategy conducted by the Scottish Needs Assessment Programme (2000), Douglas et al. (2001) and Gorman et al. (2003) mention that three scenarios and their impact on health were considered based on low, moderate, and high amounts of spending on transport. These scenarios were broadly classified as having a very positive, positive, no, negative, or very negative impact on affluent and deprived population groups including young families and the elderly. Physical activity was considered as one of five ways the City of Edinburgh's Strategy impacts health.

In the U.S. a few metropolitan areas and local transportation planning agencies are using scenario planning as part of their long-range planning processes. In 1997, the D.C. District Department of Transportation (DDOT) was an early user of scenario planning in its strategic transportation plan, although the plan did not consider health concerns. Since then, other agencies and MPOs, such as the Wasatch Front Regional Council (WFRC, the MPO for the Salt Lake City region), the Metropolitan Washington Council of Governments (MWCOG), and the Thomas Jefferson Planning District Commission (TJPDC, the MPO for the Charlottesville, Virginia, region) have used scenario planning in their long-range transportation plans. While DDOT, TJPDC, and MWCOG's scenarios are more general and city- and region-wide, WFRC's scenarios are specific to certain types of transportation systems and improvements. Though WFRC considers some health concerns in their environmental impact analysis of the scenarios and MWCOG also considers some health concerns in their regional study, neither MPO considers physical activity. However, the model used to generate TJPDC's scenarios estimates the proportion of walking and bicycling trips for each scenario. In this way, scenario planning incorporates health/activity concerns into the transportation planning process.

Performance Measures and Indicators

Only a few of the sources reviewed have considered the incorporation of health-related performance measures and indicators into the transportation planning process. Killingsworth et al. (2003) state that the use of performance measures should be expanded beyond their traditional role to include the transportation system's ability to offer choices for transportation, the quality of these options, the system's ability to generate non-motorized transportation and encourage physical activity, and the impact of the existing transportation system on people's mental and physical health, on social networks, and on the environment. The Surface Transportation Policy Project (STPP) calls for the adoption of performance measures that incorporate health outcomes to ensure that projects meet community health needs. STPP suggests that Congress ask the National Academy of Sciences to come up with recommendations that the Department of Health and Human Services, EPA, and DOT could then use as a basis for rulemaking.

While Killingsworth et al. (2003) and STPP make no specific recommendations as to what these recommended measures would be, the London Health Commission (2001) specifically calls for statistics that could include road accident deaths and injuries, cardio-vascular and cerebro-vascular hospital admissions, and the proportion of all journeys to school completed by walking/cycling. The WHO Healthy Cities project (1997) lists several types of data that could be incorporated into a city health plan to show the current levels of various aspects of community health. Quantifiable objectives could then be developed and these levels could then be monitored to gauge the effectiveness of the city health plan. Though his estimate is rough and does not (admittedly) account for a number of other factors that may affect the costs, Litman (1999) puts a dollar figure on the costs of non-motorized travel versus the costs of motorized travel. Figures like this could be used in performance measures (e.g., cost per trip or mile) when considering health in future transportation planning processes. As an example of how performance measures can be used in practice, the City of Tucson created quantitative pedestrian activity and facility indicators to guide their long-range planning.

Community Impact Assessments

The greatest amount of attention to the incorporation of health concerns into the transportation planning process may be as part of health impact assessments. Most of this work has been based in the United Kingdom and Scandinavia. In these countries, health impact assessments have been performed on, or have been considered for, transportation plans and strategies (Department for Regional Development, 2002; Scottish Needs Assessment Programme, 2000; and the London Health Commission, 2000 and 2001). Though these HIAs consider physical activity as one part of the overall health assessment, the HIAs are in their infancy and are mainly broad and qualitative in their methods and findings. To address these limitations, a number of studies (Douglas et al., 2001; Dora, 1999; Fleeman and Scott-Samuel, 2000; Gorman et al., 2003; Julsén, 1997; Transport and Health Study Group, 2000; London Health Commission, 2000; and the World Health Organization) describe ways to improve HIAs, make them more accurate, and, therefore, more likely to be used.

In the United States, two FHWA publications (1996 and 1998) describe how to conduct a community impact assessment and highlight case studies where transportation planners mitigated the impact of the transportation system on the community. Aside from providing more parkland as a result of the transportation agency's mitigation efforts (FHWA, 1998), health and physical activity was not directly considered in the community impact assessments. Killingsworth et al. (2003) and King et al. (1995) call for the use of health impact statements for proposed developments in the United States and Killingsworth et al. (2003) goes further by describing how a human impact statement could be applied. The Wasatch Front Regional Council considers some aspects of health in their projected impact analysis of the various scenarios considered in their long-range transportation plan, but does not consider physical activity.

Planning for Safety

By considering the safety of pedestrians and bicyclists in the transportation planning process, decision-makers facilitate the public's participation in physical activity; safety, particularly of children, is a goal that readily engages public attention. Like the pedestrian and bicycle improvements that Litman (2003) calls for as part of his examples of mobility management strategies, the context-sensitive traffic calming that Moscovich (2003) advocates, and most of the policies borrowed from Europe that Pucher and Dijkstra (2003) recommend to improve the conditions for walking and bicycling in the United States, a multitude of studies call for physical and policy interventions to increase the level of safety for pedestrians and bicyclists (see for example Dora, 1999; Killingsworth et al., 2003; Hoehner et al., 2003; British Medical Association, 1997; and Litman, 1999).

A number of Dixon's (1995), Sarkar's (1994), and the City of Ft. Collins' (1997) level of service measures involve the safety of pedestrians and bicyclists; the relationship is that increased levels of service lead to increased levels of safety. Additionally, a number of HIAs consider pedestrian and bicyclist safety in their assessments (London Commission, 2000 and 2001; Scottish Needs Assessment Programme, 2000; Department for Regional Development, 2002) as does the comparison of the scenarios in Wasatch Front Regional Council's long-range transportation plans. As Dora (1999) states, "Safe conditions for walking and cycling are therefore part and parcel of their promotion."

Assessments of Alternatives

In the research and programs reviewed, there did not appear to be much attention given to the assessments of alternatives with respect to health in planning processes. However, two studies in Europe relate closely to this topic. As part of Juslén's (1997) interviews, he found that transportation planners in Finland stressed the importance of assessing different alternatives in their decision making processes with respect to social impacts. A social impact assessment was then carried out on the Revision of the Helsinki Metropolitan Area Transportation Plan in 1997. The alternatives assessed - a public transport and a private transport alternative - were the ones formulated by the Area Council for the environmental impact assessment. The Merseyside Health Impact Assessment Steering Group (1999) lists considerations for performing assessments of alternatives as part of performing a health impact assessment.

In the U.S., assessments of transportation alternatives appear to occur in a broader context that does not explicitly take into account health concerns, as demonstrated by Laube and Stout's (2000) evaluation of transportation alternatives for the Grand Canyon National Park. With respect to pedestrian safety, however, Moscovich (2003) reports that San Francisco has undertaken area-wide studies to assess the viability of traffic calming alternatives in the larger metropolitan context. In this way, alternative assessments create a more holistic understanding of the larger transportation planning issue.

Level of Service Assessments

A few of the sources mention the use of level of service measurements in the transportation planning process to promote walking and bicycling at the community level. Dixon (1995) discusses the pedestrian and bicycle level of service performance measures that were used by Gainesville, Florida. These measures are point-based and weighted. Sarkar's (1994) more qualitative level of service measures for pedestrians with examples from Europe are based on safety, security, convenience and comfort, continuity, system coherence, and attractiveness of the environment. Ft. Collins, Colorado (1997), blends quantitative and qualitative approaches in their pedestrian and bicyclist level of service measures that gauge directness, continuity, street crossings, visual interest, and security. For all of these approaches, the assumed relationship is that higher levels of service will make walking and bicycling more pleasant. The assumption is that people will therefore increase their physical activity.

Participation, Outreach, and Communication

A number of sources call for the involvement of public health professionals and the general public in transportation planning processes as ways to increase the consideration of health concerns in transportation decision making. The idea is that if the public and public health professionals can gain influence and influence decision-makers, then transportation planners will consider health concerns in their decision making processes. On the public health side, Dora (1999) and Schmid et al. (1995) state that it is key that health professionals are involved in the transportation planning process, especially as advisors and providers of information, such as Brownson et al.'s (2001) study that helps demonstrate that there is support for creating more facilities for and removing barriers to physical activity. Killingsworth et al. (2003) and Hoehner et al. (2003) also call for collaboration among public health officials and transportation planners in practice and in research as does King et al. (1995) and the British Medical Association (1997) to promote physical activity goals.

With respect to the involvement of the general public, Julsén (1997) states that transportation planners in Finland need to involve different types of people in their processes despite the perception of a disconnect between the public and planners. As part of their report of a HIA, the London Health Commission (2001) calls for the involvement of the boroughs in the development and implementation of plans to improve transit in London. Killingsworth et al. (2003) provides examples of how public input has been successfully integrated into the transportation planning process and the City of Tucson provides an example of how the input of over one thousand people can be considered in the planning process.

On the organization side, the National Association of County and City Health Officials provides information and tools for its constituents; facilitates partnerships with public health professionals and other agencies, including planners; and encourages public health professionals to become actively involved in and contributing to the planning processes. CDC's Division of Nutrition and Physical Activity (DNPA) and Active Community Environments Initiative (ACES) provide resources to the health professional and advocates for physical activity at the community level. Other organizations, such as the National Coalition for Promoting Physical Activity (NCPPA), are more specific - the NCPPA concentrates on building collaborations. Still other organizations, such as the National Governors Association, do not play advocacy roles but inform their interested constituents of options to address the issue.

The joint planning requirements of the Transportation Equity Act for the 21st Century (TEA-21) in 1997, and the predecessor law, the Intermodal Surface Transportation Efficiency Act in 1991, encourage statewide and metropolitan transportation planning processes to be conducted with "proactive" public involvement. By looking at MPO staff lists, transportation programs that stress safety such as safe walk to school campaigns, air quality campaigns, and security and emergency planning processes, it is evident that public health professionals are involved in a number of transportation planning processes. Also, a number of the programs and agencies that have incorporated health concerns into the transportation planning process with respect to the methods outlined in this document are a result of the involvement of public health professionals. Nonetheless, effective public and public health involvement is not universal, so the continued and enhanced involvement of the general public and public health officials would be necessary to establish the consideration of health concerns as an important part of the transportation planning process.

General Sources on Health and Activity and/or Planning

A number of sources are too broad in their focus to be categorized or are not classifiable into the categories devised for this report. Frank et al.'s (2000) annotated bibliography and organizations like Smart Growth America focus more on land use, transportation, and the intersection of urban form and transportation but do not appear to explicitly consider public health. However, these are useful sources for exploration into these related fields of research. Sallis et al. (1998) consider the current universe of studies that have looked at the affect of environmental or political interventions to increase physical activity and conclude that much remains to be developed and concluded.

Some organizations are more focused on other topics, such as the National Alliance for Nutrition and Activity that is more involved in lobbying, policy formation, and nutrition, and the Prevention Institute and its THRIVE program that have more to do with the broader field of public health than research into the incorporation of health concerns into the transportation planning process. Other organizations like the Robert Wood Johnson Foundation's Active Living programs and the CDC are involved in a number of the approaches outlined in this report. Other sources are forthcoming: the findings of CDC's Task Force on Community Preventive Services and the National Academies' Physical Activity, Health, Transportation, and Land Use project are likely to be of significant importance in understanding the potential to integrate public health/activity goals as part of transportation planning.

Overlap in Methods Considered

This bibliography indicates that there is a significant amount of overlap in how the sources reviewed approach the seven identified methods for incorporating health concerns into the transportation planning process. The following are examples of overlap identified in the reviews of sources.

• The authors of health impact assessments and documents evaluating HIAs consider planning for the safety of pedestrians and bicyclists as part of the assessment. Additionally, these authors call for and in some cases recommend performance measures to gauge the impact of a particular transportation policy, investment, or strategy on public health.
• The methods of assessing alternatives and scenario planning are related because the approaches for analyzing alternatives are similar if not the same as the approaches for analyzing various scenarios. However, the time frame between the two methods differs since alternatives are typically assessed in the near-term while planning for scenarios is more oriented toward twenty- or even fifty-year horizons. Despite this temporal difference, authors of HIAs and related research use and advocate assessment of alternatives and scenario planning approaches.
• Various alternatives to the planned (baseline) course of action are analyzed and advocated as part of the recommendations of the HIAs.
• Level of service measurements and performance measures are related because both attempt to assign quantitative values to create policy and recommend different courses of action.

IV. SUMMARY AND CONCLUSION

Although this bibliography was not intended to be exhaustive, it represents a broad range of research and programs that consider linkages between community design, including transportation, and physical activity. To contribute to improved understanding of potential linkages between the fields of transportation planning and public health, this bibliography has two critical focuses:

1. Transportation planning and decision making in contrast to a broader focus on the health impacts of transportation decisions themselves. Rather than considering the implications for physical activity of specific decisions, including investments, coordination of multi-modal systems, or strategies, the focus is on the transportation planning process that leads to these decisions. This process is developed at the statewide, metropolitan area, or local level by state Departments of Transportation, MPOs, counties, cities, or transit agencies and follows the broad framework defined in the federal legislation under TEA-21.
2. Physical activity from daily activities in contrast to more general research and programs that includes broad aspects of public health, including respiratory and other disease related to air or water pollution, or safety. Physical activity is one specific focus among many under the broad heading of public health. This report focuses on activity from routine daily activities as opposed to that from recreation.

The bibliography identified several key transportation planning methods that may be applicable when pursuing physical activity goals:

• Scenario and long-range planning;
• Performance measures and indicators;
• Community impact assessments;
• Planning for safety, especially for the elderly and routes to school for children;
• Assessments of alternatives;
• Level of service assessments; and
• Participation, outreach, and communication.

Note that this is not intended to be an exhaustive list.

The following are summary observations reached from compiling the bibliography and completing the synthesis of how the sources reviewed approach the integration of physical activity and health goals into the transportation planning process.

• Consideration of the overall transportation planning process. In general, the sources reviewed do not explicitly consider how physical activity goals might be integrated within the overall transportation planning process. This may indicate that the sources are not focusing on the holistic transportation planning process adapted by states, metropolitan areas, and cities and counties, and transportation providers. The sources may not be focusing on the importance of the national framework for statewide and metropolitan planning encouraged by the federal legislation under TEA-21.
• Consideration of key methods of the transportation planning process. The sources reviewed do consider the integration of physical activity within transportation planning when it is considered from the perspective of the seven methods identified rather than as a holistic process. The bibliography describes important examples of research completed and current programs focusing on key aspects of transportation planning, including vision or scenario planning, public participation, and use of performance measures.
• Overlap among transportation planning methods. The review of sources, synthesis, and summary in Table One demonstrate that there are numerous overlaps in the methods addressed by the researchers and programs reviewed. Some implications seem clear:
1. There may not be a single best way to incorporate physical activity concerns into the transportation planning process. Transportation planners and public health practitioners might effectively borrow from the range of methods and applications documented in the research depending on local circumstances and priorities.
2. The prevalence of overlaps is an important aspect of the sources reviewed and might indicate progress toward a more holistic approach to transportation planning.
3. Transportation planners and researchers might consider expanding overlaps between methods or investigate new overlaps. For example, additional performance measures that allow health and activity impacts to be considered alongside traditional transportation goals of reduced congestion or improved accessibility might strengthen vision or scenario planning. Transportation planners might be interested in expanding public participation by introducing safety, physical activity, or health performance measures to bolster public interest.

• Documenting practical applications. Transportation planning agencies considering whether to include physical activity dimensions require analytical methods and scientific data to determine the significance of relationships between transportation, activity, and health, and relevance to their jurisdictions. Planners will also benefit from documentation of experiences of peers incorporating health and activity goals into planning processes. This should include before and after technical evaluations of short- and long-term effects to demonstrate the extent to which transportation affected physical activity and, ultimately, whether community health improved. It would also be helpful to document experience using methods employed to incorporate activity and health goals, such as scenario planning, performance measures, or outreach techniques.

Several of the sources reviewed involve pilot projects, case studies, or other peer evaluations that will be useful both to transportation planners and public health practitioners.

• Expanding mutual awareness between transportation planners and public health practitioners. Incorporation of physical activity and health goals into transportation planning is a new and evolving area of interest. This integrated approach is certainly the exception rather than the rule. A Volpe Center study for FHWA of statewide transportation plans did not identify any examples of substantive integration of health and activity goals.⁴ Transportation planners interested in physical activity and health would benefit from greater awareness of the research and the programs underway on the topic of integrated approaches. Public health researchers may not have a strong awareness of the overall transportation planning process as practiced at statewide, metropolitan area, and local levels, as encouraged by TEA-21 and adapted in each jurisdiction. Hopefully this bibliography will be a useful tool for expanding understanding from both perspectives.
• A role for future capacity building. This brief bibliography can help document the range of research completed and programs underway. It can also help determine where further research in the field is needed, for example: performance measures need to be reviewed, understood, and tested; HIAs should be more quantitative to complement qualitative health impact assessments; and all of the methods need more practical application. It might be useful to develop guides, courses, or other materials that describe the overall transportation planning process for public health researchers and practitioners. Also, physical activity and health research, as related to community design and transportation planning, might be made more available to transportation planners. It might also be helpful to develop special summaries of the transportation planning processes targeted to health practitioners and of physical activity and health research targeted to transportation planners.
• Importance of partnerships. To succeed, future capacity building will require partnerships between transportation planners and public health practitioners and their agencies and organizations at national, state, and local levels.

¹U.S. DOT, FHWA/FTA. "Frequently Asked Questions." 2003. http://www.planning.dot.gov/faq.asp

²CDC, "Physical Activity and Good Nutrition." 2003. http://www.cdc.gov/nccdphp/aag/aag_dnpa.htm

³Ewing, R. and R. Cervero. "Travel and the Built Environment - Synthesis." Paper prepared for Transportation Research Board Conference, Jan. 2001.

⁴Noerager, K. and W., Lyons. "Evaluation of Statewide Long-Range Transportation Plans." Apr. 2002. Available online at http://www.fhwa.dot.gov/hep10/state/evalplans.htm