CENTERS FOR DISEASE CONTROL AND PREVENTION
Volume 16 • Number 1 • Winter 2003

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Building Healthier Communities

The public health community has long recognized that changing personal health behaviors before disease develops is far better than treating debilitating diseases later in life. For some health problems, especially those related to physical inactivity, community-level interventions may be more effective in helping change healthrelated behaviors at the population level than physician-recommended preventive measures. 

Findings from national surveys that use CDC’s Health-Related Quality of Life (HRQOL) questions are now being used along with other community indicators such as rates of suicide, alcoholism, divorce, births to teenage mothers, and unemployment to identify vulnerable subgroups and aid in planning community-level interventions to improve not only health-related quality of life, but overall population health as well. 

A New Coalition Between Public Health and Urban Planners to Fight Chronic Disease 
In the last decade, an important relationship has been described between health-related quality of life and community design and layout. Although the strength of this relationship has not been firmly established, community design does appear to influence health and health behaviors. 

“Advocates of the new urbanism have been enumerating the effects of land use and transportation on communities for more than a decade,” wrote Richard E. Killingsworth, MPH, a former CDC staff member currently with the University of North Carolina School of Public Health, and Jean Lamming, project manager of health and land use programs at the nonprofit Local Government Commission in Sacramento, California. “Today, an old partner of planning—public health—has resurfaced and is proving to be an important asset for advancing issues of smart growth, better community design, and equitable transportation systems.” 

Community planners and administrators who have access to findings from local HRQOL surveys can use these data to bolster plans for designing, upgrading, or retrofitting neighborhoods in ways that encourage physical activity and therefore decrease the population’s risk for obesity, heart disease, diabetes, and a number of other chronic diseases. 

“Changes in the community environment to promote physical activity may offer the most practical approach to prevent obesity or reduce its comorbidities. Restoration of physical activity as part of a daily routine represents a critical goal,” wrote former CDC Director Jeffrey Koplan, MD, MPH, and William Dietz, MD, PhD, Director of NCCDPHP’s Division of Nutrition and Physical Activity, in Focus on Livable Communities: Why People Don’t Walk and What City Planners Can Do About It. This fact sheet lists barriers that keep people from walking. For example, 

• In neighborhoods where through streets connect to multiple destinations, people walk up to three times as often as people in areas where streets “look like spaghetti,” with no direct routes for people to take. 
• Areas with midblock crossings make walking more convenient than in areas with long blocks and no crossings in between. 
• Windows and people along the street create a safe and pleasant place to walk, as opposed to areas with “dead wall space” and few other people around where walkers might feel vulnerable or unsafe. 
• Narrow, shaded streets can slow traffic and be up to 10 degrees cooler than wide, unshaded streets, making walking far more pleasant. 

In January 2002, the National Association of County and City Health Officials (NACCHO) conducted a Land Use Planning Focus Group to discuss the connections between chronic disease prevention and land use planning. It was held in conjunction with a national conference, New Partners for Smart Growth, which addressed the link between health and the built environment. 

The focus group followed its discussions by identifying ways that local public health staff can work with community planners and other stakeholders in the design of communities that encourage healthy behaviors. (For detailed information about the focus group’s findings, visit www.naccho.org/project81.cfm.*) Through a cooperative agreement with CDC, NACCHO is continuing its work to address chronic disease prevention issues, particularly as they relate to nutrition and physical activity. In an initiative designed to promote changes in local community design, transportation, and architecture that increase opportunities for and remove barriers to physical activity, NACCHO is in the process of awarding grants of up to $200,000 each to 25 community partnerships across the country. These “Active Living by Design” partnerships will develop and implement strategies that will make it easier for people to enjoy routine physical activity as part of their daily lives. 

Active Community Environments Initiative (ACES) 
ACES is a CDC-sponsored initiative to encourage the development of areas where people of all ages and abilities can easily enjoy walking, bicycling, and other forms of recreation, and to promote active forms of transportation like walking and bicycling. Active Community Environments Initiative are envisioned as places that 

• Support and promote physical activity. 
• Have sidewalks, on-street bicycle facilities, multiuse paths and trails, parks, open space, and recreational facilities. 
• Promote mixed-use development and a connected grid of streets, allowing homes, work, schools, and stores to be close together and accessible by walking and bicycling. 

The development of the KidsWalk-to-School program and collaboration with public and private agencies to promote National and International Walk-to-School Day are two important ACES activities. 

“At first glance, it may not appear that walking to school, to a transit stop, or to a restaurant can provide meaningful health benefits,” wrote Mr. Killingsworth and Ms. Lamming, “but the fact is that these simple, routine activities provide a tremendous opportunity to accumulate physical activity throughout the day to achieve the recommended 30 minutes of exercise. This strategy is also a better approach than advocating sports, aerobics, or weightlifting because structured activities only resonate with a small percentage of the population. ACES, on the other hand, could enable millions of sedentary Americans to integrate physical activity into their lives seamlessly.” 

Program staff in the Division of Nutrition and Physical Activity have created an ACES manual to help state and local public health workers develop similar initiatives. The program also is working in partnership with the National Park Service’s Rivers, Trails, and Conservation Assistance Program to promote the development and use of close-to-home parks and recreational facilities. 

Community Initiatives
Bolstered by community health assessments that often include Healthy Days measures, many communities, as well as public and private organizations, are taking steps to help people get out of their cars and be more physically active. 

• Employers, encouraged by recent changes in the federal tax code, are finding it increasingly attractive to offer incentives for not driving, such as nontaxable transit and vanpool benefits or cash incentives for employees who give up their parking spaces at work. 
• In San Diego, solo drivers can pay fees for access to high-occupancy vehicle lanes; their payments then support new express transit service by buses equipped with bicycle racks. 
• City planners are working with developers to create walkable, mixed-use, mixed-income communities that give their residents a neighborhood feel. For example, the Highlands Garden Village project in Denver includes single-family homes, townhomes, cohousing, affordable and market-rate rental housing, live/work studios, retail facilities, and offices surrounding a series of connected open spaces, and all are within walking distance of a local shopping center or a short bus ride to downtown Denver. Milwaukee’s Riverwalk development created walking paths that give downtown workers easy walking access to restaurants, apartments, stores, and offices; the development cost $9.5 million, but created 15 times that amount in private development, according to the city’s mayor. 
• Cohousing developments that combine private homes and extensive community amenities such as meeting rooms and recreational facilities are becoming more common. Near downtown Atlanta, the East Lake Commons cohousing development was designed and arranged by consensus of the residents to promote and enhance a sense of place. East Lake Commons’ residents enjoy 10 acres of green space and share the fruits of an organic garden. Automobiles are parked on the edge of the property, and residents take winding pathways through the neighborhoods; all paths and entryways are ramped for wheelchair and stroller access and are wide enough to permit easy use. One CDC staff member who lives there, Jim Lando, MD, MPH, says that the main reason he sought a cohousing development was to allow him to get to know his neighbors better. Because he knows that few of the other parents there allow their children to watch a lot of television, he can be confident that his children are not doing that at their friends’ homes. He believes his children are more active because they can roam the large common area. “It’s all about interacting with the people around you,” he said. 

Public health professionals are becoming familiar with the notion that land-use decisions can have important effects on public health, and are looking for opportunities to influence such decisions. According to Richard J. Jackson, MD, MPH, Director, National Center for Environmental Health, “We must be alert to the health benefits, including less stress, lower blood pressure, and overall improved physical and mental health, that can result when people live and work in accessible, safe, welldesigned, thoughtful structures and landscapes.” CDC’s health-related quality of life measures are helping bolster the new multidimensional public health paradigm that includes all aspects of health—physical and mental, community and environmental—and diverse partnerships for improving the quality of life in all our communities. 

For Further Reading 
Development and Public Health: Could Our Development Patterns Be Affecting Our Personal Health? Available at www.lgc.org/freepub/land_use/articles/
develop_and_publichealth.html.* 

Focus on Livable Communities: Why People Don’t Walk and What City Planners Can Do About It. This fact sheet was developed by the Local Government Commission through a contract with the University of California, San Francisco, as part of a project funded by the Physical Activity and Health Initiative, California Department of Health Services, under a Preventive Health Services Block Grant from CDC. It is available at www.lgc.org/freepub/land_use/factsheets/plan_to_walk.html.*

Creating a Healthy Environment: The Impact of the Built Environment on Public Health, by Richard J. Jackson, MD, MPH, and Chris Kochtitzky, MSP. Sprawl Watch Clearinghouse Monograph Series, 2001. Available at www.sprawlwatch.org/.*

ACES (Active Community Environments Initiative). For additional information, visit www.cdc.gov/nccdphp/dnpa/aces.htm.

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