On the Health Track

By Laura Pedulli, photos by Alex Garcia

The fusion of public health and planning isn't new, but it's gaining steam. During the past 15 years at least, planning and public health entities, as well as nontraditional grassroots organizations, have collaborated to improve community health through better programs, policies, and planning of the built environment.

The American Planning Association and the American Public Health Association's Plan4Health project aims to accelerate these efforts in communities throughout the U.S. In March, the associations kicked off a three-year, $9 million nationwide initiative — funded by the federal Centers for Disease Control and Prevention — that provides grants to unique local coalitions to tackle two major contributors to chronic disease: lack of physical activity and lack of access to nutritious foods.

This first year, 18 coalitions were awarded a cumulative $2.25 million to support their projects. APA and APHA currently are vetting 85 proposals from 38 states to determine the second round of grantees for the coming year.

While coalition projects from the communities of Bensenville, Illinois; northeastern Connecticut; Austin, Texas; Savannah, Georgia; and Boston are shaped by unique populations, political environments, and resource challenges, they all present a blueprint for the next chapter in public health and planning collaboration.

B-Well in Bensenville

Like many towns, Bensenville (pop. 18,500) struggles with high obesity rates among young people and families. Roughly half of this culturally diverse population is Hispanic and poor; as a whole, the village is at severe risk of negative health outcomes, many of which have been attributed to lack of physical activity.

The B-Well Bensenville Plan4Health Coalition hopes to get people moving by heightening awareness of the importance of active living for everyone, says Becky McFarland, community initiatives coordinator at the DuPage County Health Department. The coalition includes Bensenville Community Youth Services Coalition and members of the village board, library, park district, and school districts. Another key player is FORWARD (Fighting Obesity Reaching Healthy Weight among Residents of DuPage) — an initiative that has addressed obesity in DuPage County for five years.

These groups decided to join forces and share resources in a unified vision for a healthier Bensenville, says McFarland. "The timing is right to galvanize support for active transportation like walking, biking, and public transit."

The Plan4Health grantee is pursuing a complete streets policy, including an educational component to engage residents. Industrial areas account for 36 percent of the village's land use. Many residents work locally, suggesting a need for better connections between the village's industrial parks and existing walking and biking trails to increase safety, convenience, and health. The village lacks on-street bike lanes or signed bike routes, which discourages bicycling to the local train station that takes commuters to Chicago jobs.

Plan4Health grant funding allows the coalition to reach short-term outcomes by increasing communications and marketing to link residents to opportunities for physical activity. A portion of the grant includes translation and communication services. It also funded a 2015 survey, provided to the targeted population in English and Spanish. Early results found that two-thirds of residents say better sidewalks — fixing missing sidewalks or repairing broken ones — is their top priority.

"The addition of crosswalks and connections across some of the busy arterials that currently are barriers will become a priority in upcoming projects," says McFarland.

By the end of the grant period, McFarland says, the changes could establish a more unified community so residents have adequate access to work, school, and other locations. "Active transportation goals were voiced as a priority for the village from a multitude of stakeholders and residents. The guidance from this grant provided a means to move forward on those goals effectively," she says.

The coalition hopes its project will serve as a model for municipalities throughout DuPage County and beyond.

Boston Inner Core

Boston's "Inner Core" communities struggle with disease and risk factors disproportionately concentrated in highly segregated, low-income, minority, and immigrant populations. For these communities, which include Cambridge, Somerville, Medford, Malden, Everett, Melrose, and Wakefield (all within 20 miles of Boston), healthy food options are limited. Less than 35 percent of the population eats the recommended five servings of fruits and vegetables per day, according to Lola Omolodun, public health planner at the Metropolitan Area Planning Council.

As a Plan4Health grantee, the Inner Core Community Health Improvement Coalition is working to bring affordable, nutritious food to those who most need it. It is also activating local coalitions so that regional, and perhaps statewide, impacts will result. Coalition members say the work will result in short- and long-term reductions in chronic disease related to poor nutrition.

The seven communities of the Inner Core (with a combined population of about 390,121) all have their own regional urban centers, but contain notable pockets of poverty. Large tracts and neighborhoods have been classified as food deserts — meaning at least 500 people, or at least 33 percent of the tract, live one or more miles from a grocery store, Omolodun says. These neighborhoods are dense and walkable, but many residents lack cars.

"Residents often have to walk or use public transportation to carry groceries while juggling young children or end up paying for taxis whose costs can add up over time, causing significant financial hardship," says Omolodun.

The coalition first came together under the federal Community Transformation Grant program, which focused on systems and environmental changes to improve community health. The Massachusetts Department of Public Health was integral to its formation.

"Our Coalition is a 'coalition of coalitions,' as it includes several local community coalitions with members representing diverse areas," says Omolodun. These include public health and nontraditional partners from urban planning, health care, community-based organizations for each Inner Core community, and others.

"It's important to identify and engage all stakeholders, even those that may seem marginally affected by the project early in the process, to address concerns as well as get varying perspectives," says Omolodun. Strong buy-in from local and state municipal decision makers also is crucial to institutionalizing changes.

The Inner Core Plan4Health project leverages efforts already under way, in particular establishing distribution networks that cater to small food retailers and support expansion of healthy retail initiatives — including its healthy corner store work, which the coalition started with CTG funding.

Advancing new strategies to improve healthy food access requires collaboration with grocery stores as well as with local farmers. "We are ... just beginning to reach out to distributors and local farmers about the potential to distribute or supply foods to small retailers," Omolodun says.

An important component of the project is changing how residents see corner stores. This requires communications strategies sensitive to the targeted community. "We want to promote these stores as a great option to get healthy food items in between larger grocery store trips, or as a great place to get healthy snacks on the go."

As an end product, the coalition aims to have a viable distribution system or network in place that will enable corner stores to purchase healthier foods at a reasonable cost and improve access to those foods for residents within the Inner Core region. "We also hope to have developed strong partnerships with grocery stores and established innovative models to promote healthy foods in grocery stores," says Omolodun.

Rural Connecticut

Most documented efforts to yoke public health and planning have taken place in urban centers. The Eastern Highlands Health District Coalition, whose geographic area covers 10 contiguous small towns in northeastern Connecticut (pop. 82,000), hopes to prove that the convergence can happen in rural communities as well.

"While there is a lot we can learn from these urban examples, we are also challenged by the potential response of 'Yes, but we're not Philly or Amsterdam: This will never work in our town,'" says Jordana Frost of the EHHD staff, who is also a member of Connecticut Public Health Association.

The Plan4Health Coalition, known locally as the Community Health Action Response Team, includes members of the CPHA, local parks and recreation departments, local child advocacy groups, representation from schools and social service agencies, health care services, residents, town planners, and town administrations. Because these groups are long-standing partners, the Plan4Health project is a "perfect fit" that enables the coalition to work on sustainable policy, systems, and environmental changes that promote health and prevent chronic disease, says Robert Miller, director of health for EHHD and founding member of CHART.

The project includes the development and strategic dissemination of a toolkit designed for rural or small town planning and zoning commissions to improve opportunities for healthy eating and active living.

Smaller towns may not have full-time town staff to provide technical expertise, and volunteer commissioners may have little time to pursue relevant training and orientation. Moreover, commissioners can be swamped by day-to-day permit-related requests, and they can lose sight of their larger role in planning the long-term development and direction of their community, says Frost.

"While lay volunteers are armed with a strong love for their community and a desire to be good stewards for their town's future development, they can often be challenged by a number of system-related factors that are beyond their control," says Frost. "This project essentially promotes a paradigm shift so that the intersection between public health and planning and zoning can move from an afterthought to the normative way of thinking about the built environment, so that it can become purposefully 'healthy by design.'"

In this early stage of the project, several interviews with planning and zoning commissioners have found that most towns have little citizen engagement — or that engagement tends to be issue-driven and focused on individual properties. Moreover, dual-income families of young professionals in their 30s and 40s are not at the table, she says.

"Our challenge is changing this level of involvement so more local groups can become aware of the potential that planning and zoning commission decisions can have on influencing the health, well-being, and overall quality of life of their community," says Frost.

While the coalition is asking to be included on the agendas of already established interest groups, Frost says it also is "thinking about additional ways to engage the public to get our point across in a more creative and experiential fashion," such as open streets events, better block events, festivals, and fairs.

By the end of the project period, EHHD hopes to change the culture of local planning and zoning so that the establishment and maintenance of equitable active living and healthy eating opportunities is the norm and integral to planning and zoning decisions, says Miller.

Healthy Savannah

Diabetes is a rapidly growing chronic disease in Chatham County, Georgia (pop. 283,000), affecting about 10 percent of residents, and cardiovascular disease is the leading cause of death. More than one-quarter of county residents report that they don't have reasonable access to physical activity, according to Healthy Savannah Coalition's application.

The Healthy Savannah Coalition, created in 2007, brings together planners, health professionals, public agencies, and business owners to improve these statistics. In the past, the coalition has advocated for a smoke-free air ordinance, a public school wellness policy, guidelines to promote walking and biking access for students, and a complete streets ordinance.

"Making the connection between community health and planning is an effective way to engage community leaders in thinking about public policy goals and strategies," says Whitney Shephard, principal of Transport Studio and Plan4Health project manager. "When we talk about childhood obesity and opportunities to walk to school, it can lead to a richer conversation about complete streets policy or the need for physical infrastructure like sidewalks, crosswalks, and lighting."

The Plan4Health coalition includes the Coastal Health District (a division of Georgia Department of Public Health), Armstrong State University Health Sciences Department, planning consultants, community organizers, regional hospitals, the public school system, and public agencies.

The coalition's goal is increasing access to nutritious foods, but supply remains a "major challenge," says Shephard. "Sustainably producing more local food through increased market share, waste reduction, and establishing shared resources are three areas of focus."

Directly engaging the most at-risk communities is a challenge, but Healthy Savannah is committed to working with underserved neighborhoods for the long haul, says Shephard. "Talking to families in their schools, churches, doctors' offices, clinics, and neighborhoods is key to understanding the choices they make today, and how to shift to a healthier lifestyle over time. Plan4Health is an important step in a larger movement in this community."

The coalition has partnered with the Savannah Chatham Public School System and Memorial University Medical Center to increase local and healthy food in schools and hospitals. Part of the group's job is reviewing procurement methods to facilitate purchase from local suppliers. Another task is to look for ways to build on current farm-to-school efforts like school gardens and featured farmers. Local chefs are being invited to schools to teach students about food sourcing and cooking healthy and delicious meals.

Connecting schools and health care facilities to alternative retail like Farm Truck 912, a newly formed mobile market, also is important. "People should be able to buy healthy food more easily. Partnering with our major institutions is a big step toward food access for all," says Shephard.

The coalition will propose public policies that promote the Farm Truck, farmers markets, and farm stands. It will also address food service, processing, and packing. "We need to make it easier for food startups to get cooking! Connecting food businesses to our large tourism market is a very real opportunity. Everyone who visits Savannah should take home a locally grown product," says Shephard.

"In the end, we're asking people to change: Eat healthy food, sell healthy food, incentivize healthy food businesses, adopt policies to promote healthy food access, and partner with diverse stakeholders to reduce health disparities," she adds.

Restoring Austin

Chronic disease accounts for three out of every four deaths in Austin. Cancer, cardiovascular disease, stroke, and diabetes also contribute greatly to economic costs in Travis County, says Philip Huang, MD, medical director and health authority for Austin/Travis County.

Austin's 30-year comprehensive plan, Imagine Austin, adopted in June 2012, and the Community Transformation Grant have helped the community focus on how the built environment impacts population health. The Plan4Health Coalition answers that call, representing an opportunity to further build relationships and capacity among transportation, health, and planning professionals.

"We hope to align with these priorities by increasing local food production and decreasing food insecurity. We hope that this process increases the pilot community's knowledge of how to create change — through policies, programs, or initiatives — to lead to healthier outcomes," says Ashley LeMaistre, program coordinator with the Austin/Travis County Health & Human Services Department.

The coalition serves as the core capacity-builder across Austin, and it includes APA Texas, the Texas Public Health Association, and the Chronic Disease Prevention and Control Coalition. The project is being carried out by the Austin Transportation Department and Office of Sustainability, with support from the Health and Human Services, Planning, Parks and Recreation, and Public Works departments.

"We have found that integrating health into the planning process has been crucial — including nontraditional partners in community health improvement planning," says LeMaistre. She adds that integration "has been essential to getting on the same page and learning each other's language."

The coalition's first goal is increasing physical activity by implementing communitywide programs encouraging biking, walking, and public transit use. Second, it seeks to increase access to healthy eating by conducting neighborhood engagement and outreach to improve the local sustainable food system.

"By taking a community and place-based approach, we hope to gain insights into the many ways we can empower the community to take action, both through individual behavior change and through community-based organizing, to regularly enjoy regular physical activity and healthier food," says Edwin Marty, food policy manager with the city of Austin's Office of Sustainability.

The project is data-driven. Among the data sets that the coalition is examining is the Behavioral Risk Factor Surveillance System, which tracks risk factors for chronic disease, as well as local mortality data and hospital discharge data.

Also, the coalition is looking at mode share data to better understand the rates of walking, bicycling, and transit. A travel survey is assessing individual travel behavior, as well as crash frequency and crash rates. GIS mapping of hotspots around the city provide data on the highest risks for chronic disease; food insecurity and lack of access to healthy food; and where connectivity, active transit, and parks can be improved.

The coalition intends to expand community and school gardens, farmers markets, food banks and pantries, and commercial kitchens. Part of the work is based on field research along the main corridor identifying additional food access points — grocery stores, corner markets, convenience stores — and the type of food each provides.

By the end of the grant period, "we hope to have provided community leaders with new knowledge about how they can continue to improve access to physical activity in their neighborhoods. We hope to improve attitudes towards using active transportation to access daily needs," says Laura Dierenfield, Austin's active transportation program manager.

Starting this fall, the coalition will begin qualitative interviews with North Austin residents.

On-the-ground research so far indicates that access to healthy, culturally relevant foods and beverages is widely available, says Mike McAnelly, FAICP, executive administrator at the APA Texas chapter. "Opportunities to improve residents' access may need to be more focused on shifting behaviors through community engagement to encourage purchasing of healthier foods, making healthy options convenient, and offering guidance to consumers to help them make healthier decisions," he adds.

The coalition will develop a food system toolkit, based on resident feedback, which could support any number of initiatives: new or expanded community gardens or school gardens; commercial urban farms; food processing businesses; and hubs for food distribution, among many other possibilities.

"We have spent significant time on aligning our resources and outreach efforts with other organizations working in the area in order to establish an outreach approach that is authentic, respectful of residents' time, and not duplicative," says LeMaistre.

Laura Pedulli is a Marion, Massachusetts-based freelance writer with more than 15 years of experience writing for newspapers, magazines, and trade press publications. She has written extensively on national health policy, technology, business development, and municipal planning.

Resources

Images: Top — A city crew tears up ground to lay a new sidewalk along East Irving Park Road in the downtown area of Bensenville, Illinois, as part of a citywide initiative to improve community health. Middle — The lack of crosswalks and connections across some of Bensenville's busy arterials forces Dave Trevino to venture into the street to get where he needs to go. "I'm sick of being on the streets. They're dangerous," he says. Bottom — The B-Well Bensenville Plan4Health Coalition in Bensenville, Illinois, has adopted a complete streets policy because it believes walking, biking, and public transit are key to improving the health and well-being of residents. Fixing the village's sidewalks is a top priority, though future projects will also focus on creating crosswalks and connections across busy roads. That's a relief to residents like Noel Ramos. "It's too hard to cross the street," he says.

Planning and Community Health Center: www.planning.org/nationalcenters/health

Plan4Health: www.plan4health.us

Plan4Health Coalitions: www.planning.org/nationalcenters/health/psecoalitions

On Wednesday, September 9, U.S. Surgeon General Vivek Murthy, MD, announced his long-anticipated call to action, Promoting Walking and Walkable Communities. Along with it comes a guide for decision makers, like planners, that highlights best practices in building healthy communities: http://tinyurl.com/of4ykzv