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Translating the Cost Benefits of the Formal and Systematic Integration of Public Health in Community Design

Rogers, Valerie MPH; Parker, Daniel MSP; Price, Julianne RS

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Journal of Public Health Management and Practice: May 2008 - Volume 14 - Issue 3 - p 320-322
doi: 10.1097/01.PHH.0000316493.88006.83
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Land-use practices and community design decisions can have a tremendous effect on the public's health and well-being. Research suggests that land uses, community design, and transportation planning can influence a variety of health issues, such as asthma, obesity, injuries, unsatisfactory water and sanitation conditions, and the proliferation of health inequalities.1–3 These problems have gained increased media attention, given the correlations among sprawl, rising obesity rates, and resulting chronic diseases. According to a 2006 report from the Trust for America's Health, one of every four Americans is now overweight or obese.4 Confronting the obesity epidemic has prompted local health departments (LHDs) to think beyond traditional health promotion and prevention activities to engage nontraditional partners (planners, developers, citizen groups, etc) to address associated health concerns that may be impacted by decisions made about the built environment (eg, health inequities, climate change). LHDs have historically been involved in the traditional regulatory role of inspection and permitting and in some cases development review.5,6 However, the prospect of reconnecting with the science and the art of land-use planning offers the opportunity for LHDs to expand their purview to take a closer look at areas they comment on, such as air quality, hazardous waste, and water and sanitation, thereby increasing LHDs' ability to meet key public health functions and essential services through assessment, policy development, and assurance.

To achieve these goals, NACCHO advocates for the formal and systematic integration of public health and environmental health considerations in transportation, land-use planning, and community design to address needed changes in leadership, workforce, political will, and knowledge barriers that may lead to improvements in the health status of communities.7 Three areas may serve as the key strategic points of integration: (1) economic impact assessment; (2) community planning; and (3) public health assessment.

An innovative example of such integration can be found in the State of Florida, where LHDs and the state department of health face challenges to managing growth in a healthy and environmentally sustainable way. Florida has a booming population of 18 million; the number of trips made by foot is estimated to decrease by 42 percent over the next 20 years; the number of trips under a half-mile made by vehicle is projected to increase by 54 percent8; and there is a growing obesity problem (approximately 58% of adults are overweight or obese, and 26% of high school students are overweight or at risk of being overweight).9 A key to Florida's success in tackling such challenges is the establishment of strong partnerships through community environmental health assessments—primarily through NACCHO's Protocol for Assessing Community Excellence in Environmental Health (PACE EH) tool. This statewide initiative provided the necessary support for LHDs to develop partnerships and cooperatives with non–public-health stakeholders to effect change in policies, projects, and the real living conditions of Florida's residents.

According to Florida's PACE EH Coordinator, Julianne Price (oral communication, 2008), “PACE EH projects all identify built environment issues and therefore are faced with finding a solution to the problem. This has geared us towards directly interacting with planners to solve the issues but also made us realize the importance in being involved in the planning process locally to ensure community issues such as lack of sidewalks, lighting, paved roads, safety, connectivity, etc., are not perpetuated in the present and future”.

In the counties where PACE EH has been completed, the health status of the focus community has improved along with the development of new partnerships with professionals in housing, police, utilities, nonprofit agencies, etc. Thus, a greater return in dollars invested is relayed in the economic, environmental, social, and health conditions of the communities.

Perhaps the greatest return has been the move toward adoption of specific legislation, FL SB1598, which modifies the mission of the Florida public health system to incorporate local land-use planning and development assessments. SB1598 also directs planning agencies to employ smart growth principles, encourage public health membership on various planning bodies, offer incentives for developers and community redevelopment projects to encourage healthy development, and use health impact assessment (HIA). Although this legislation did not pass during the 2007 session, its appearance bodes well for future collaboration between planning and public health.

The culmination of programmatic and legislative actions has also resulted in the use of HIA, which is broadly “…a practical assessment of policies, programs and projects that may affect the public's health, and which provides recommendations to maximize positive health effects and minimizing the negative health aspects of proposals, policies and projects.”10 In Florida, Palm Beach County Health Department has developed and used an HIA tool; health departments in Polk and Hillsborough counties are currently developing HIA tools with their local planning agencies.

Finally, efforts in Florida have led the Florida Department of Health to become the first public health partner in the USEPA's Smart Growth Network. In support of this partnership, a new “public health planner” position was established at the state level with the intention of furthering the integration of public health considerations in planning projects throughout the state. The public health planner provides an expert safety net for LHDs addressing built environment issues by assisting with the review of local plans and pending developments, establishing contacts between health and housing authorities, and assisting in the rationale of why a development issue is a public health issue. At the local level, similar positions are being introduced in Orange and Sarasota counties, which seek to provide local expertise to planning and public health departments supporting smarter, more valuable growth, and healthier neighborhoods.

The Florida example illustrates that LHDs have much potential to expand their core functions to address built environment issues. To assist with this task, NACCHO has developed Toolbox, an on-line clearinghouse of resources to educate and build the capacity of LHDs in overcoming jurisdictional, political, economic, and social barriers to taking an active role in the planning process. Specific tools, such as sample HIAs, development-review checklists, model ordinances, land-use policies, and the “Planning for Health 101” CD-ROM, are available on NACCHO's Web site at

Furthermore, NACCHO has partnered with the American Planning Association to educate local planning departments about the need for LHD participation in order to bring a more informed health message into the planning process and to facilitate long-term partnerships between these disciplines in the design of healthier communities. NACCHO has also worked with the American Planning Association to identify a collection of practical yet innovative model and promising practices, cross-training opportunities in the form of technical assistance calls and training workshops on strategic points of public health integration in planning, and HIA methods.

As LHDs revive their shared history with planning to protect the public from outbreaks of disease and improve the quality of people's lives, the fields of public health and planning must work together to use the three strategic points of integration and influence via economic impact assessment, community planning, and public health assessment. The Florida example shows us that strong leadership is critical to this process. Leaders in the public health and planning fields must consistently raise awareness about the connections between the two fields. Flexible budgeting is also critical. The more planners, developers, community members, and other key stakeholders are involved in community assessment, the more likely they will be to support efforts to add economy to public health impacts. The more LHDs can show how the cost benefits of healthy development (eg, streetlights, sidewalks, increased social capital, or mixed use) can be expected to offset healthcare costs, the greater the chances that communities may demand sustainable development, healthier lifestyles, reduction of chronic diseases (eg, obesity), and decreased environmental impacts.


1. Frank LD, Engelke P. Multiple impacts of the built environment on public health: walkable places and the exposure to air pollution. Int Reg Sci Rev. 2005;28:193–216.
2. Frumkin H, Frank LD, Jackson, R. Urban Sprawl and Public Health. Washington, DC: Island Press; 2004.
3. Jackson R, Kochtitzky C. Creating a Healthy Environment: The Impact of the Built Environment on Public Health. Washington, DC: Sprawl Watch Clearinghouse; 2001.
4. Levi J, Gadola E, Segal LM. F as in fat: how obesity policies are failing in America. The Trust for America's Health Web site: Published August 2007. Accessed December 28, 2007.
5. National Association of County and City Health Officials. 2005 National profile of local health departments. Published 2005. Accessed December 28, 2007.
6. National Association of County and City Health Officials. 2003 Focus Group report: exploring the role of local public health officials in land use community design. Accessed December 28, 2007.
7. National Association of County and City Health Officials. Resolution to support land use planning/community design. Accessed December 28, 2007.
8. Parker D. Public health and urban planning. the Florida Department of Health, Division of Environmental Health Web site: Accessed January 30, 2008.
9. Florida Department of Health. The Florida Governor's Task Force on the Obesity Epidemic Web site: Accessed January 30, 2008.
10. Word Health Organization. The World Health Organization Health Impact Assessment Programme Web site: Accessed December 28, 2007.
© 2008 Lippincott Williams & Wilkins, Inc.