Transportation and Public Health: An Integrated Approach to Policy, Planning, and Implementation

By M. D. Meyer and O. A. Elrahman

Transportation and Public Health: An Integrated Approach to Policy, Planning, and Implementation helps current and future transportation professionals integrate public health considerations into their transportation planning, thus supporting sustainability and promoting societal health and well-being. The book defines key issues, describes potential solutions, and provides detailed examples of how solutions have been implemented worldwide. In addition, it demonstrates how to identify gaps in existing policy frameworks. Addressing a critical and emerging urgent need in transportation and public health research, the book creates a coherent, inclusive and interdisciplinary framework for understanding.

By integrating principles from transportation planning and engineering, health management, economics, social and organizational psychology, the book deepens understanding of these multiple perspectives and tensions inherent in integrating public health and transportation planning and policy implementation.

• Bridges the gap between transport and public health, two fields that have traditionally traveled on separate and parallel tracks
• Synthesizes key research and practice literature
• Includes teaching and learning aids, such as case studies, chapter objectives, summaries and discussion questions

• Language: English
• Publisher: Elsevier Science
• Release date: Jun 17, 2019
• ISBN: 9780128172964

M. D. Meyer

Michael Meyer is Senior Strategy Advisor for the multinational engineering and design firm Parsons Brinckerhoff. He is the former Director of Transportation Planning and Development for the state of Massachusetts, former Professor of Civil Engineering at MIT and Georgia Institute of Technology, and former Director of the Georgia Transportation Institute. He is the author of more than 200 articles and co-authored texts on transportation planning and policy, including Urban Transportation Planning (McGraw Hill). He is an active member of numerous professional organizations and has chaired committees on transportation planning, public transportation, environmental impact analysis, transportation policy, transportation education, and intermodal transportation.

Book preview

Transportation and Public Health

An Integrated Approach to Policy, Planning, and Implementation

Editors

M.D. Meyer

Senior Strategy Advisor, WSP USA, Inc., Georgia, Atlanta, United States

O.A. Elrahman

Senior Research Scholar, Rensselaer Polytechnic Institute’s Center for Infrastructure, Transportation, and Environment, Watervliet, NY, United States

Table of Contents

Cover image

Title page

Copyright

About the authors

Preface

Acknowledgment

Chapter 1. Transportation and public health: An introduction

Introduction

Why focus on transportation?

Purpose and organization of the book

Chapter 2. Dimensions of public health affected and influenced by transportation

Introduction

Social determinants of health

Transportation and the social determinants of health

Transportation and urban planning

Nashville's efforts to improve transportation-related social determinants of health

Summary

Discussion questions

Chapter 3. Institutional frameworks: Laying the groundwork for mainstreaming public health into transportation decision-making

Introduction

The transportation public sector

The public health sector

Coming together in response to major disruptions to transportation systems and communities

International agreements that integrate social determinants of health into regulations and legal practices

United Nations Millennium Development Goals

Summary

Discussion questions

Chapter 4. Air and water pollution: An important nexus of transportation and health

Introduction

Air quality and public health

Air pollution and the natural environment

Transportation-related contributors to air pollution

Air quality management: Success at the confluence of public policy, science, technology, and advocacy

Transportation-related strategies for reducing air pollutant emissions

Critical perspectives on air quality and transportation

Road transportation, water pollution, and public health

Chapter 5. Community development, active transportation and public health

Introduction

Evidence of active transportation-related public health impacts

Long-term role of transportation and urban design in encouraging urban form, and public health consequences

Policy and regulatory framework

Integrated land use/urban design/transportation strategies for reducing public health impacts

Summary

Discussion questions

Chapter 6. Transportation design, operations, and public health

Introduction

Design guidance

Complete Streets

Climate change and adaptive design: An emerging design paradigm

Summary

Discussion questions

Chapter 7. Transportation system safety and public health

Introduction

Evidence of public health impacts of crashes and accidents

Human factors

Economic costs of crashes

Policy and regulatory framework

Summary

Discussion questions

Chapter 8. Transportation and _______

Introduction

Public health and what transportation systems convey

The ride-alongs in transportation

Transportation and hazardous materials

Public health and disrupted transportation systems

All-hazards approach in responding to major incidents/disasters

Discussion questions

Chapter 9. Incorporating public health concerns into transportation decision making

Introduction

A conceptual framework

Health impact assessments

Some observations

Bringing the transportation and public health communities closer together

Discussion questions

Index

Copyright

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About the authors

M.D. Meyer, PhD

Dr. Michael Meyer is the founding principal of Modern Transport Solutions, LLC and a senior advisor to WSP USA, Inc. and, in that capacity, has led numerous projects and studies on enhancing transportation system performance. Prior to his current position he was a professor of civil and environmental engineering and former Chair of the School of Civil and Environmental Engineering at the Georgia Institute of Technology and MIT. From 1983 to 1988, Dr. Meyer was Director of Transportation Planning and Development for Massachusetts where he was responsible for statewide planning, project development, traffic engineering, and transportation research.

Dr. Meyer is an active member of numerous professional organizations and has chaired committees relating to transportation planning, public transportation, environmental impact analysis, transportation policy, transportation education, and intermodal transportation. He served as chairman of the Transportation Research Board of the National Academies of Science, Engineering and Medicine in 2006. He has written 31 books/book chapters and more than 300 technical articles focusing on transportation planning and policy, transportation system resilience, and environmental/community impacts of transportation systems. Dr. Meyer has focused his attention over the past 10   years on transportation system resiliency and has led many research/consulting projects on the impacts of system disruption due to manmade and natural causes.

Dr. Meyer is the recipient of numerous awards including the 2000 Theodore M. Matson Memorial Award in recognition of outstanding contributions in the field of transportation engineering; the 1995 Pyke Johnson Award of the Transportation Research Board for best paper in planning and administration delivered at the TRB Annual Meeting; and the 1988 Harland Bartholomew Award of the American Society of Civil Engineers for contribution to the enhancement of the role of the civil engineer in urban planning and development. Dr. Meyer has a PhD in civil engineering from the Massachusetts Institute of Technology, MS in civil engineering from Northwestern University, and a BS in civil engineering from the University of Wisconsin–Madison. He is a registered professional engineer in the State of Georgia.np

O.A. Elrahman, PhD

Dr. O. A. Elrahman is a senior research scholar at the Center for Transportation Infrastructure and Environment (CTIE), Rensselaer Polytechnic Institute. Prior to academia, Dr. Elrahman worked at New York State Department of Transportation (NYSDOT) in different capacities/divisions, most recently as the Head of the Research Coordination and Technology Transfer group of the Transportation Research & Development Bureau. His extensive research and management activities spanned several departmental divisions, including Environmental Analysis, Policy, Transit, Project Development, and Economic Development. He has applied and teaching experience in transportation planning and engineering. Dr. Elrahman served on several national research panels of the National Science Foundation (NSF), National Cooperative Highway Research Program (NCHRP), and National Cooperative Transit Research Program (TCRP). He also served as an advisor for several European Commission's sponsored research projects and an expert evaluator for the European Commission's Research Horizon 2020 program. Dr. Elrahman's recent research focuses on mainstreaming public health considerations into transportation planning, design, and implementation.

During his career, Dr. Elrahman has authored more than 70 peer-reviewed papers and technical reports. He has organized and chaired numerous national and international conference workshops and sessions and served on the editorial board of several scholarly journals. Dr. Elrahman served on several Transportation Research Board's (TRB) committees. He is currently a member of the Executive Subcommittee on International Activities, Transportation Research Board (TRB), National Academies of Science. He also served, for two terms (2013-2019), as the co-chair of TRB's Standing Committee on International Cooperation. He is the recipient of several awards including NYSDOT award for Outstanding Performance in Research and Service to the Department and the TRB award for Outstanding Service in international activities and global cooperation.

He serves on the Board of Directors of the International Professional Association for Transport & Health (IPATH), an organization that serves as a platform for cross-disciplinary and multisector professionals working at the intersection of transport and health.

Dr. Elrahman holds a PhD in Urban and Environmental Studies from Rensselaer Polytechnic Institute (RPI), and an MSc in Transportation Planning and Engineering from the Polytechnic Institute of New York, School of Engineering, New York University. He also holds a postgraduate certificate in Management Development from Cornell University.

Preface

This book examines the intersection of public health with transportation. The authors argue that understanding the relationship between transportation systems and public health is a critical foundation to any public policy that seeks to improve health conditions. The book explores this relationship by providing an overview of key concepts and an in-depth understanding of why and how transportation represents a key public health strategy. Topics include, (1) social determinants of health and the transportation linkages, including the physical social economic, occupational, environmental, intellectual, and emotional dimensions of public health affected by transportation; (2) the legal frameworks that integrate social determinants of health into regulations and legal practices and the levels at which mainstreaming public health issues into transportation take place; (3) the relationship between transportation and air and water pollution–related health conditions; (4) the connections between transportation system, facility design and physical activities that promote health, and transportation design and planning that facilitate active transportation and physical health; (5) the link between transportation injuries and fatalities and the role of regulations and new technologies in mitigating public health concerns; and (6) climate change mitigation and adaptation. The book concludes with a framework for incorporating public health concerns into transportation decision making.

This book is designed for students, researchers, and practitioners of transportation and public health as well as policy makers, transportation planners, transportation engineers, and public health professionals. They will find important guidance and useful insights into integrating public health considerations into transportation decisions and developing public health policy decisions that mitigate the impacts of the transportation system on human health and well-being.

Acknowledgment

We would like to give special thanks to Dr. Jessica Wall, who was instrumental in reviewing and offering her expertise as a medical doctor. We are indebted to her valuable insights and feedback from a medical perspective. Dr. Wall’s perspective provided a critical balance to the transportation perspective and allowed us to integrate and harmonize two professional perspectives that are often in tension with each other. Her contributions were important in bridging important gaps that exist in developing coordinated and collaborative approaches for achieving effective public health outcomes.

Chapter 1

Transportation and public health

An introduction

Abstract

The chapter advances the argument that any meaningful public policy effort that seeks to improve health outcomes must be grounded in an in-depth understanding of the relationship between transportation systems/facilities and public health. The goal of the book is to explore the relationships between transportation system design/operations and public health and identify strategies that can be used to improve public health. The chapter identifies the different areas the book examines, including definition of the different dimensions of public health and the ways in which planning, design, and operations of transportation systems affect and/or influence public health outcomes; the medical and public health evidence of the public health outcomes of transportation system design and performance; transportation-related strategies that can be used to reduce negative public health outcomes; and incorporating public health concerns into the decision-making processes relating to investing in and operating the transportation system.

Keywords

Integration of public health concerns into transportation decisions; Relationship between public health and transportation; Strategies for improving public health

Introduction

Public health is a major focus of public policy, legislation, and regulations throughout the world. In some cases, this policy focuses on specific health-related behaviors such as regulating the use of tobacco and alcohol. In other cases, this focus targets sectoral activities that have been shown to lead to unhealthy consequences, such as reducing the concentration of motor vehicle–related emissions that are precursors to lung-related illnesses. In this latter example, legislation and regulations have focused on the motor vehicle manufacturing industry (to reduce engine-related emissions) and on public policies relating to investment in transportation systems (to reduce the amount of travel in pollutant-emitting vehicles). Thus, it is very common to see policy makers attempting to achieve public health goals by legislating and regulating those activities that might lead to unhealthy outcomes (T4 America, 2017; Richter et al, 2001).

As suggested above, the transportation sector is one such area. There are many examples of where the technology of transportation systems and vehicles has been the focus of health-related policies. This is most obvious in the many policies and regulations that have been adopted worldwide to reduce the motor vehicle–related emissions known to exacerbate human illness. Early efforts focused on reducing the lead content in fuels, which was followed quickly by regulations to reduce other types of emissions, such as nitrous oxides, sulfates, carbon monoxide, and most recently greenhouse gas (GHG) emissions.

Water quality is another area where transportation systems have been the focus of health-related policies, primarily in reducing the type and concentration of the elements that emanate from vehicles and vehicle parts (such as batteries). In addition, attention has been given to the procedures used to maintain transportation system operation, such as the level of salt used to remove ice from roadways (possibly polluting nearby water aquifers).

A broader view on public health and transportation, however, is becoming an ever more important perspective in transportation policy and decision-making. Since the 1960s, transportation officials have been concerned with the more physical and obvious health-related impacts of transportation decisions. Motor vehicle safety, emissions, noise, community disruption, and motor vehicle–related water pollution impacts have been the focus of many studies and plan components, often in response to national and state legislation requiring such attention. Over the past decade, however, the public health nexus with transportation has broadened to include many other issues, such as the role of transportation system design on physical activity (and thus on the incidence of obesity and chronic disease), access to healthy food (in particular for underrepresented population groups), the lack of mobility and its effect on mental health and sense of isolation, transportation facilities serving as conduits for the spread of disease (especially in concert with climate change), and vulnerabilities of transportation systems to extreme weather events, and the like.

Fig. 1.1 illustrates the concept that many different sectors and agencies in their own way contribute to public health outcomes. From an institutional perspective, the agencies and organizations constituting each sector utilize resources (e.g., funding and personnel) to produce organizational products or services (called outputs in the figure) that eventually produce policy or program outcomes. Many factors can influence what the ultimate outcomes will be, most of which are not controlled by the agencies or the respective officials. Fig. 1.2 provides more detail for both the transportation and public health sectors. For both sectors, the figure shows a pathway for how initial organizational actions lead to eventual health outcomes. As will be seen throughout the book, strategies for enhancing public health outcomes can intervene anywhere along this pathway. For example, such strategies could provide more resources to affect agency outputs, influence agency products and services through direct regulation, or try to position the products and services to take advantage of the exogenous factors that will affect the eventual impact on public health.

Figure 1.1 Sectoral contribution to public health outcomes.

These two figures greatly simplify very complex interactions of many different variables and factors that influence health outcomes. For example, Fig. 1.2 shows social determinants of health (discussed in more detail in Chapter 2) as possibly affecting organizational actions along this pathway. and ultimately public health. These determinants represent a wide range of socioeconomic, environmental, community, and personal factors that can lead to the health profile associated with any particular individual.

The motivation for this book is that there is a growing awareness that transportation systems and their impacts/consequences have an important role in the incidence and magnitude of health issues over and above simply being the source of unhealthy pollutants (Giles and Corti, 2016). The book discusses the relationships and linkages between the transportation and public health sectors....in other words, the interaction that would be represented in Fig.1.2 as two-headed vertical arrows between the two sectors. Concepts similar to those shown in Fig. 1.2 are discussed in more detail later in the book where an understanding of the role of transportation in the social determinants of health is presented.

Figure 1.2 Pathway from transport policy to health outcomes.

Why focus on transportation?

Subsequent chapters provide greater detail on the specific nature of the public health–transportation relationship. However, it is useful at the beginning of the book to make the case why transportation should even be of interest to those concerned with public health outcomes. Consider the following.

Transportation safety

Road safety by far represents the greatest transportation-related public health challenge of those discussed in this book. In 2017, for example, 37,133 people died in traffic crashes in the United States, one of the largest numbers of fatalities since 2007. In addition, there were over 2   million people injured. This number included over 5300 pedestrians and just over 800 bicyclists killed in motor vehicle–related crashes. Worldwide, the World Health Organization (WHO) estimates that 1.35   million people are killed every year in motor vehicle–related crashes, with the highest road traffic fatality rates in low-income countries. In contrast, no people died in 2017 and 500 people died in 2018 due to commercial passenger airplane crashes.

One of the most important reasons for focusing on traffic safety and its relationship to public health is the disproportionate impact of crashes and injuries on selected population groups. Table 1.1, for example, shows the relative ranking of road traffic injuries in comparison to all other injuries to children of different age groups. As can be seen, traffic crashes are a significant contributor to child mortality worldwide.

Another reason why road safety and public health is of interest, besides the absolute magnitude of fatalities and injuries, is that governments and public action can have a strong influence on creating positive safety outcomes (Sleet et al, 2007). Such governmental influence occurs through the following:

Table 1.1

Source: Reproduced from World Road Association, PIARC Road Safety Manual The Impact on Public Health, Website. https://roadsafety.piarc.org/en/strategic-global-perspective-scope-road-safety-problem/impact-public-health.

• Investments in safe highway and road projects (the use of complete street designs, for example) and, in particular, focusing investment attention on high-crash locations (APHA, 2011).

• Physical design standards and operating rules adopted by public agencies on how facilities are designed (road width, sign readability standards, and right-of-way rules, for example).

• Ordinances and vehicle operating rules designating how the facilities and systems should be used (driver licensing and seat belt use laws, for example).

• Regulation of vehicle characteristics, such as safety standards relating to occupant survivability and performance in inclement weather.

• Regulation of engine and fuel characteristics, such as vehicle emission and engine performance standards.

• Enforcement of laws and ordinances aimed at promoting safe vehicle operations.

• Public education on the safe operation of vehicles and rules of the road.

Motor vehicle emissions and air quality

As noted earlier, motor vehicle emissions have been the focus of public policy throughout the world for decades, and significant progress has been made in reducing the amount of pollutant emissions originating from motor vehicles. The basis for motor vehicle emissions and safety regulations is the impact that each has on overall public health and on individuals exposed to transportation system emissions or who find themselves in an accident. And although overall pollutant concentrations have been reduced in most urban areas from previous years, motor vehicle–related emissions still constitute a significant portion of many of the most serious pollutants released into the atmosphere. For example, in the United States in 2016, the transportation-related contribution to the national inventory of pollutant gases included 63% of national carbon monoxide (CO) emissions, 58% of nitrogen oxide (NOx) emissions, and 25% of volatile organic compound (VOC) emissions (USEPA, 2017a). Other important pollutants of concern include particulate matter (PM) (especially for diesel fuels), ammonia (NH3), sulfates, and ozone (O3), which includes NOx and VOC as precursor pollutants.

Consider the following:

• The California Air Resources Board (CARB) has estimated the statewide health effects of truck-related nitrogen oxide and particulate matter of 2.5-micrometer diameter (PM2.5) pollutants as shown in Table 1.2. The estimated cost to society of these emissions is substantial.

Table 1.2

a  Includes respiratory and cardiovascular hospitalizations.

b  Uncertainty ranges only reflect uncertainty in the concentration–response function and do not reflect uncertainty in emission projections, spatial interpolation, and aggregation.

c  Includes asthma and cardiovascular emergency room visits.

Source: CARB (2016).

• A study in New York City (NYC) estimated that all on-road mobile sources of air pollution in the NYC region contributed to 320 (95% confidence interval [CI]: 220–420) deaths and 870 (95% CI: 440–1280) hospitalizations and emergency department visits annually within NYC due to PM2.5 exposures, accounting for 5850 (95% CI: 4020–7620) years of life lost. Trucks and buses represented the largest share of on-road mobile-attributable ambient PM2.5 levels. The impacts were not evenly distributed; high-poverty neighborhoods experienced a larger share of the exposure and health burden than low-poverty neighborhoods. The authors concluded that reducing motor vehicle emissions, especially from trucks and buses, could produce significant health benefits and reduce disparities of the impacts (Kheirbek et al., 2016).

• The US Environmental Protection Agency (USEPA) notes that an extensive body of scientific evidence shows that long- and short-term exposures to fine particle pollution, also known as fine particulate matter (PM2.5), can cause premature death and harmful effects on the cardiovascular system, including increased hospital admissions and emergency department visits for heart attacks and strokes. Scientific evidence also links PM to harmful respiratory effects, including asthma attacks. Ozone can increase the frequency of asthma attacks, cause shortness of breath, aggravate lung diseases, and cause permanent damage to lungs through long-term exposure. Elevated ozone levels are linked to increases in hospitalizations, emergency room visits and premature death (USEPA, 2017b).

• Despite considerable improvements over the past several decades, air pollution is still responsible for an estimated 467,000 premature deaths in Europe each year (European Commission, 2016).

• For PM, the WHO concluded that long-term exposure to ambient PM concentrations may lead to a marked reduction in life expectancy. The reduction in life expectancy is primarily due to increased cardiopulmonary and lung cancer mortality. Increases are likely in lower respiratory symptoms and reduced lung function in children and chronic obstructive pulmonary disease and reduced lung function in adults (WHO, 2003).

• A significant health consequence of ozone has been found during summer seasons leading to higher rates of mortality associated with increased daily ozone concentrations. Ozone daily levels have been associated with hospital respiratory admissions at all ages. As noted by WHO, there is evidence that during days when ozone levels are high, asthmatic subjects increase their use of medication (WHO, 2003).

Whereas motor vehicle–related air pollution still ranks as one of the most important transportation-related health issues, it should be noted that public policy has made major advancements in reducing the amount of emissions generated by motor vehicles. This has been primarily done through vehicle emission standards and mandated use of less polluting alternative fuels. For example, the following reductions in pollutants in US cities have occurred over the past 45   years as measured by the USEPA (2017c).

Carbon Monoxide (CO) 8-Hour Concentration, 77% Reduction

Lead (Pb) 3-Month Average Concentration, 99% Reduction

Nitrogen Dioxide (NO2) Annual Tons, 54% Reduction

Nitrogen Dioxide (NO2) 1-Hour Concentration, 47% Reduction

Ozone (O3) 8-Hour Concentration, 22% Reduction

Particulate Matter 10 microns (PM10) 24-Hour Concentration, 39% Reduction

Particulate Matter 2.5 microns (PM2.5) Annual Tons, 37% Reduction

Particulate Matter 2.5 microns (PM2.5) 24-Hour Concentration, 37% Reduction

Sulfur Dioxide (SO2) 1-Hour Concentration, 81% Reduction

There is little doubt that these impressive results have occurred because of government regulations relating to motor vehicles. New US passenger vehicles are 98%–99% cleaner for most tailpipe pollutants compared with the vehicles of the 1960s. Fuels are much cleaner, lead has been eliminated, and sulfur levels are more than 90% lower than they were prior to regulation. Such public policy action has had an important impact on public health.

Transportation and the built environment

A fundamental paradigm in transportation planning is that investment in the transportation system influences land use and development decisions and that changing land uses in turn influence travel behavior and the need for changes in the transportation system. When development decisions are considered together and over some period of time, the result is urban form. In other words, the development patterns that over time define the physical, economic, and often sociodemographic characteristics of individual communities are the same elements that, in the aggregate, shape a region (Meyer, 2016).

Much research has been conducted over the past 15   years on the relationship between community development patterns (that are influenced by the design and use of the transportation system along with many other factors) and the (generally lower) level of individual physical activity, which has been linked to public health concerns such as obesity and cardiovascular disease (The Heart Foundation, 2009). Representative conclusions from such studies and policy positions include the following:

• Researchers have found convincing evidence that people who live in communities characterized by mixed land use (e.g., with stores in walking distance of homes), well-connected street networks, and high residential density are more active, especially for transportation, than those who live in communities designed for automobile dependence. Other researchers have concluded that proximity to recreational facilities, along with pleasing aesthetics, is associated with more recreational physical activity(Public Health Canada, 2014).

• Changing built environments and policies is expected to have long-term impacts on most or all of the people in such places. Characteristics of built environments, from neighborhoods to cities, have been linked to rates of chronic disease and mental health and risk factors such as obesity and hypertension. Physical activity is believed to be a critical mechanism by which built environments can affect chronic disease(Sallis et al., 2012).

• Physical activity is one of the most important things Americans can do to improve their health. Walking is an easy way to start and maintain a physically active lifestyle. Walkable communities make it easier for people of all ages and abilities to be active(US Surgeon General, undated).

• A study on the relationship among transportation, land use, and built environment variables along with demographic and socioeconomic factors on people's general health and obesity found that a one percent decrease in the use of automobiles can decrease obesity by 0.4% (Samimia et al., 2009).

• Travel behavior is complex, with various factors simultaneously affecting decisions about how much, where, when, and how to get around. Although the magnitude of the effect is widely debated, a large body of evidence shows that community design affects travel behavior. Moreover, the effect is large enough that changes in community design could help mitigate a range of transportation, air quality, human health, and greenhouse gas problems(USEPA, 2013).

• The promotion of active transport (cycling and walking) for everyday physical activity is a win-win approach; it not only promotes health but can also lead to positive environmental effects, especially if cycling and walking replace short car trips(WHO, 2011).

There are many other linkages between transportation and public health besides those highlighted above. They all point attention to this relationship as a key component of a comprehensive community public health program. Such a program necessarily includes professionals from many different fields, including city planning, emergency management, public health, and transportation, to name a few. The intent in this book is to focus on the important role that transportation has in promoting positive public health outcomes. In particular, it will recommend to transportation officials the types of strategies and actions that could be considered for enhancing the public health of the communities served by the transportation system.

Some definitions

A cogent discussion of transportation and public health will often involve professionals from many different disciplines, and thus it is important that readers have a common understanding of the terms used in this book. The following key terms are found in many of the following chapters.

Active transportation: Physical activity primarily to move from one destination to another, usually by walking or bicycling (Dannenberg et al., 2011).

Built environment: All of the physical parts of where we live and work (e.g., homes, buildings, streets, open spaces, and infrastructure). The built environment influences a person's level of physical activity (CDC, 2011).

Community resilience: A measure of the sustained ability of a community to utilize available resources to respond to, withstand, and recover from adverse situations (RAND, 2019).

Health impact assessments (HIAs): A health impact assessment (HIA) provides decision-makers with sound information about the health implications of policies, programs, and projects as assessed in formal assessments of project impacts (World Health Organization, 2017).

Health in All Policies: A collaborative approach to improve health by incorporating health considerations into decision-making across sectors and policy areas. A Health in All Policies approach identifies the ways in which decisions in multiple sectors affect health and how better health can support the goals of these multiple sectors. It engages diverse partners and stakeholders to work together to promote health, equity, and sustainability, and simultaneously advances other goals such as promoting job creation and economic stability, transportation access and mobility, a strong agricultural system, and improved educational attainment (Rudolph et al, 2013).

Health indicator: A measurable characteristic that describes the health of a population—such as life expectancy, mortality, or disease incidence or prevalence; or that serves as a determinant of health—such as health behaviors, health risk factors, physical environments, or socioeconomic environments (Dannenberg et al., 2011).

Health outcome: A change in the health status of a population, group, or individual that is attributable to a policy or program or to a legal or environmental intervention, whether or not the intervention was intended to change health status. Health outcomes are usually assessed through health indicators (Dannenberg et al., 2011).

Morbidity: The state of being diseased or the incidence of disease in a specific population. Data are usually collected according to the disease type, gender, age, and area.

Mortality: The number of people who have died in a specific population. Mortality rates are generally expressed as the number of deaths per 1000 individuals per year.

Public health: According to the Centers for Disease Control and Prevention Foundation, public health is the science of protecting and improving the health of families and communities through promotion of healthy lifestyles, research for disease and injury prevention and detection and control of infectious diseases. Overall, public health is concerned with protecting the health of entire populations. These populations can be as small as a local neighborhood, or as big as an entire country or region of the world (CDC Foundation, 2017).

Risk management: A process of analytical and management activities that focus on identifying and responding to the inherent uncertainties of managing a complex organization and its assets (FHWA, 2012).

Social determinants of health: The structural determinants and conditions in which people are born, grow, live, work and age. They include factors like socioeconomic status, education, the physical environment, employment, and social support networks, as well as access to health care (Marmot et al., 2008).

Sustainability: A process of change in which "the exploitation of resources, the direction of investments, the orientation of technological development and institutional change are all