Building Bridges Project

Since the 1990s when conversations, projects and research questioned whether the built environment impacted health, we now have an expanded understanding of how community planning and design choices do impact health, safety and prevention; at the micro-level of individual buildings to the macro-level of regional transportation systems. Planning and design present both opportunities and threats to population health outcomes, and as such, there is a need to develop and train the workforce in both the design (urban planning, architecture, transportation engineering, etc.) and health (public health, healthcare infrastructure, etc.) arenas to be able to work collaboratively on the design, creation and maintenance of health-promoting places.

The following abstracts offer background and insights into both this need and possible mechanisms for addressing workforce development at the intersection of health and the built environment. The primary motivation for this work undertaken during Fall 2013 is drawn from the National Prevention Strategy and the Built Environment and Public Health Curriculum, and includes both public health and planning/community design documents. The reports, articles and book chapters abstracted are an initial foundation for the Expert Panel on Public Health and Community Design Cross-Sectoral Workforce Development supported by the September 2012 National Network of Public Health Institutes and the Centers for Disease Control and Prevention, and convened by Faculty in the School of City and Regional Planning at the Georgia Institute of Technology. We welcome suggestions on additional documents that help advance this work to build and strengthen bridges between planning and public health.

MOTIVATIONS

A Model Curriculum for a Course on the Built Environment and Public Health: Training for an Interdisciplinary Workforce  |  Despite growing evidence of the direct and indirect effects of the built environment on public health, planners, who shape the built environment, and public health professionals, who protect the public’s health, rarely interact. Most public health professionals have little experience with urban planners, zoning boards, city councils, and others who make decisions about the built environment. Likewise, few planners understand the health implications of design, land use, or transportation decisions. One strategy for bridging this divide is the development of interdisciplinary courses in planning and public health that address the health implications of the built environment. Professional networking and Internet-based searches in 2007 led to the identification of six primarily graduate-level courses in the U.S. that address the links between the built environment and public health. Common content areas in most of the identified courses included planning and public health histories, health disparities, interdisciplinary approaches, air and water quality, physical activity, social capital and mental health. A model curriculum is proposed that will help bridge the divide between the built environment and public health and enable both planners and public health professionals to value, create and promote healthy environments.

National Prevention Strategy | Many of the strongest predictors of health and well-being fall outside of the health care setting. Social, economic, and environmental factors all influence health. People with a quality education, stable employment, safe homes and neighborhoods, and access to high quality preventive services tend to be healthier throughout their lives and live longer. When organizations, whether they are governmental, private, or nonprofit, succeed in meeting these basic needs, people are more likely to exercise, eat healthy foods, and seek preventive health services. While knowledge is critical, communities must reinforce and support health, for example, by making healthy choices easy and affordable. We will succeed in creating healthy community environments when the air and water are clean and safe; when housing is safe and affordable; when transportation and community infrastructure provide people with the opportunity to be active and safe; when schools serve children healthy food and provide quality physical education; and when businesses provide healthy and safe working conditions and access to comprehensive wellness programs. When all sectors (e.g., housing, transportation, labor, education, defense) promote prevention-oriented environments and policies, they all contribute to health.

Key Public Healthy Documents

Key Planning/Community Design Documents

Abstracted Public Health Documents

(Emphasis regarding public health and planning workforce applicability added by Botchwey.)

  • Accreditation Criteria for Public Health Amended June 2011  |  The Council on Education for Public Health (CEPH) is the independent agency recognized to accredit graduate schools of public health and graduate public health programs operating outside schools of public health. CEPH assists schools and programs in evaluating the quality of their instructional, research and service efforts, and grants accreditation to those schools and programs that meet its published criteria.  Their educational functions derive from the variety of functions performed by school and program graduates in the health and medical care system and in society. All accredited schools of public health must require courses in the following core knowledge areas:
    • Biostatistics
    • Epidemiology
    • Environmental Health Sciences
    • Social and Behavioral Sciences
    • Health Services Administration

CEPH supports schools of public health in offering continuing education courses for the public health workforce.

  • American Public Health Policy Statements  |  The American Public Health Association is the oldest and most diverse organization of public health professionals in the world and has been working to improve public health since 1872. The Association aims to protect all Americans, their families and their communities from preventable, serious health threats and strives to assure community-based health promotion and disease prevention activities and preventive health services are universally accessible in the United States. APHA represents a broad array of health professionals and others who care about their own health and the health of their communities.  APHA members and staff work closely with members of Congress, regulatory agencies and other public health organizations to ensure that public health is priority in the legislative and policy-making process. APHA’s Environment Section recognizes that the complexity of environmental public health issues as well as the emergence of new issues requires a well prepared environmental public health work force and a work force with strong communication skills.  As an organization, they are committed to building capacity to strengthen and support environmental public health services and creating strategic partnerships to foster communication and interaction among stakeholders, especially policymakers.
  • Association of State and Territorial Health Officials Position Statements  |  The Association of State and Territorial Health Officials (ASTHO) represents public health agencies in the United States, the U.S. Territories, and the District of Columbia, and over 100,000 public health professionals these agencies employ. ASTHO members, the chief health officials of these jurisdictions, formulate and influence sound public health policy and ensure excellence in state-based public health practice. ASTHO’s primary function is to track, evaluate, and advise members on the impact and formation of public or private health policy which may affect them and to provide them with guidance and technical assistance on improving the nation’s health.  The members of ASTHO serve as the face and voice of state and territorial public health and are frequently called on by federal and state lawmakers and national organizations to provide input on the development of public health policy. Their leadership, coordination, and position in state government enables them to effect change in public health policy both in their states and on a national level.  ASTHO’s Environmental Public Health policy statement supports a comprehensive approach to environmental public health which includes emphasis on the built environment where the implications of land use, transportation, and housing trends on the public’s health are considered.
  • Confronting the Public Health Workforce Crisis  |  The Association of Schools of Public Health (ASPH) estimates that the public health workforce will face a shortage of more than 250,000 workers by 2020.  As both the U.S. and global populations continue to grow, public health professionals are in high demand.  In an effort to address the shortage of public health workers, ASPH suggests cross-disciplinary training with other fields including medicine, veterinary medicine, nursing, dentistry, law, public policy, social work, business administration, and law.  In addition, ASPH provides the following recommendations:
    • increasing federal funding to support public health professional education,
    • building public health education capacity through offering joint degree programs and cross-disciplinary training,
    • providing grants to state health departments to promote worker training,
    • establishing a U.S. Global Health Service to coordinate U.S. efforts to build a workforce prepared to meet international needs, and
    • institutionalizing a process for periodic enumeration of the public health workforce in order to identify current and future needs.
  • Core Competencies for Public Health Professionals | These are a consensus set of competencies for the practice of public health.  Over 60 percent of state health departments and approximately 30 percent of local health departments report using these competencies.  In addition, the network of Public Health Training Centers funded by the Health Resources and Services Administration is required to use the Core Competencies in their needs assessments and training programs.
  • Framing the Future: The Second 100 Years of Education for Public Health  |  In 1915, public health leaders gathered at Johns Hopkins to create the Welch-Rose Report, a blueprint for public health education in the United States.  In the years since this report was published, the public health profession has evolved to include individuals from diverse educational backgrounds who address a broad range of health-related issues.  Because public health is an evolving field, the Association of Schools of Public Health established in February 2012 a task force to reconsider the role of public health education over the next century.  The task force will consider the following themes:
    • The call for an educated citizenry in public health (Institute of Medicine, 2003)
    • The growing interest in global health and the globalization of public health education and practice
    • The rapid growth of undergraduate public health education and training programs, both within and outside accredited schools and programs of public health and across the undergraduate curriculum, including general education and undergraduate electives
    • The expansion of doctoral degrees in public health
    • The need for clear articulation between undergraduate and graduate education related to public health
    • The growing importance of interprofessional approaches to the education and practice of health professionals
    • Reaffirmation of the vital need for strong connections between academic public health and the practice field
    • Changes in how education is structured and delivered.

The Task Force, including representatives from schools of public health, trade associations, and local public health agencies, intends to rethink education in public health from undergraduate (including two-year colleges) through doctoral levels, consider interdisciplinary and interprofessional perspectives, and respect the changing needs of the national and global workforce.  The anticipated outcome is a more comprehensive framework for public health education and training.

  • The Future of the Public’s Health in the 21st Century  |  The beginning of the twenty-first century provided an early preview of the health challenges that the United States will face in the coming decades. The systems and entities that protect and promote the public’s health, already challenged by problems like obesity, toxic environments, a large uninsured population, and health disparities, must also confront emerging threats, such as antimicrobial resistance and bioterrorism. The social, cultural, and global contexts of the nation’s health are also undergoing rapid and dramatic change. Scientific and technological advances, such as genomics and informatics, extend the limits of knowledge and human potential more rapidly than their implications can be absorbed and acted upon. At the same time, people, products, and germs migrate and the nation’s demographics are shifting in ways that challenge public and private resources. Against this background, the Committee on Assuring the Health of the Public in the 21st Century was charged with describing a framework for assuring the public’s health in the new century. The report reviews national health achievements in recent decades, but also examines the hidden vulnerabilities that undercut current health potential, and that, if not addressed, could produce a decline in the future health status of the American people. The concept of health as a public good is discussed, as is the fundamental duty of government to promote and protect the health of the public. The report describes the rationale for multisectoral engagement in partnership with government and the roles that different actors can play to support a healthy future for the American people. In addition, it is recognized that public health practitioners should be trained in a wide range of disciplines including biological and health sciences, education, epidemiology, and urban planning.
  • Healthy People 2020  |  Established 30 years ago, Healthy People is designed to improve the public’s health by setting 10-year national objectives.  Healthy People 2020includes the following overarching goals.
    • Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.
    • Achieve health equity, eliminate disparities, and improve the health of all groups.
    • Create social and physical environments that promote good health for all.
    • Promote quality of life, healthy development, and healthy behaviors across all life stages.

In order to achieve these goals, Healthy People 2020 outlines four foundation health measures including (1) general health status, (2) health-related quality of life and well-being, (3) determinants of health, and (4) disparities.  The interrelationships among these factors determine individual and population health.  Determinants of health reach beyond the boundaries of traditional health care and public health sectors to sectors that address education, housing, transportation, agriculture, and the environment. By providing multidisciplinary training to public health and non-public health professionals pertaining to social and physical determinants of health, health outcomes can be improved.

  • National Association of County and City Health Officials Position Statements  |  The National Association of County and City Health Officials (NACCHO) represents local health departments across the country.  NACCHO’s mission is to be a leader, partner, catalyst, and voice for local health departments in order to ensure the conditions that promote health and equity, combat disease, and improve the quality and length of all lives.  In order to advocate for public health, NACCHO creates policy statements that support the goals of its members. In their Integration of Environmental Health and Public Health Practice policy statement,  NACCHO endorses the development and enhancement of coordinated training for the environmental public health workforce in public health sciences such as epidemiology, land use planning, and the social and behavioral sciences and similar training for other public health workers in environmental sciences, such as contaminant fate in the environment and food and water biology.  In addition, they believe that many of the social factors that determine health are largely influenced by measures that are often managed by government sectors other than health. The social determinants of health include factors like the quality of schools; socioeconomic conditions, such as poverty; transportation options; public safety; and residential segregation. Therefore, professionals in all of these fields should receive training regarding the health implications of their work.
  • A National Strategy to Revitalize Environmental Public Health Services  |  The field of environmental public health has expanded over the last 50 years to cover many new responsibilities, such as poor air quality, childhood lead poisoning, asthma, and exposures to hazardous chemicals. In addition, new and complex technologies are now available. The implementation of the goals, objectives, and activities described in this plan will enhance our ability to achieve CDC’s vision for the 21st century: healthy people in a healthy world through prevention. Many of the activities described build upon existing or developing efforts or are in the planning stages.  All of these activities will require the stakeholders to build and improve long-term, strategic partnerships and to establish commitments. Implementation of this strategy will help build capacity at all levels of government; support research to translate science into practice; foster the leadership necessary to apply the public health principles of assessment, policy development, and assurance in environmental public health; improve our ability to communicate and market environmental public health services; establish support systems to improve the performance of the environmental public health workforce across the United States; and create viable and long-lasting strategic partnerships among CDC stakeholders.
  • Public Health Accreditation Board, Standards and Measures, Ver. 1  |  The Public Health Accreditation Board helps to promote high performance and continuous quality improvement, recognize high performers that meet nationally accepted standards of quality and improvement, illustrate health department accountability to the public and policymakers, increase the visibility and public awareness of governmental public health, and clarify the public’s expectations of health departments through voluntary accreditation of public health departments.The Public Health Accreditation Board (PHAB) Standards and Measures document serves as the official standards, measures, required documentation, and guidance blueprint for PHAB national public health department accreditation. The Standards and Measures document provides guidance especially for public health departments preparing for accreditation, as well as site visit teams that meet with health department staff and review documentation submitted by applicant health departments. Accredited health departments are encouraged to address gaps in knowledge of core competencies amongst the public health workforce through training opportunities and continuing education.
  • Public Health Solutions Through Changes in Policies, Systems, and the Built Environment: Specialized Competencies for the the Public Health Workforce  |  Throughout the country, public health professionals are helping communities decrease the burden of disease and injury by making it easier to develop a healthy lifestyle. Rather than change the individual behavior of one person at a time, they are influencing public and organizational policies, improving organizational and inter-organizational systems of operation, and enhancing the built environment. Population-based strategies can help state and local health agencies demonstrate their effectiveness at preventing disease and promoting health. Public Health Solutions Through Changes in Policies, Systems, and the Built Environment: Specialized Competencies for the Public Health Workforce explains the policy process as it relates to public health and demonstrates how policies can be created to improve health outcomes.
  • Recommendations for Future Efforts in Community Health Promotion  |  An expert panel met in March 2006 to provide guidance in directing the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) efforts in activities to promote community health. The panel’s recommendations are intended to help NCCDPHP to 1) forge linkages across various sectors of research and practice in community health promotion; 2) enhance current initiatives in health promotion across the nation’s local communities; 3) establish NCCDPHP as a national clearinghouse for efforts in community health promotion; and 4) pioneer a cross-cutting movement in community health promotion.The expert panel offered the following eight recommendations for NCCDPHP to consider pursuing for the next 3 to 5 years:
  1. Enhance surveillance systems to go beyond individual risk factors to include community and social determinants of health.
  2. Promote community-based participatory research by coordinating federal efforts, building capacity within communities, and disseminating research.
  3. Champion a focus on wellness that acknowledges the roles of mental health, spirituality, and complementary and alternative medicine across the lifespan.
  4. Promote training and capacity building that gives the public and private workforce in the area of public health the knowledge, skills, and tools to implement community health promotion approaches and principles, which may include strategies that address sustainability, program evaluation, and socioecological dimensions of health.
  5. Promote an electronic mechanism to facilitate virtual community health promotion with capabilities to share knowledge, disseminate evidence-based programs and promising practices, and promote the dialogue between communities and CDC.
  6. Shift a measurable part of NCCDPHP programs and funding for community health promotion to focus on improving living conditions across the lifespan and engages evidence-based interventions and promising practices in community health promotion.
  7. Maximize the impact of federal resources dedicated to community health promotion through greater collaboration and coordination across federal agencies.
  8. Maintain and improve successful CDC programs with integrated, long-term funding that is sufficiently flexible to meet the unique needs of local communities.
  • The Surgeon General’s Call to Action to Promote Healthy Homes  |  The link between one’s health and living environment is well established.  Many potential health hazards can exist in homes and their surrounding environments. The factors that can influence health and safety in homes include but are not limited to structural quality, indoor air and water quality, chemicals, and resident behavior.  The Surgeon General’s Call to Action to Promote Healthy Homes suggests the following interventions for improving the public’s health and promoting healthy homes: improving indoor air quality by promoting smoke-free housing policies, preventing carbon monoxide poisoning, and mitigating exposure to radon gas; improving water quality; reducing exposure to harmful chemicals through preventing exposure to pesticides, household chemicals, and medicines; improving housing structure and design in an effort to prevent injuries, fires, drowning, suffocation and strangulation, and firearm injuries.  Improving healthy homes requires the talents and skills of traditional and nontraditional housing partners. Each member of a multidisciplinary healthy homes workforce must understand basic housing-related health issues. Healthy and environmentally friendly housing education should be incorporated into training programs for public health, environmental health, business administration, housing professionals, urban planners, architects, and engineers.
  • Who Will Keep the Public Healthy: Educating Public Health Professionals for the 21st Century  |  Many achievements in reducing mortality and morbidity during the past century can be traced directly to public health initiatives. The extent to which we are able to make additional improvements in the health of the public depends upon the quality and preparedness of the public health workforce that is dependent upon the relevance and quality of its education and training. This report recommends multidisciplinary training on the determinants of health including environmental, social, and behavioral factors that affect health outcomes.  In addition, it is suggested that schools of public health should actively collaborate with other academic departments, such as medicine, nursing, education, and urban planning, to holistically address public health issues.

Abstracted Community Design Documents

  • Comprehensive Planning for Public Health:  Results of the Planning and Community Health Survey, American Planning Association  |   The comprehensive plan is a vital tool available to planners for charting the path of a community.  Comprehensive plans, which typically look twenty to thirty years into the future, are complex and in-depth blueprints for the direction of a jurisdiction’s built and social environment.  Increasingly, planners are incorporating public health elements into comprehensive plans; nonetheless, this trans-disciplinary approach is still foreign to many.  This report outlines the results of an American Planning Association survey of planners working in local government.  The survey questioned practitioners on the role of public health within their jurisdiction’s comprehensive plans and sustainability plans, respectively.  Ultimately, 27% of comprehensive plans and only 3% of sustainability plans explicitly addressed public health.  Results also found that local health departments generally had little role in assisting with the creation of health-related portions of local plans, implying that there is a need for greater interdisciplinary communication between public health and planning.  Additionally, within planning education, there may be a need for greater awareness of the connections between sustainability and health.
  • Creating a Healthy Environment:  The Impact of the Built Environment on Public Health, Sprawl Watch  |   Chronic disease is the characteristic health problem of the 21st century; in order to tackle it, planners and health professionals need to expand their definitions of “the environment” to be able to address critical health issues.  This monograph discusses a handful of issues related to health and the built environment, including land use and air quality, urban design as a factor in physical activity, and water quality.  The paper concludes by offering a pair of recommendations for public health professionals and for planners.  It stresses commonalities between the two professions, as well as the need to stay abreast of developments in the other’s field:  “Public health professionals and those in architecture, urban design, and planning have much in common. The challenge now is for each profession to learn from each other how best to address the needs of the communities they serve, to determine what answers each has that the other needs, to create a common language, and to initiate the opportunities to use it.”
  • Does the Built Environment Influence Physical Activity?  |   This paper examines educational programs that link the fields of public health and urban planning for the purpose of training future researchers and professionals, with a focus on the need for interdisciplinary curricula and training.  Universities should develop interdisciplinary education programs to train professionals in conducting the recommended research and prepare practitioners with appropriate skills at the intersection of physical activity, public health, transportation, and urban planning. Ideally, new interdisciplinary programs should be developed with a core curriculum that brings together the public health, physical activity, transportation, and urban planning fields in a focused program on the built environment and physical activity. At a minimum, existing programs in public health, transportation, and urban planning should be expanded to provide courses related to physical activity, the built environment, and public health. Similarly, practitioners in the field—local public health workers, physical activity specialists, traffic engineers, and local urban planners—could benefit from supplemental training in these areas.
  • Driving and the Built Environment  |  The purpose of this study is to examine the relationship between land development patterns and motor vehicle travel in the United States to support an assessment of the scientific basis for and make appropriate judgments about the energy conservation benefits of more compact development patterns. More specifically, the study request, contained in Section 1827 of the Energy Policy Act of 2005 (see Appendix A), calls for consideration of four topics:
    • The correlation, if any, between land development patterns and increases in VMT.
    • An assessment of whether petroleum use in the transportation sector can be reduced through changes in the design of development patterns.
    • The potential benefits of – Information and education programs for state and local officials (including planning officials) on the potential for energy savings through planning, design, development, and infrastructure decisions.
  • Healthy Community Design Expert Workshop Report, CDC  |   The sharing of knowledge by experts experienced in cross-disciplinary collaboration between the planning and public health fields is vital.  Identifying what has worked in the past, and establishing a common vision for the future, will help coordinate efforts and solidify priorities.  This paper is based on a meeting of experts held at CDC in 2009 to “discuss raising awareness about the health impact of community design decisions.”  The expert panel was convened following concern about the lack of a common language between planners and public health practitioners, as well as a lack of synergy between the two disciplines’ activities.  CDC was seen as possessing the natural potential for a leadership role in prompting discussion on these problems.  The paper emphasizes “inclusion of public health impact in the training of built environment professionals” as well as “recognition by public health professionals that collaborating with architects, planners, transportation planners, and developers is key to advancing healthy community design”.
  • The Impact of the Built Environment on Community Health:  The State of Current Practice and Next Steps for a Growing Movement, The California Endowment  |  As coordination between practitioners in the fields of public health and planning has begun to blossom, California has frequently become a site of particularly exciting collaborations.  This report outlines issues in health and the built environment and, notably, is partially drawn from interviews with those working in these fields.  Most relevantly, it explicitly mentions a number of training materials that have been able to bring the two disciplines together in California (p 17-18).  Recommendations, based on the professional interviews, underscore the need for better cross-disciplinary training; many practitioners particularly desired greater access to information, in the form of a clearinghouse, a best practices repository, sample planning documents, etc.  One idea to unite these disparate needs was “a central resource center, with expertise in public health, land use development, design, and planning.”
  • The PAB Accreditation Standards and Criteria dated April 14, 2012 | The Planning Accreditation Board (PAB) ensures high quality education for future urban planners. The Accreditation Standards and Criteria document highlights the scope and quality of minimum educational outcomes for planners. They include General Planning Knowledge (purpose and meaning of planning, planning theory, planning law, human settlements and history of planning, the future, and global dimensions of planning), Planning Skills (research, written, oral and grpahic communication, quantitative and qualitative methods, plan creation and implementation, planning process methods, leadership), and Values and Ethics (professional ethics and responsibility, governance and participation, sustainability and environmental quality, growth and development, and social justice). There are also Areas of Specialization and Electives that are built on top of general planning foundation and add significantly to the basic planning knowledge, skills and values, and explore other areas such as exposure to other professions, specializations, and emerging trends and issues.
  • Planning in America:  Perceptions and Priorities, American Planning Association  |  Despite a seeming upsurge in opposition to planning as a concept, evidence shows that, to the contrary, a majority of Americans are interested in planning as a way to ensure the security and health of their communities.  This report is the result of a survey conducted by the APA seeking the public’s perceptions on various issues of planning, particularly their vision of how (and how much of it) should be conducted.  The study found that people are concerned and displeased with the direction of the country, and thus of their communities, and that they look positively upon planning as a potential avenue for restoring prosperity.  Rather than seeking an impersonal and technocratic variety of planning, the majority of those surveyed desired to be involved in the planning process.  Many features rated as “high priority” for an ideal community had direct public health implications, including the ability to age in place, walkability, and energy-efficient homes. 
  • Sorting out the Connections Between the Built Environment and Health:  A Conceptual Framework for Navigating Pathways and Planning Healthy Cities, Journal of Urban Health  | Since World War II, the fields of planning and public health have gradually grown further and further apart from each other.  To achieve best results for health and the built environment, empirical data needs to be collected in the context of a framework incorporating perspectives from both disciplines.  This paper offers up a new conceptual framework called “Social Determinants of Health and Environmental Health Promotion”.  This model of public and environmental health explicitly incorporates facets of the built environment.  The authors note the importance of health impact assessments in bringing public health and planning practice better into sync with one another, but above all, “we need to reinvigorate the historic collaborative link between urban planning and public health professionals, and together conduct informed science.”
  • Training the Next Generation to Promote Healthy Places, in Making Healthy Places: A Built Environment for Health, Well-Being, and Sustainability  |  Achieving the goal of healthy places will require a new generation of public health and planning leaders equipped to seamlessly integrate skills, theory, and tools from both fields. Much of the current activity in the study of the built environment and health has focused on establishing an evidence base for links or associations between community design and a variety of disease states or behaviors. There is now increasing recognition that similar innovation is needed  in the practice of healthy design and the training of new leaders. Training programs to prepare a new generation of leaders will need to focus on (1) developing a shared language for urban planning and public health, (2) expanding support for multidisciplinary research, and (3) formalizing interdisciplinary training for built environment and health. Additionally, a set of core competencies must be established that bridge the two disciplines. Model curricula for integrated courses in urban planning and the built environment and health are available online. Further development and real-world evaluation of interdisciplinary training for new leaders who can promote healthy places is ongoing.