A Design Protocol for Mobilising Healthy Living 2

Health + Mobility

A DESIGN PROTOCOL FOR MOBILISING HEALTHY LIVING 2

Health + Mobility A design protocol for mobilising healthy living

This report is a product of a research collaboration between Arup, BRE, University College London and AREA as part of Arup’s Global Research Challenge 2015.

RESEARCH TEAM

Arup Laurens Tait, Project Director Ikumi Nakanishi, Project Manager Paul Grover, Associate Director Thomas Paul, Planner Kim Cooper, Planner

BRE Helen Pineo, Associate Director for Cities

University College London Professor Nick Tyler, Chadwick Chair of Civil Engineering Dr Xenia Karekla, Research Associate at Centre of Transport Studies

AREA Research / Perkins + Will David Green, Principal Lydia Collis, Architect/Urban Designer Ingrid Stromberg, Knowledge Manager

Acknowledgments The authors acknowledge the following people for providing valuable input:

Amanda Sacker, Institute of Epidemiology & Health, UCL Jenny Mindell, Institute of Epidemiology & Health, UCL Marcella Ucci, The Bartlett School of Environment, Energy & Resources, UCL Jemima Stockton, Institute of Epidemiology & Health, UCL Adriana Ortegon, Department of Civil, Environment & Geomatic Engineering, UCL Catherine Garnell, Assistant Chief Executive, Liverpool City Council Martin Thompson, Policy Officer, Liverpool City Council Ian Williams, Research Officer, Liverpool City Council Basak Alkan, Urban Designer for the Baton Rouge Project, Perkins + Will Health + Mobility 3

Health + Mobility A design protocol for mobilising healthy living 4

Arup is a global firm of designers, engineers, BRE is an independent and impartial, research-based planners and business consultants providing a consultancy, testing and training organisation, diverse range of professional services to clients offering expertise in every aspect of the built around the world. Arup is renowned for its specialist environment and associated industries. We help expertise in multiple disciplines encompassing all clients create better, safer and more sustainable aspects of the built environment. products, buildings, communities and businesses - and we support the innovation needed to achieve Arup is dedicated to an interdisciplinary approach this. The BRE Trust funded a three-year research that brings its full complement of skills and project to explore the links between urban knowledge to each project. Since its inception in environments and health and develop indicators to 1946, it has been the creative force behind many of support policy and decision-makers. the world’s most innovative and sustainable designs.

www.arup.com www.bre.co.uk

University College London is one of the world’s AREA Research is an independent, non-profit top ten universities. The Department of Civil, organisation operating parallel to Perkins + Will. Environmental and Geomatic Engineering (CEGE) AREA is a platform that connects the design leads research programmes that seek to optimise professions, academia, and research institutions, built environments for health such as: the Pedestrian supporting innovative research to improve the Accessibility and Movement Environment Laboratory built environment, and by extension, the lives of its (PAMELA) programme and the Healthy Infrastructure inhabitants. AREA and Perkins + Will together bring Research Group. By working with UCL’s partnership a depth of knowledge across practices including of 25 hospitals, these groups combine cutting edge healthcare, higher education, science + technology, research in both health and infrastructure to create a city planning and transportation. healthier environment.

www.ucl.ac.uk www.arearesearch.org Health + Mobility 5

Contents

Executive Summary 7

Introduction 8

Urban Mobility Impact on Health 10

Health + Mobility Framework 18

Design protocol 26

Applying the Design Protocol 30

Knowledge Quarter, Liverpool UK 34

Baton Rouge, Louisiana US 50

Way forward 70

Glossary 75

Appendix 76

A. Existing tools and methodologies 77

B. Data sources 78

C. References 79

Biographies 87 6 Health + Mobility 7

Urban living requires significant being designed, city leaders and Executive transport and mobility infrastructure design teams should consider health to enable people to travel for school, at the earliest stages. Cost-benefit Summary work or leisure activities. Transport analyses of different options must affects health and wellbeing through take into account the full range of many pathways, resulting in a myriad benefits that active transport and high of positive and negative impacts. quality public transport systems have Transport offers Transport infrastructure contributes been shown to achieve. to greenhouse gas emissions and one of the greatest influences the environment in a Planners, engineers and design number of ways. It can be the source professionals are increasingly opportunities for of both solutions and problems around aware of the relationship between some of society’s biggest challenges transport and health. Yet there improving public including climate change, increasing are still challenges to overcome rate of chronic diseases and rising in implementing high quality health. healthcare expenditure. transportation infrastructure as cities and service providers require Transport is a major contributor to a convincing business case to invest. 3.7 million deaths globally from Transport and design professionals ambient air pollution1, and has an need to work with public health annual count of 1.3 million deaths specialists and local communities to from road accidents and 78.2 million gather data about priorities and jointly non-fatal injuries requiring medical develop solutions. care2. The transport sector is also a major contributor to climate change, There are many successful examples responsible for 23% of global carbon of strategic integrated planning emissions3. It is possible to design for transport and mobility that a low carbon transport network achieve wider social, economic and powered by sustainable energy with environmental objectives. These benefits for health and wellbeing, projects should be used as the for people, the economy and the evidence-base to inform economic environment. However, the legacy of appraisals that go beyond traditional carbon based technologies and car- methods. Cost savings may occur centred infrastructure will be with us across multiple city agencies or for decades to come and continues to national departments. A more be included in the design of new cities joined-up approach with strong and communities. leadership will be required to capture opportunities to improve urban A city’s transport network and infrastructure to address complex mobility infrastructure includes challenges like health. everything from trains and buses to street lighting and benches. Studies This design protocol offers one have demonstrated that a mixture of approach for using city data to traffic reduction measures, coupled understand local health and with supportive infrastructure for transport issues and opportunities. pedestrians, cyclists and public This evidence can inform designs, transport, can result in benefits to specifications and supplier briefs local economies, social networks, for better transport and mobility health and the environment4, 5, 6. An infrastructure that will support people, upfront cost to improving existing the economy and the environment. infrastructure is significantly compensated through savings from reduced injuries and decreased rate of health deterioration. Where new transport systems and streets are 8

The body of knowledge that describes The research assessed current Introduction the effects of integrated transport studies and literature, best practice planning on citizens, the economy case studies and current tools and and the environment has grown to methodologies in an attempt to a substantial size. Research shows comprehend the links, application Researching health that multiple physical and mental and assessment methods of mobility health aspects are affected by the infrastructure and health. The impacts and urban accessibility and availability of active outcome was a framework which and non-active transport modes in structures the relationship between mobility door-to-door journeys. A recent report mobility infrastructure and health combining evidence from over 500 outcomes alongside a design protocol academic papers shows that 9% of which utilises the framework through premature deaths worldwide are data. attributed to physical activity7 and cities designed for activity benefit Both the design protocol and from increased employment, safety, framework have been developed to private investment and health be applicable to any planning, urban outcomes8. design or transport project interested in improving the health and wellbeing Yet despite the growing body of of the community. They are flexible knowledge on the interdependence enough to use existing and available between health and transport, datasets along with data from sensors governments and planning bodies and other connected devices to do not seem to be aware of (or able provide evidence for decision making to exploit) the opportunities their on healthy mobility infrastructure. projects offer for the improvement of health outcomes and reduce health The flexibility and application of the inequalities. design protocol and framework was tested on two project case studies This research aims to help decision- in Liverpool, UK and Baton Rouge, makers to deliver better mobility Louisiana, USA during the research. infrastructure in their city by While both project case studies are understanding its relation and impact in areas with a strong interest in on health and wellbeing. improving the health of the local community, the design protocol and AIM framework revealed different issues Help decision-makers to deliver better and opportunities. mobility infrastructure in their cities by understanding its impacts on health, This research is the outcome of a well-being and other factors. collaboration between Arup, BRE, HOW UCL and AREA as part of Arup’s Develop a clear framework that Global Research Challenge 2015. The structures the relationship between Global Research Challenge is part of mobility infrastructure and health Arup’s annual research investment outcomes. and aims to nurture open innovation Develop workﬂow and process that around prioritised topics through uses data to guide transport collaborations between academia, decision-making for the best health outcomes. industry partners and Arup’s employees. OUTCOME The result is a design protocol and supporting framework which use data to help design mobility infrastructure for health outcomes through evidence-based decision-making. Health + Mobility 9

This report provides an overview of the research with particular focus on the health and mobility framework, design protocol and its application on project For this project, the following key case studies. The report contains the following chapters and appendices: definitions have been used:

MOBILITY URBAN MOBILITY IMPACT ON HEALTH Mobility describes the ability of Why health and mobility? people to move between places and the ease with which they reach HEALTH + MOBILITY FRAMEWORK activities, such as accessing essential How can we make sense of the complex relationship between health and facilities, communities and other mobility? destinations that are required to support a decent quality of life and DESIGN PROTOCOL a resilient economy. Mobility is How can we design for health through mobility infrastructure? affected by transport infrastructure and the services that facilitate these APPLYING THE DESIGN PROTOCOL movements9, 10. What does the design protocol look like when applied on real case studies? MOBILITY INFRASTRUCTURE The physical environment built by WAY FORWARD humans, that includes bridges, roads, How can the health and mobility agenda be taken forward? railways and transit hubs, together with the natural environment, compile APPENDIX mobility infrastructure9. What are the existing tools/methodologies? What are currently available data sources? HEALTH References Health is described by the World Health Organization as: “Health is a state of complete physical, mental and social well-being and Increasing transportation investments not merely the absence of disease or infirmity.”11 for projects that are focused on poor, This project focuses on human health in OECD countries. elderly, people with disabilities and other vulnerable populations, is critical for health at a national level as it can reduce risk of obesity, cancer, mental health disorders, asthma and heart disease12. 10

1 Urban Mobility Impact on Health Health + Mobility 11

What are the key relationships between health and mobility? 12

TRENDS AND DRIVERS and diabetes16. Among other factors, Urban Mobility Transport and mobility are significant the risk factors for these diseases determinants of health and wellbeing include physical inactivity and being Impact on in urban areas. The way that we move overweight or obese16. In 2012, about cities on a daily basis can impact noncommunicable diseases were Health our health in many ways, both positive responsible for 68% of global deaths and negative. Even when we are not and more than 40% of these were travelling, the impacts of transport premature17. The impacts of these Transport plays a key infrastructure such as air and noise diseases have social, economic and pollution can affect our health. human costs. role in global health The global epidemics of obesity and The shift toward people living longer challenges diabetes have achieved significant with chronic conditions is resulting in media coverage with emphasis on growing costs for health care services sedentary lifestyles amongst other (see Fig 3). In the United States, causal factors. In the UK, 62% of 86% of all health care spending in adults are overweight or obese13, 2010 was used for the treatment of and nearly 4 million adults suffer people with chronic conditions19. from diabetes14. The cost of treating The World Health Organization diabetes-related conditions rose to recognises the complexity of £10 billion in 2011-2012 in the UK15. these challenges and the need Obesity and diabetes are not the only to involve multiple stakeholders concerning health conditions brought across government agencies and the on by our modern lifestyle. development industry to produce urban environments that contribute Noncommunicable diseases, also to preventing disease20. The answers known as chronic or lifestyle diseases, will not come from healthcare are rising globally (see Fig 1 and Fig practitioners alone; a whole-of-society 2). The four main chronic diseases are: approach is needed. cardiovascular diseases (such as heart attacks and stroke), cancers, chronic A cross-sector effort to produce respiratory diseases (like asthma) healthy environments is required

60% 100%

Non-communicable diseases 90%

50% High income countries 80%

Upper middle income countries 70% 40%

Communicable diseases, 60% maternal, neonatal and World nutrition disorders 30% 50% Lower middle income countries 40% Percentage of total DALYs Percentage of total deaths 20% 30% Low income countries Injuries 20% 10% Projections Baseline scenario 10%

0 0 1990 1995 2000 2005 2010 2000 2005 2010 2015 2020 2025 2030

Fig 1: Global burden of diseases shown Fig 2: The increasing development of through causes of loss of healthy life years18. noncommunicable diseases shown through resulting deaths18. Health + Mobility 13

because many factors influence our health and wellbeing. Healthcare 10% services and genetics are only part of a bigger picture of complex interactions between our lifestyle, environment and individual characteristics that 9% determine health22. These wider OECD average expenditure on health care factors are known as the ‘social determinants of health’. Transport and 8% mobility infrastructure fall into this category as do education, housing, employment and many other aspects Percentage of GDP of our lives. Studies have tried to 7% estimate the extent to which these environmental domains influence our health and wellbeing, resulting in the 6% values ranging from 45% to 60%22. 2001 2003 2005 2007 2009 2011 2013 Year Inequalities also strongly influence health. There is a social gradient in Fig 3: OECD total health expenditure as a percentage of GDP21. health with the poorest people dying earlier and suffering longer from disability than wealthier people23. This is starkly evident in cities where the life expectancy gap in different neighbourhoods can range widely, for example from 8 years in New York City24 to 15 years in Glasgow25. In cities, deprived neighbourhoods may suffer from multiple inequalities, such as poor quality housing, transport, and schools. These challenges can be self- reinforcing and are associated with poor health.

It is clear that the social determinants of health are very important, yet they are governed by many different policy areas outside of health. The diagram shown in Fig 4 translates this concept for urban planners by demonstrating how the built and natural environments interact with social and economic factors to influence health. The diagram shows how transport and mobility are linked to each section of this rainbow, with the potential to positively impact our health and wellbeing every day. Fig 4: The Health Map: Health determinants relating to the built environment26. 14

PHYSICAL ACTIVITY environmental and safety benefits8. increasing a city’s resilience to climate One significant way to improve change impacts to improving its population health is to increase Experts estimate that a strategic, long- competitiveness. Accessibility and opportunities for physical activity term approach towards increasing availability of active and non-active in everyday activities such as physical activity may be more cost- transport modes can promote exercise, commuting. In addition to reducing effective than other initiatives that reduce inequalities and increase the risk of chronic diseases, physical promote exercise, sport and active connectivity. This also has a positive activity helps to: leisure pursuits in a short term32. impact on social cohesion, education • Prevent excess weight gain27 City leaders and decision-makers and employability. • Improve mental health28 may focus on the short-term costs • Improve quality of life29 incurred in building health promoting IMPROVING HEALTH THROUGH • Reduce the risk of premature environments. The long-term costs are TRANSPORT death4. far higher and will affect individuals, The global trend of rising rates employers and society at large. In of chronic diseases coupled with Although the health and wellbeing addition to the health costs, cities with low levels of physical activity benefits of regular physical activity low levels of physical activity have demonstrates the size and complexity are clear, half of the British population lower productivity – losing on average of the challenges facing healthcare does not meet recommended levels one week per working citizen per providers. Public health practitioners of physical activity30. In the United year33. will not be able to change behaviours States one in four adults report that through healthy eating and exercise they do not engage in any physical There are many different approaches programmes alone. A fundamental activity outside of their job31. Recent in transport policy and urban design shift in the way we design cities and research has demonstrated that cities to encourage physical activity transport infrastructure is required that promote physical activity through through public transport use and to tackle these problems. Transport transport and mobility infrastructure active transport (usually walking agencies, planners and infrastructure and dedicated programmes enjoy and cycling). These can also have providers can create walkable significant economic, social, health, multiple co-benefits ranging from neighbourhoods by reducing distances

City-wide transport infrastructure improvement -Bogotà, Columbia

Decentralisation of urban planning The transport system improvements powers in the mid-1980s led to a have increased physical activity34 radical transformation of transport and have positively impacted income infrastructure in Bogotà, one of levels for those living near stations, the densest cities in the world. A particularly lower and middle- city-wide Bus Rapid Transit (BRT) income groups6. People living near system, TransMilenio, with dedicated TransMilenio stations were more lanes was constructed alongside an physically active35, 36, walking around extensive cycle route, Ciclorutas, in 30 minutes or more per day37. The 2000. These interventions aimed to cycling system, in combination with reduce air pollution, traffic congestion street design, route connectivity and private car dependence. In and proximity to a ciclovia path, also addition, the city upgraded pedestrian encouraged physical activity and infrastructure and banned parking on resulted in people walking on average sidewalks. 150 minutes per week or more37. Health + Mobility 15

Prioritising cycling and walking -Paris, France

In 2002 Paris introduced Quartier Paris’s bicycle-sharing system, Vélib, Verts (Green Neighbourhoods) to was introduced in 2007, aiming to improve active transport which reduce traffic congestion, air and included: widening sidewalks, noise pollution, and to revitalise the reducing the speed limit to 30km/h, city’s public spaces. City leaders paid and eliminating through-routes to attention to lessons learned from slow traffic. Other measures across the other bicycle sharing schemes and city included banning free parking, used a combination of measures to giving priority to pedestrians on ensure Paris’s system would be a a network of shared streets, and success, such as: a large and dense converting roadways and parking network (400 Km), ease of use, and spaces into pedestrian/cycle paths. security deposits. There are estimated These improvements led to a 20% to be 70,000 – 145,000 trips per day reduction in private vehicle use; a 9% on Vélib bicycles40. reduction in carbon emissions and a 25% reduction in road injuries72.

Safer intersections for cyclists in Denmark -Copenhagen, Denmark

In an effort to reduce cyclist and Evaluations show that the intervention moped accidents, the Municipality of acts as an effective ‘warning signal’ Copenhagen transformed signalised and affects road safety if there is one crossings by applying blue cycle lanes. painted lane. Single lane crossings These blue painted lines highlight showed a 32% reduction in road the area of conflict between motor accidents and a 34% reduction in vehicles and cyclists and provide a injuries. However, intersections where dedicated lane for cyclists through the two to four blue cycle crossings were intersection. marked, have shown an increase in road accidents of approximately 30%. The first blue crossing was created in (45) This indicates that consideration 1981, growing to 65 by 2003. They is required when identifying the are now used throughout Denmark, appropriate arrangement for as well as in other countries such as intersection design. Researchers Sweden and in the US. The number note that safety is increased with a of blue lanes varies between one and combination of appropriate lanes, four lanes. signs and signals. 16

between destinations and improving litter, graffiti and dog mess were 50% zones, road causalities fell by 42% cycling and pedestrian facilities. This less likely to be physically active, and from 1986 to 2006 with children and will encourage physical activity and 50% more likely to be overweight or cyclists being the main beneficiaries reinforce social support networks that obese41. City managers need to pay of reduced causalities4. This policy has are important for health38. attention to environmental cues of risk significant financial benefits as well. In and insecurity such as abandoned or Hull, England the city estimated that The details count when it comes to run-down buildings. Adequate street 200 serious and 1000 minor injuries creating infrastructure that supports lighting and passive surveillance can were prevented during an 8 year walking and cycling. Pedestrians help people feel more secure. Parents’ period after introducing 20 mph zones feel safer and are more likely to perceptions of safety (from crime or on residential roads. The cost savings walk when there are sidewalks, traffic) are associated with the extent exceeded more than 10 times the frequent crosswalks on busy roads, of children’s participation in physical initial £4 million set-up cost4. good wayfinding signage and street activity42. Transport planners need to lighting39. For cyclists, cycle lanes or take all of these needs into account Public transport networks can be shared-use paths feel safer39. Women and encourage local communities, categorised as a form of active are twice as likely as men to fear for including minorities and under-served transportation because people usually their safety when cycling and they are populations, to participate in all walk to or from stops and stations. more likely to cycle on off-road paths stages of planning to ensure transport Improving public transport services, than busy roads40. Cyclists also need infrastructure will benefit everyone12, especially in low-income and minority secure places to store bicycles at the 43. communities, can improve wellbeing end of journeys. through greater access to social One intervention that is widely shown networks and employment. Locating People’s perceptions of safety and to improve safety for all street users major commercial and institutional crime within a neighbourhood is the 20 mph zone. According to the activity centres in highly accessible influence the amount of time spent World Health Organization, this is the areas, increasing frequency of outdoors walking or cycling. Results recommended speed limit for built-up services, and reducing travel times from a European cross-sectional areas with shopping streets, schools can all help improve public transport survey found that respondents from and residential streets44. In areas use and the associated social and residential areas with high levels of of London that introduced 20 mph economic benefits. Infrastructure

Reducing traffic emissions -London, England

In 2003, the central London Transport for London (TfL) estimates Congestion Charge was introduced to that the following reductions were improve congestion, car journey time achieved in the first few years of reliability, goods and services delivery, the scheme: 8% reduction in road and bus services64. The current daily traffic emissions of nitrogen oxides

charge of £11.50 per vehicle (between (NOx); 7% reduction in emissions

07:00 and 18:00 on weekdays) was of fine particulate matter (PM10); applied within specified areas of and 16% reduction in emissions of 65 central London and has resulted in carbon dioxide (CO2) . TfL also credit fewer cars, safer streets and cleaner the Congestion Charge with a 27% air. reduction in vehicles (80,000 fewer cars per day) and a 66% increase in The Congestion Charging Zone has cycling in the charging area since the been credited with a 50% increase in scheme was introduced66. bus usage (2002 to 2003)65. Health + Mobility 17

such as shelters at bus/tram stops Creating an environment where people and convenient ticket payment also improve service uptake. actively choose to walk and cycle as part of

NEGATIVE HEALTH IMPACTS OF everyday life can have a significant impact TRANSPORT Car ownership is increasing globally on public health and may reduce inequalities year by year, with new vehicle registrations rising by almost 6% in health. It is an essential component of a in the EU and 9% in the UK (2013 to 2014)46, and nearly 3% in the strategic approach to increasing physical USA (2012 to 2013)47. Private cars and other motorised vehicles affect activity and may be more cost-effective than health through air pollution, noise and traffic injuries with additional indirect other initiatives that promote exercise, sport impacts resulting from car-centred 32 development patterns. and active leisure pursuits .

Road injuries are the eighth-leading of city streets and transit waiting Young and older residents of streets cause of death globally and they are areas52. with light traffic reported twice as the biggest cause of death for people many acquaintances and friends on aged 15 to 252. Poor traffic policies Transport systems are a great their street than residents of streets and infrastructure, such as unsafe contributor to air pollution through with heavy traffic60, 61. In addition, pedestrian crossings can lead to vehicle emissions. Ambient air heavy traffic results in a feeling of accidents. Human behaviours, such pollution was linked to 3.7 million ‘reduced ownership’ of streets, which as excessive speeding and alcohol premature deaths globally in 201253 can be prevented by better street consumption, are responsible for 90% and 40,000 deaths annually in the design, promoting socialising among of road fatalities48. Pedestrians are UK54. Vehicle emissions contribute residents38. A meta-analysis on the the most likely road users to be killed substantially to air pollution through links between social relationship in road accidents38 and chances for nitrogen oxides (NOx), particulate and mortality found that the quality their survival decrease with increasing matter (from road dust, brake linings and quantity of social relationships vehicle speed. Roads with speed limits and tire wear) and volatile organic influences mortality to the extent of 20 mph are the safest, with only compounds55, 56. Air pollution, amongst comparable with well-established 5% of pedestrians likely to die from tobacco smoking, allergens and risk factors such as smoking and collision with a vehicle at this speed. occupational risks, is considered alcohol consumption62. Different In collisions at 30mph, about half of a primary risk factor for chronic transport modes can also aid the pedestrians die, with fatalities rising respiratory conditions and is closely social interactions and cohesion to 95% at 40mph49. associated with increased incidences through direct contact alongside the of cancer57, 58. possibilities of people meeting and Areas where residents tend to drive socializing. less and rely on alternative modes People living near major roads with have lower traffic fatality rates heavy traffic experience constant Research has suggested correlations than more automobile dependent traffic noise and can suffer from sleep between travel mode and stress levels communities50. Research shows that deprivation and annoyance as well with several studies indicating that presence of more pedestrians and as stress and depression59. Traffic commuting by automobile generally cyclists on the street is associated noise can be reduced through quieter appears to be more stressful than with a reduced risk of motor vehicle road surfaces such as porous asphalt travelling by other modes. This collision, suggesting that motorists which is considered to reduce noise stress appears to be attributable to drive more cautiously due to by 4–8 dB, roughly the same effect as factors outside the driver’s control increased awareness of high levels reducing traffic volume by half. including traffic delays, unpredictable of pedestrian/cycling activities51. behaviours of other drivers, anxiety Increased walking, cycling and public Heavy traffic is also linked to and time pressures56, 63. transport appears to increase overall community severance, reduced security of places and reduce crime social interaction and inability to rates by providing passive surveillance access social services and support. 18

2 Health + Mobility Framework Health + Mobility 19

How can we make sense of the complex relationship between health and mobility? 20

The health and mobility framework regular journeys. The built Health and was set up as part of this work to help environment is focused on mobility structure the complex relationship infrastructure (i.e. hard infrastructure) Mobility between the built environment in particular. It is acknowledged, (focusing on mobility infrastructure) however, that softer measures Framework and health. The framework aims to including policy and education review all transportation modes and to programmes also have an important capture their numerous relationships role in how the built environment can Defining and with health. This was done to affect health. understand the broad and overall organising the relationship rather than concentrating The area of affordability is not exclusively on active transport, on directly included in the framework relationship between which much recent research has at this stage but it is recognised that focused, or the impacts of safety or transportation can create or reduce health and mobility emissions which have often been financial burdens, particularly for the only health related outcomes lower-income households where considered in planning decision transportation expenditures comprises making. a large percentage of household budgets. A reduction of financial The framework was designed and burden can allow money to be better populated through a literature review. spent on purchasing healthy food and This provided references of the medical care55. individual steps or connections, and revealed the overall relationships STRUCTURE of mobility infrastructure to health. The health and mobility framework This approach was undertaken as is based on the determinants of the determinants of health exist in health: environmental and lifestyle a complex system, which can make and behaviour factors. The third direct causality of specific built determinant, personal factors, (i.e. environment elements especially hard genetics) was not considered as part to determine. of this framework.

For this project, mobility for transport From the determinants of health, (as opposed to recreation) has been health impacts were identified which the key interest as it provides a huge then lead to a health outcome. An opportunity for improving public overview of the structure can be seen health through the population’s in Fig 5.

Fig 5: High level structure of the health and mobility framework based on health determinants Health + Mobility 21

MOBILITY INFRASTRUCTURE AND Environmental factors refer to the Personal factors refer to the users’ MODAL CHOICE conditions created which can be actual characteristics including gender, The relationship of the determinants and/or perceived. This differentiation age and socio-economic status as of ‘environment’ and ‘lifestyle and is made as studies have found that mentioned above. The cultural factors behaviour’ to health can be broadly an individual’s perception of the refer to the societal characteristics, categorised in two ways: environment influences modal choice attitudes and values which affect • Environment impacting health even though there may be little the individual’s behaviours. This directly (i.e. air pollution) association between perception and includes broader values to the specific • Environment impacting health reality (objective environment)67. attitudes around transport modes through influencing lifestyle and which can differ between countries. behaviours (i.e. modal choice). These environmental conditions fall under the following interrelated main All three of these factors influence In the health context, the substantial themes listed below: each other. research on the relationship • Safety between automobile oriented urban • Comfort It is important to note that the development and inactivity has • Attractiveness individual’s decisions that influence created a strong interest in modal • Directness mobility choice are quite complex choice. Alternatives such as public • Access and have been simplified for the transport or active transportation • Coherence framework. An international literature (walking and cycling) contribute review of over 300 studies, policies, to physical activity as they require These environmental factors are models and reports on encouraging physical exertion to get from one of particular interest as they relate walking and cycling modes concluded place to another. Accordingly, directly to the design of mobility that our understanding of how users a number of studies have been infrastructure. While each of these respond to various interventions undertaken to ascertain how to create themes is relevant to each of the is limited. While there is a large this modal shift and what motivates transport modes, the hierarchy of body of research available, complex the public to walk, cycle or take public relevance, or priority, is dependent psychological, social and economic transport. on the characteristics of the factors make it difficult to pinpoint transportation mode as well as the the impact of various interventions. The framework currently identifies users. An example of this can be seen Improved study designs and three key factors which influence the where safety becomes a large aspect datasets are required to isolate the link between mobility infrastructure of a parent’s decision whether to confounding factors67. and modal choice: allow their children to walk or cycle68. • Environmental Conversely for the elderly, coherence • Personal (i.e. wayfinding) can play a bigger role • Cultural. in deciding to walk69. 22

Framework structure

For clarity, the framework begins with the built environment on the left and DETERMINANTS OF HEALTH HEALTH IMPACT HEALTH OUTCOME health outcomes on the right. The steps in between are categorised according to the way the built environment affects health, directly or through lifestyle and behaviours ENVIRONMENT LIFESTYLE & BEHAVIOUR (i.e. travel behaviour or mobility choice) and the health ‘impact areas’. Factors which influence certain relationships are introduced including MOBILITY INFRASTRUCTURE MOBILITY CHOICE the ‘conditions’ created or provided by mobility infrastructure and its performance. CONDITIONS PERCIEVED | ACTUAL Mobility infrastructure covers three WALKING FOR TRANSPORT EXPOSURE TO NOISE ILLNESS & CONDITIONS components of: SAFETY • Links - segments of a route MODES CYCLING FOR TRANSPORT EXPOSURE TO AIR POLLUTION FUNCTION & QUALITY OF LIFE • Intersections - crossing of links and COMFORT modes DIRECTNESS • Routes - comprised of links and WALKING PUBLIC TRANSPORT USE PHYSICAL ACTIVITY MORTALITY crossings to form a journey from ACCESS origin to destination. COHERENCE These components are applicable for CYCLING CAR FOR TRANSPORT USE ACCIDENTS & INJURIES each transportation mode. PUBLIC TRANSPORT SOCIAL CONTACT The framework currently identifies the following areas in which transport is PERFORMANCE considered to impact health directly PRIVATE MOTORISED VEHICLE FRUSTRATION and indirectly: NETWORK RELIABILITY • Exposure to noise NETWORK EFFICIENCY • Exposure to air pollution VEHICLE EFFICIENCY • Physical activity • Accidents and injuries • Social contact • Stress/frustration

The framework only represents one way of structuring the complex and multi-directional relationship between the built environment and health. Health + Mobility 23

DETERMINANTS OF HEALTH HEALTH IMPACT HEALTH OUTCOME

ENVIRONMENT LIFESTYLE & BEHAVIOUR

MOBILITY INFRASTRUCTURE MOBILITY CHOICE

CONDITIONS PERCIEVED | ACTUAL WALKING FOR TRANSPORT EXPOSURE TO NOISE ILLNESS & CONDITIONS

SAFETY

MODES COMFORT CYCLING FOR TRANSPORT EXPOSURE TO AIR POLLUTION FUNCTION & QUALITY OF LIFE

DIRECTNESS WALKING PUBLIC TRANSPORT USE PHYSICAL ACTIVITY MORTALITY ACCESS

COHERENCE CYCLING CAR FOR TRANSPORT USE ACCIDENTS & INJURIES

PUBLIC TRANSPORT SOCIAL CONTACT

PERFORMANCE PRIVATE MOTORISED VEHICLE FRUSTRATION NETWORK RELIABILITY

NETWORK EFFICIENCY

VEHICLE EFFICIENCY 24

The health and mobility framework WALKING Measures, can be used via indicators to allow • Percentage of land used for planners, designers and decision commercial purposes by Indicators and makers to determine, assess and neighbourhood monitor how mobility infrastructure • Percentage of roadways with Data is affecting health-related behaviours sidewalks and outcomes. Further detail on the • Percentage of sidewalks with shade process of using the framework and tree coverage Evidence-based indicators to aid evidence-based • Number of pedestrian prioritised decisions in designing for health crossings design through the outcomes through mobility can be • Average crossing time found in Chapter 3: Design protocol. • Average volume of daily framework pedestrians at counting stations Indicators have been included as • Distance covered by 15minute walk part of this project to help assess and • Number of pedestrian and vehicle understand the complexity of the incidents transport and health system, with the aim of improving evidence-based CYCLING decision-making and allowing ongoing • Number of bicycle share locations review and improvement. Indicators • Number of bicycle parking at are a simple measure necessary to destination locations help understand information in a • Percentage of streets with cycling complex system, but should not be specific facilities seen as a comprehensive source of • Percentage of cycling network with information. lighting • Length of continuous cycling path The framework areas which can • Number of cyclists per day against be measured through a number of cycling facility types indicators are as follows: • Number of cyclist and vehicle • Mobility Infrastructure incidents • Conditions • Performance PUBLIC TRANSPORT • Lifestyle and Behaviours (including • Percentage of population living factors which influence lifestyle and within 500m of a public transport behaviour such as demographics stop and culture) • Frequency of public transport per • Health impact areas hour • Health outcomes. • Percentage of residential area serviced by public transport Each of these areas can be measured network through a number of indicators to • Number of public transport stops allow for flexibility depending on per km of road data availability. Based on a review • Number of public transport services of research, tools and metrics, the • Number of public transport patrons following examples of indicators are daily provided: • Frequency of public transport per hour Health + Mobility 25

MOTORISED VEHICLE SCALES AND DATA ISSUES • Number of traffic counts The majority of the data which feeds There are a number of consideration • Number of vehicular incidences into the indicators are spatially when gathering data for the indicators. • Percentage of modal splits attributable (i.e. the data can These include the following: • Average number of cars per be related to a spatially defined • Data availability and coverage is household boundary). This is important to not consistent across different • Method of journey to work provide a structure for comparing and countries, cities or locations. • Average vehicle miles travelled contrasting different neighbourhoods Depending on the data, information daily or regions within the appropriate area may be biased to certain framework • Average commute time unit. areas (i.e. built environment data • Roadway level of service (LOS) is abundant while there is limited When acquiring data, finer grained health data) which can result in an data is generally preferred. It can unbalanced assessment. DEMOGRAPHICS help identify the level of influence • Different datasets are often • Age profile of population of design on a local scale for aggregated differently including • Sex profile of population health impacts. It can also be easily different spatial boundaries which • Social economic status aggregated to a higher scale while do not correspond to each other. aggregating city level data to a local This can make it hard to compare level may not provide the appropriate different datasets. HEALTH IMPACT information. • Much of the data required to input • dB level from roadways near into the indicators, particularly residences The ‘grain’ or scale of data needs health related indicators, are • Percentage of Nitrogen Oxides in air to be considered with the different typically aggregated to a higher • PPM levels transportation modes since each mode scale (i.e. council level) to • Percentage of population has a different reach and impact. For anonymise and protect the privacy undertaking sufficient physical example, walking tends to have a of individuals. This makes it difficult activity greater impact on the local scale while to assess health impacts on a local • Number of traffic related incidences public transport/automobile generally level. • Number of street crime incidences has a city scale or regional impact. • The data can range in age and quality. With this in mind, it is important to HEALTH OUTCOME consider the data required beyond These issues can cause difficulty • Life expectancy at Birth the project boundary as the issues in acquiring appropriate data for • Population’s self-reported health and opportunities held by the project indicators and caution should be taken level distribution may lie elsewhere, depending on the when applying data and indicators to • Prevalence of obesity, BMI of 30+ transportation mode involved and the aid evidence-based decision making. (percentage of population) type of network. • Type 2 diabetes prevalence A list of open data sources for several (percentage of population) countries is provided in ‘Appendix B. • Respiratory problems prevalence Data sources’ as a starting point. (percentage of population) • Asthma prevalence (percentage of population) • Cancer prevalence (percentage of population) • Coronary heart disease prevalence (percentage of population) 26

3 Design protocol Health + Mobility 27

How can we design for health through mobility infrastructure? 28

Design protocol

Planning and design should contribute BENCHMARKING positively to creating IDENTIFYING SYMPTOMS How is the area currently performing? an environment that What vital signs could be improved? DIAGNOSIS promotes health.

The mobility + health design protocol SYMPTOMS is a guidance procedure to help design AND and assess mobility infrastructure in ASSESSMENT relation to health outcomes. OPPORTUNITIES & The design protocol is based on Health Impact Assessments (HIA) CONSTRAINTS processes (see appendix A. Existing SYMPTOMS ASSESSMENT tools and methodologies) and Why is the area performing like this? the framework (Chapter 2) which What are the opportunities and describes the relationships between constraints? the built environment (mobility infrastructure) and health outcomes. The protocol helps to highlight: • Which particular health areas can be influenced by mobility; and • What mobility infrastructure design measures could influence health outcomes.

It is intended to be a supplement to SCENARIO TESTING current planning and design processes INTERVENTIONS AND PRESCRIPTION such as visioning, masterplanning What are the design options? or strategy development to ensure What should be prioritised? that opportunities to create an TREATMENT environment which promotes health through mobility infrastructure are considered alongside other key PRESCRIPTION outcomes. AND CHECK UP The guidance procedure is based on the following steps which are interrelated and can be taken FOLLOW UP sequentially or standalone: CHECK UP How is the area performing after implementation? Are there further areas to improve? Health + Mobility 29

Diagnosis For the benchmarking process to have Treatment value, measures and indicators from BENCHMARKING at least two of the framework areas SCENARIO TESTING Benchmarking helps identify how should be evaluated such as mobility Design scenarios can be based on the something measures up against the infrastructure and health impact outcomes of the Opportunities and average or a standard. Accordingly, areas. This can then give an indication Constraints assessment. The scenarios for each indicator or measure that is of which relationships need to be that are developed can either be: used in the benchmarking process, further investigated and which built • A series of design options a relevant and appropriate standard environment areas could help improve which respond to the various is required to allow comparison and the outcomes. opportunities and constraints assessment. simultaneously; or The benchmarking process is intended • A series of design options which Different geographic scales need to to help identify potential issues or address only a single goal issue or be considered in the benchmarking ‘symptoms’ in a ‘mobility – health’ opportunity (i.e. scenario where process. This is because different context that should be taken to the the only goal is to create better air transport modes influences different next stage of the protocol. quality). scales (i.e. walking on a local scale) resulting to health impacts being OPPORTUNITIES AND CONSTRAINTS The scenarios can then be qualitatively seen in different scales. The different This stage assesses the issues/ assessed against a number of health geographic scales should consider symptoms identified in the outcomes relationships which can be the type of project and mobility benchmarking process to understand influenced through the framework infrastructure which is being designed. the related opportunities and by understanding the wider and Suggested scales include: constraints and potential solutions. interrelated relationships. • Street (micro) Comparison with best practice Using the framework, the FOLLOW UP • Precinct (study area) improvement areas identified After the chosen design has been Comparison to best practice or through the benchmarking process implemented, the outcomes should surrounding neighbourhood can highlight the relationships be monitored periodically to check averages which need to be further examined. whether they meet the expectations. • City (metropolitan area) Once these relationships have been The outcomes can be monitored in Comparison to similar or best identified, small focus studies can be relation to lifestyle/behaviour, health practice cities undertaken. These studies can involve impacts or health outcomes. • Region (macro) further focused data collecting and Comparison with national average. benchmarking to drill down to the key This step helps to close the gap issues to identify key opportunities between knowledge/design intention The areas to be benchmarked are and challenges. and actual outcomes. The results from derived from the four areas of the the follow up should be fed back into framework: The outcome of the assessment the Health and Mobility framework, • Mobility infrastructure provides input for a design brief of contributing in this way to further Availability/type/condition and improving or transforming the areas develop the health and mobility body performance that require attention according to the of knowledge. • Lifestyle and Behaviours (including identified symptoms. demographics) The Health and Mobility framework • Health impact areas is a continually evolving piece • Health outcomes of research and does not aim to definitively state relationships but A list of potential measures and provides potential links as defined indicators can be found in ‘Chapter through the literature review. As 2: Health + Mobility Framework’ the relationships are complex and alongside discussion around of issues still being actively researched, related to data. it’s expected that the framework also evolve as new information is uncovered. 30

4 Applying the Design Protocol Health + Mobility 31

What does the design protocol look like when applied on real case studies? 32

KNOWLEDGE QUARTER, LIVERPOOL UK

BATON ROUGE, LOUISIANA USA Health + Mobility 33

assets including the Philharmonic In the creation of the Baton Rouge Testing the Hall, theatres, a number of leading Health District, planners worked with a universities, the Royal Liverpool coalition of health care providers and design protocol University Hospital and other related community entities to identify best international medical institutions. practices in design of healthy places While the area contributes as well as the organisational structure significantly to the city’s economy, required to support such change. Identifying the environmental and social context has suffered from piecemeal and The Baton Rouge Treatment Plan takes opportunities, uncoordinated urban and transport a “medical approach” to diagnosing planning and inconsistent public realm problems and prescribing solutions, constraints and in a context of severe deprivation. identifying key health indicators, For an area that contains some of the benchmarks in similar contexts, and interventions for two key health institution which operates metrics for success with regard to on an international level, the urban health and healthy behaviours. The real case studies. realm can be significantly improved to Treatment Plan also calls for regular support healthy living. check-ins, to measure progress Two case studies were selected to be and understand where changes in assessed against the design protocol Liverpool City Council recognises approach are needed. and framework. The Knowledge the area as a key regeneration Quarter in Liverpool, UK and the Baton opportunity which can capitalise on While it does not lay out one Rouge Health District in Louisiana, recent and future investment from specific physical design solution, USA were chosen based on both the the universities, hospitals, and private the Plan identifies specific physical need and desire to improve the health sector investment as well as a growing characteristics and priority design of their community. While the two student population. elements based on the Design studies share similar traits, they are Protocol. Scenario testing of these set in different contexts and different BATON ROUGE, LOUISIANA, USA elements in combination led to the stages of the regeneration process. The city of Baton Rouge in Louisiana, creation of a potential full-build United States, is a microcosm of scenario as illustrated in the following KNOWLEDGE QUARTER, LIVERPOOL the health and healthcare issues pages. The identification of success UK communities across the nation are metrics is critical to ensuring that any The City of Liverpool, United Kingdom facing, from high rates of diabetes future final designs meet the goals sits in North West England and and obesity to a lack of alternatives laid out in the plan. displays significantly poorer health to private vehicles. However, the rates when compared to other parts concentration of health care providers of the country with large variations within the Baton Rouge Health District across the city. The city has been listed provides an opportunity as well as as one of England’s most deprived incentive to improve health condition local authority in the past few years, of people living and working in and with the city region ranking amongst around the District. the most deprived on the income, employment and health and disability As hospitals and healthcare systems domains of the Index of Multiple expand their focus to population Deprivation 201573. Programmes such health, planning at the district level as “Healthy Liverpool”, led by the NHS enables them to influence health are soft initiatives and respond to beyond the walls of their facilities Liverpool’s health problems. They are and the boundaries of their campuses. promoting healthy lifestyles, whilst Across North America, competitive offering a fresh approach to care and healthcare institutions are tackling health services. Liverpool City Council these issues as collaborative, place- recognises that the built environment based “health districts.” Both through is a key determinant of health. their structure and mechanisms of The Knowledge Quarter occupies the functioning, health districts support a east edge of the city centre and hosts culture of health. a combination of learning and cultural 34

i Knowledge Quarter, Liverpool UK

The Liverpool Knowledge Quarter, located east of Liverpool City Centre, is an area of higher education, science, medical expertise, knowledge and wealth creating potential. It hosts a cluster of world class biomedical institutions including the Royal Liverpool University Teaching Hospital, the Liverpool School of Tropical Medicine, Merseybio Incubator and a number of bio-medical research institutions. The educational institutions of the University of Liverpool, Liverpool John Moores University, Liverpool Hope University, Liverpool Community College and Liverpool Institute for Performing Arts are situated here.

Although dominated by science and educational institutions, the Knowledge Quarter assets are supported by an increasingly high quality cultural and leisure offer, focused around Hope Street. The area also contains clusters of residential properties which are occupied by both students and local residents.

Together the Knowledge Quarter institutions generate in excess of £1billion for Liverpool each year, more than 15% of the city’s total GVA. These institutions support over 14,000 full-time jobs, equating to approximately 7% of the total jobs in Liverpool74.

The area is considered to be crucial in the wider regeneration of Liverpool. In this case study opportunities for interventions in the mobility infrastructure are identified, that will contribute to improving the health and wellbeing of Liverpool.

The area is at an early stage of the regeneration process. The design protocol has been used to provide a high level assessment of the transport in relation to health outcomes. The evaluation obtained is context-specific and aims to facilitate creation of vision and strategy leading to it.

City centre Key routes Health + Mobility 35

Liverpool John Moores University

Moorﬁelds Cultural The Royal Liverpool Station Quarter University Hospital

Lime Street station Central Retail Area

Three Graces James Street Station University of Liverpool Central Station Liverpool John Moores University

Albert Dock

Liverpool Women’s Hospital Echo Arena

Exhibition Centre Liverpool 36

City of Liverpool

LIVERPOOL IS A MARITIME CITY ON THE EASTERN SIDE OF THE MERSEY ESTUARY. ALTHOUGH THE CITY DATES BACK TO AROUND 1200, MAJOR URBANISATION AND EXPANSION OF THE CITY TOOK PLACE DURING THE INDUSTRIAL REVOLUTION LEADING TO LIVERPOOL PLAYING AN IMPORTANT ROLE IN THE GROWTH OF THE BRITISH EMPIRE. SUCH WAS LIVERPOOL’S ROLE IN WORLD TRADE THAT IT WAS GRANTED WORLD 7.5 km HERITAGE STATUS IN 2004 AS A 30 min PROTECTED MARITIME MERCANTILE CITY.

LIVERPOOL CITY Size 111.8 km2

POPULATION City 473,100 (2014) Rank 9th (England) City region 1.517.500

The Knowledge Quarter occupies the Liverpool has an extensive road east of the City Centre and is within network. Multiple roads classified as a 7.5km radius from the wider city “Class A - Principal road in Urban area” boundary. run through the city, often carrying large volumes of traffic. However, In Liverpool there is a close correlation these roads do not cater for users between social deprivation and poor other than cars and buses and often health. The life expectancy as well function as barriers to pedestrian as the number of premature deaths movement. Despite this extensive are significantly worse than the road network, congestion is often England average. 76% of all deaths in reported as a problem in Liverpool. Liverpool are premature, due to cancer, cardiovascular disease and respiratory The number of local buses serving the disease75. whole of the city and its surrounding areas is notable. These services run Liverpool’s transport infrastructure is from two centrally located terminals very much centred around road and (Queen Square and Liverpool ONE Bus rail networks. The local urban rail Stations). Additionally, a coach station network serves the whole of Liverpool offers long distance coach services. city region. The national mainline network provides Liverpool with Most of Liverpool, not taking connections to major towns and cities topography into account, is within across England. Both networks are bicycle range. Yet, the modal share for accessible from Liverpool Lime Street cycling is low. A bicycle hire scheme station, at the fringe of the Knowledge has recently been installed, however Quarter area. cycling infrastructure is limited. Health + Mobility 37

HEALTH ISSUES Mortality from cardiovascular diseases and cancers is up to 1.3 times higher than the England average. Within England, hospital admissions due to asthma and respiratory Liverpool’s road problems are highest in the North West and, traffic causes within the North West, they are highest in congestion, poor air Liverpool75. quality and has a negative impact on INACTIVITY ACTIVE MOBILITY INFRASTRUCTURE the ability to cycle of all and walk. 52.4% 28.5km adults in Liverpool are dedicated cycle lanes physically inactive76. in Liverpool78. Copenhagen TRANSPORT RELATED EMISSIONS (Population: 580,184)

57% of the NO2 has a total of 454 km (main cause of poor cycle lanes79. air quality across the MODAL CHOICE UK) from local roads in Liverpool is accounted 44-69% for by buses75. of all trips to work are within cycling range80.

wasted 37 hrs of all trips in traffic annually 49% to work are by car81 per driver in 2015 in while only 2% are by Liverpool (UK is 6th in bicycle81. 77 Europe with 30 hrs) . 38

Surrounding neighbourhoods

APART FROM THE CITY CENTRE Surrounding Neighborhoods AND THE RIVERSIDE, THE AREA SURROUNDING THE KNOWLEDGE Knowledge Quarter Core Area QUARTER IS CHARACTERISED BY Liverpool wards ONE OF THE HIGHEST DEPRIVATION Kirkdale RATES IN ENGLAND Everton In terms of demographics, these areas display high levels of 18-24 year olds (37.2%), when compared to the rest of Liverpool82. This is due to the presence of the universities and student Kensington & Fairﬁeld accommodation.

Central Almost 39% of residents from the neighbourhoods surrounding the Knowledge Quarter travel less than Pincton 2km for work: either within their own neighbourhood, the Knowledge Quarter or Liverpool City Centre80.

The percentage of people who Princes Park walk to work is comparable and car Riverside ownership is relatively low in these neighbourhoods81.

Based on the all above, one can conclude that the areas surrounding the Knowledge Quarter are largely pedestrian used areas. However, major infrastructure unintentionally promoting short elements such as railways, inner distance travel by motorised transport, With its central location the ring roads and the subsequent urban due in part by the areas topography. Knowledge Quarter plays an important clearance lead to a poor pedestrian role by physically connecting the and cycling environment with a low deprived neighbourhoods with the social security level. This is likely Liverpool opportunities available in the city to be discouraging the residents Surrounding neighbourhoods centre. from walking or cycling while Knowledge Quarter

Modal choice for travel to work Distance travelled to work 60% 45%

40% 50% 35%

40% 30%

25% 30% 20% 20% 15%

10% 10%

5% 0% Rail Bus Taxi Car or van Passenger in a Cycling Walking Other or work 0% car or van from home < 2km 2km - 5km 5km - 10km > 10km

Fig 6: Modal choice for travel to work and distance travelled for the City of Liverpool, the Knowlege Quarter and its surrounding neighbourhoods. Health + Mobility 39

DEPRIVATION Everton, Kirkdale and Princes Park Wards have the largest population within the 1% most deprived in England83. The neighbourhoods surrounding the All of the LSOAs1 within Kensington & Fairfield, Liverpool Knowledge are within the 10% most deprived in England83. Quarter are mainly CAR OWNERSHIP MODAL CHOICE pedestrian used areas. 66% of 55-68% households in of all trips to work are the surrounding within cycling range80. neighbourhoods do not have a car84. 2% of all trips are by bicycle81.

39% of all trips to work are made by walking81.

1 A Lower Layer Super Output Area (LSOA) is a geographic area, used for reporting of small area statistics in England and Wales. 40

Knowledge Quarter - Precinct

THE KNOWLEDGE QUARTER OFFERS HIGH QUALITY ASSETS WHICH ARE LOCATED IN A GENERALLY POOR, FRAGMENTED AND DISCONNECTED URBAN ENVIRONMENT

70/h Lime Street Train Station 30/h 20/h 100/h

100/h 120/h

1.2 km Queen Square Bus Station 15 min 25/h 40/h

Liverpool One 10/h 50/h 10/h Bus & Coach Station

12/h

30/h 20h Bicycle lane (in the direction of the end marker)

Roads which are part of bus network

Major road link north of the Knowledge Quarter

Fig 7: Indication of the number of buses per hour in one direction on different segments in thearea 85, 86, 87.

It takes 15 minutes to walk across the The overall quality of pedestrian Demographics, car ownership, modal Knowledge Quarter. Pedestrians enjoy routes is suboptimal with poorly choice and distance travelled to work a number of architecturally attractive maintained footpaths, limited seem to suggest that residents of landmarks which aid in legibility in access to green space and cluttered the Knowledge Quarter travel the the area. In contrast, the environment street furniture. Furthermore, cycle neighbourhood by walking. They use outside the core area is fragmented infrastructure is very limited within public transport or car on trips outside and, in places, disconnected. the Knowledge Quarter. None of the the area. scarce bicycle paths running towards Generally the road infrastructure is the area continues through the car-dominated with multiple high Knowledge Quarter. capacity urban roads running through the area. Access to bus services can be considered outstanding. Multiple high frequency bus services are within walking distance. On the downside, a number of roads along the edges and even through the area cater for over a 100 buses per hour. This creates challenges with noise and air pollution, as well as congestion. Health + Mobility 41

MAJOR ROAD INFRASTRUCTURE CAR OWNERSHIP

20-37k 73% of cars drive along the households without major road links on car (46% in Roads in the area are an average day of the Liverpool)84. dominated by cars year (one direction)88. and buses, causing a BUS SERVICES POPULATION BY AGE negative impact on the environmental 55 bus stops 68% of people quality. in the Knowledge bus routes 28 Quarter are aged within walking range 18-24 compared to in the core area86. 14.2% in Liverpool Local Authority82.

Car-dominated streets

Many roads in Liverpool display a combination of factors which have a negative impact on the quality of the urban environment. Wide roads, cars parked on sidewalks and clumsy placing of signs make for a poor pedestrian environment and discourage the development of a street life. Absence of dedicated bicycle lanes and poorly maintained roads make cycling unnecessarily dangerous and uncomfortable. 42

Air quality and active travel

BELOW IS AN APPLICATION OF THE FRAMEWORK IN THE DETERMINATION OF SOME OF THE DETERMINANTS THAT COULD LEAD TO A HEALTHIER TRANSPORT INFRASTRUCTURE FOR THE KNOWLEDGE QUARTER

DETERMINANTS OF HEALTH HEALTH IMPACT HEALTH OUTCOME

ENVIRONMENT LIFESTYLE & BEHAVIOUR

DESIGN CONDITIONS MOBILITY INFRASTRUCTURE REDUCE CAR USE EXAMPLES PERCIEVED | ACTUAL

SAFETY EXPOSURE TO NOISE RESPIRATORY PROBLEMS DOES THE USER FEEL SAFE AND IS THE ENVIRONMENT SAFE? INCREASE CYCLING FOR TRANSPORT REDUCED CONFLICT BETWEEN USERS AND MODES LIGHTING PROVIDED (WELL LIT) VISIBILITY REDUCE VEHICLE EMISSIONS EXPOSURE TO AIR POLLUTION ASTHMA SIDEWALKS PERCEPTION OF BEING SAFE PASSIVE SUVELLIANCE (ACTIVE FACADES) INCREASE WALKING FOR TRANSPORT CROSSINGS COMFORT PHYSICAL ACTIVITY CANCER SIDEWALK ON BOTH SIDES OF STREET DOES THE USER FEEL COMFORTABLE START / END / DURING THEIR BRIDGES JOURNEY? WALKING INCREASE PUBLIC TRANSPORT USE SIGNALISED CROSSING PROTECTION FROM NOISE, POLLUTION, SPRAY AND GLARE TUNNELS PROTECTION FROM CLIMATE / WEATHER (RAIN, WIND, HEAT) ACCIDENTS & INJURIES PREMATURE DEATH FACILITIES AVAILABLE (BEGINNING / DURING / END OF JOURNEY) PRIORITY PEDESTRIAN CROSSING (ZEBRA) PASSAGES SUITABLE SURFACES RELATABLE SCALE . . . SOCIAL CONTACT STRESS STREET FURNITURE REDUCE NUMBER OF VEHICLES

CYCLEPATHS DIRECTNESS IS THE USER ABLE TO ACCESS THEIR DESTINATION DIRECTLY AND FRUSTRATION OBESITY BICYCLE PARKING EFFICIENTLY? . . .

CYCLING BICYCLE HIRE STATIONS ACCESS CARDIOVASCULAR DISEASE IS THE USER ABLE TO ACCESS THEIR DESTINATION AND MOVE EASILY? SIGNAGE REDUCE BUS USE FOR SHORT TRIPS . . .

E-BIKE CHARGING STATIONS DIABETES COHERENCE INCREASE CYCLING FOR TRANSPORT ROADS ARE USERS ABLE TO NAVIGATE AND SPACES EASILY UNDERSTOOD? . . . INTERSECTIONS INCREASE WALKING FOR TRANSPORT SIGNAGE PERFORMANCE CAR PARKING ITS (INTELLIGENT TRANSPORT SYSTEM) NETWORK EFFICIENCY / RELIABILITY TUNNELS PATRONAGE STREET WIDTH INCREASE VIADUCTS TRAFFIC VOLUME ROAD CAPACITY TRAFFIC SIGNALS BRIDGES CONGESTION TRAVEL SPEED STREET PATTERN / DESIGN BUS LANES PREDICTABILITY OF JOURNEY TIME SERVICE DISRUPTIONS INTERSECTIONS BUS STOP / INTERCHANGE DESIGN

TERMINALS SPEED LIMITS BUS VEHICLE EFFICIENCY

BUS STOPS . . . EMISSIONS SPEED INTERCHANGES ENERGY CONSUMPTION

. . . Health + Mobility 43

DETERMINANTS OF HEALTH HEALTH IMPACT HEALTH OUTCOME

ENVIRONMENT LIFESTYLE & BEHAVIOUR

DESIGN CONDITIONS MOBILITY INFRASTRUCTURE REDUCE CAR USE EXAMPLES PERCIEVED | ACTUAL

CYCLEPATHS DIRECTNESS IS THE USER ABLE TO ACCESS THEIR DESTINATION DIRECTLY AND FRUSTRATION OBESITY BICYCLE PARKING EFFICIENTLY? . . .

CYCLING BICYCLE HIRE STATIONS ACCESS CARDIOVASCULAR DISEASE IS THE USER ABLE TO ACCESS THEIR DESTINATION AND MOVE EASILY? SIGNAGE REDUCE BUS USE FOR SHORT TRIPS . . .

TERMINALS SPEED LIMITS BUS VEHICLE EFFICIENCY

BUS STOPS . . . EMISSIONS SPEED INTERCHANGES ENERGY CONSUMPTION

. . . 44

Exposure to This, next to causing air pollution, Based on the detailed version of impacts negatively on the quality of the framework, the main challenges air pollution the urban environment, especially identified for Liverpool focus when considered from the perspective around reducing emissions from and physical of pedestrians and cyclists. transport and promotion of active modes of transportation. The latter inactivity For cyclists we see that modal share will contribute to both reducing is quite low, even though most of the emissions as well as increasing In Liverpool, the impacts of poor city could be cycled across within 30 physical activity levels. In the context air quality, due in part to the cities minutes if infrastructure would allow of neighbourhood deprivation it is maritime location and prevailing cyclists to move around efficiently. important to increase the connectivity wind direction, and lack of physical Despite the high capacity of the of the neighbourhoods surrounding activity on health condition are existing road network, continuous the Knowledge Quarter with the apparent. Mortality rates originating in increase in road traffic causes severe Knowledge Quarter and the city cardiovascular diseases and cancers, congestion, which leads to frustration centre, by removing physical barriers as well as number of admissions and even more harmful emissions. as well as improving walking and to hospital due to asthma or other cycling conditions. This will positively respiratory conditions are higher than Another observation from the impact the ability of their inhabitants in the other cities in the UK. benchmark study is that a high to access facilities and opportunities. number of bus lines, combined with Although walking seems a popular high frequency of operating, is the The following pages outline the key mode of transportation in the central main contributor to the NO2 levels aspects of these challenges as defined areas of the city, the city wide in Liverpool exceeding the imposed through the detailed framework. mobility infrastructure is very much limits. car oriented. As a result roads are dominated by motorised traffic. Health + Mobility 45

INCREASING EFFICIENCY AND Additionally, a number of traffic Reducing RELIABILITY OF THE NETWORK management improvements can be Increased efficiency and reliability of considered, including: vehicle both bus and road network is expected • Traffic reporting and variable to contribute to a modal shift to public message signs installed along the emissions transport and indirectly - to reduction roadway, to advise road users of vehicle emissions. • Linking navigation systems up to Reducing vehicle emissions can be automatic traffic reporting achieved through a number of ways, The efficiency and reliability of the bus • Providing real-time traffic counts the most obvious one being the network in Liverpool could potentially • Parking guidance and information reduction of the number of emitters, in be improved by optimising the systems. this case - motorised vehicles. This can network configuration and frequency be done by promoting a modal shift of the services. For example, lines to active transport for shorter trips can be cross-linked, number of buses and public transport for trips longer adjusted in order to increase the than 7.5km. Secondly, improving the patronage, while simultaneously throughput and quality of the road decreasing the journey times and bus network, as well as the efficiency idling times. In doing so, it should be of the bus network, could reduce ensured that the average distance emissions. Lastly vehicle emissions between bus stops and the percentage can be reduced by improving the of area covered remain acceptable. efficiency of the vehicles or switching Other possible measures include bus to different types of vehicles, for priority systems and protected bus example electric or hydrogen fuel-cell lanes. vehicles. This is especially relevant for the buses in Liverpool which have low Given the number of bus lines environmental standards. operating currently in Liverpool, an alternative public transport system MODAL SHIFT TO PUBLIC like a tram or new metro lines could TRANSPORT be considered. However, in the long There are different incentives and run the impact of the intervention will disincentives that can be used in order outweigh its cost. to promote the use of public transport rather than the use of a car: A potential opportunity would be to • Improve park and ride facilities reduce road capacity in places through • Provide more circular routes calming, shared space and allocation • Decrease parking facilities to active modes to slow traffic down • Increase the reliability of public and improve the flow. It has been transport service observed that many streets in the • Increase the predictability of Knowledge Quarter consist of 2x2 journey time lanes which means they should be • Decrease journey time. able to handle approximately 3,000 cars/hour. It is unlikely this capacity is required in all of these streets, however this assumption should be checked against traffic counts and projections. 46

wide, ending on the sidewalks or of potential users and through Promoting being cut off by major roads. engagement with businesses through corporate travel plans and planning active mobility Examples of measures to improve the conditions on new developments. cycling network are: Although the use of public transport • Dedicated and protected cycle Although the demography and scale should be promoted for longer trips, lanes of the Knowledge Quarter suggest replacing short trips by active modes • Cycle routes with priority that the mode share of cycling could has a positive impact on both air • Dedicated cycling traffic controls be a lot bigger, it is important to keep quality as well as physical activity. • Absence of clutter in signage in mind that the topography of the • Improved parking facilities at area will be a limiting factor. The land To achieve this both the pedestrian destinations rises steeply upwards from the River and cycling network need to be • Creation of clear level crossings Mersey. Pedestrian and cycle access improved at many levels, including or grade separated crossings by from the core commercial centre and additional mobility infrastructure removing barriers. public transport hubs requires a climb and the conditions of the existing up fairly steep streets, which will be a infrastructure. A strategy for implementing these counteracting factor for the use of the measures should be based on an systems. WALKING INFRASTRUCTURE understanding of the current flows The walking infrastructure of the Knowledge Quarter can be improved in different ways: • Establishing clear walking routes with signage indicating destinations and their distance • Removing obstructions in the network • Removing clutter from the sidewalks • Giving priority to the pedestrian in the design of the public realm • Minimise waiting times at intersections • Connecting walking routes to (existing) green infrastructure • Enhancing connections with surrounding neighbourhoods by creating additional crossings with major roads currently disconnecting these areas • Providing consistency in the quality of the public realm.

CYCLING INFRASTRUCTURE Even though Liverpool has the ambition to become a cyclist-friendly city, a safe, comfortable, well- connected, accessible and coherent network is still missing.

Over the past years just 2 kilometres of cycle lane has been installed, however these lanes do not form a network and contain design errors such as lanes not being sufficiently Health + Mobility 47

In addition to increased physical activity and reduced exposure to air pollution, these measures have some additional health benefits: • Fewer motorised vehicles to reduce noise pollution arising from traffic Other measures • Less motorised traffic and congestion for increased road and benefits safety • Less congestion and traffic intensity Apart from the physical interventions for decreased stress and frustration described on previous pages, there • Less congestion for better are additional measures to decrease movement of emergency vehicles. the exposure to air pollution and to promote active mobility: • Pricing strategies for public transport modes • Reducing the need for travel • Promotion of more flexible work place practices • Telecommuting encouraged through legislation and subsidies • Increasing vegetation to filter air • Parking and bus lane enforcement • Wider availability of city bicycles. 48

A PROGRAMME FOR HEALTHY INFRASTRUCTURE Design Protocol Although the Knowledge Quarter has the potential to spark a wider regeneration process, a city wide programme Summary is required to move towards a healthier mobility infrastructure for Liverpool. This would include the development of consistent and legible networks for active Knowledge Quarter modes as well as a more efficient public transport system.

BENCHMARKING OPPORTUNITIES & CONSTRAINTS

SYMPTOMS REDUCING VEHICLE EMISSIONS • High mortality rates from cardiovascular diseases • Modal shift to public transport and cancers as well as admissions to hospital with • Increasing throughput and quality of road network asthma and respiratory problems • Increasing efficiency and reliability of the bus • High percentage of inactive adults network.

• NO2 levels exceed the annual average objectives • High number of short trips taken by car or bus. PROMOTING ACTIVE MOBILITY By adding mobility infrastructure as well as improving CAUSES conditions of the existing infrastructure. • A car oriented, yet congested, urban environment • Pedestrian network • The network for active mobility fails to meet all • Cycling network. basic criteria • Major road infrastructure disconnecting surrounding neighbourhoods • An inefficient bus system.

SCENARIO TESTING POSSIBLE SOLUTIONS TO INVESTIGATE • An alternative public transport system such as a tram or extended metro system • Allocation of road space to modes other than the car • Integral design for a Liverpool cycling network including standardised solutions for crossing roads and parking • Implementing pedestrian crossings where the balance between safety and directness is restored.

FOLLOW UP MEASURING SUCCESS • Modal split • Emission levels for transport pollutants • Public transport patronage • Premature mortality • Number of vehicles circulating in the city • Respiratory hospital admissions. • Baseline person journey time per mode Health + Mobility 49 50

i Baton Rouge, Louisiana US

THE CAPITAL OF THE US STATE OF LOUISIANA IS FACING THE COMMON ISSUE BATON ROUGE METRO AREA OF HIGH RATES OF OBESITY AND DIABETES.

Centrally located in the US state of Louisiana, Baton Rouge is the second largest city (after New Orleans) and the capital of the state. Since 1947 the City of Baton Rouge and the more rural East Baton Rouge Parish have operated as a consolidated city-county government.

One of the largest challenges faced by both the state of Louisiana and the City of Baton Rouge is the rising rate of noncommunicable disease, particularly obesity and diabetes. The Centers for Disease Control and Prevention (CDC) includes East Baton Rouge Parish in the so-called “Diabetes Belt,” comprising 644 counties that stretch from Louisiana to the East Coast of the United States89.

The Baton Rouge Health District, located in South Baton Rouge, is home to much EAST BATON ROUGE PARISH of the City’s healthcare economy, including 3 large healthcare anchors and a number of other providers. It also includes a broad mix of other uses - from education, to residential. As it currently exists, however, the District suffers BATON ROUGE CITY PARISH from a lack of coherent and cohesive planning and little mobility infrastructure Size: 250 km2 not tailored to private vehicle use. Even though this is a place for wellness and healing, much more could be done to create a place that supports and POPULATION encourages healthy behaviour for those who live and work in the district. City: 229,493 (2010) Metro Area: 820,159 A guiding Health District plan (the Baton Rouge Health District Treatment Plan) proposes solutions to common issues, looking at the District at 5 scales, and DISEASE PREVALENCE IN LOUISIANA through multiple functional lenses: Healthy Place, Health Education, Health Care Diabetes: 11.6% (2013)90 Delivery, and Disaster Preparedness. Obesity: 33.1%91

Using the metaphor of medical treatment, the Plan diagnoses key issues (symptoms and vital signs), as well as benchmarks, and recommends a series of interventions to improve the physical and organisational health of the district. As the Treatment Plan addresses both the existing District as well as a future build-out scenario, it engages the portions of the Protocol dealing with improving physical conditions (walking conditions, public transport, and roads) as well as those that consider future systems (walkability, cycle-ability, access to public transport).

1. 2. 3. 4. 5. THE THE THE THE THE DISTRICT DISTRICT BATON ROUGE SOUTHEAST STATE OF CORE NETWORK METRO AREA SUPER-REGION LOUISIANA

Fig 8: The 5 Scalar Lenses of the Baton Rouge Health District Treatment Plan Health + Mobility 51

WA ME

MT ND VT MN NH OR WI NY MA ID SD MI CT RI WY IA PA NJ NE OH IN NV IL DE UT WV MD CO VA DC CA KS MO KY NC TN OK SC AZ NM AR GA MS AL

TX LA

over 10% 9.0% - 9.9% FL 8.0% - 8.9% AK 7.0% - 7.9%

6.0% - 6.9%

Fig 10: Prevalence of Diagnosed Diabetes Among Adults, by State, 201392

Water Bodies / Streams HI Open Space / Parks Buildings Surface Parking / Driveways Roads Rail Sidewalk

OUR LADY OF THE LAKE REGIONAL MEDICAL CENTER MARY BIRD PERKINS CANCER CENTER

PENNINGTON BIOMEDI- CAL RESEARCH CAMPUS LSU MEDICAL EDUCATION & INNOVATION CENTER

BATON ROUGE CLINIC

BATON ROUGE GENERAL REGIONAL MEDICAL CENTER

OCHSNER MEDI- CAL CENTER

0 500 1000 2000 ft

Fig 9: The Baton Rouge Health District Today 52

The Baton Rouge Metro Area

PRIORITY: THE NEED TO IMPROVE THE HEALTH OF THE COMMUNITY.

AREAS WITH HIGHEST SOCIO- ECONOMIC BARRIERS TO HEALTH

Community Need Index (CNI) measures economic and structural barriers to overall health by zip code, with a score of 0 indicating the lowest need, and 5 indicating the highest. A high CNI score indicates severe socio-economic barriers and has also been correlated with high hospital and BATON ROUGE HEALTH emergency room use94. DISTRICT

CNI: 4-5 CNI: 3-4

CNI: 2-3 CNI: 1.6-2

Residents in the Baton Rouge Metro MEDICARE BENEFICIARIES WITH POTENTIALLY PREVENTABLE Area and East Baton Rouge Parish DIABETES MORTALITY suffer from high rates of preventable diseases and have unequal access to healthcare. Healthcare institutions are 29% of 154 out of critical partners for a change, as next to healthcare they also provide health Medicare patients 100,000 deaths education and employment. in Baton Rouge have in Baton Rouge diabetes95 (compared are potentially to 24% in Austin, preventable with Texas, a comparable timely and effective city and 16% being care (compared to 72 the lowest rate of in the top 10% best diabetes seen among performing regions)96. states). Health + Mobility 53

The District Core

PRIORITY: THE NEED TO CONNECT INSTITUTIONS IN A HEALTHY ENVIRONMENT. PENNINGTON BIOMEDICAL BURDEN MUSEUM AND s RESEARCH CENTER CAMPUS iu GARDENS BATON ROUGE HEALTH DISTRICT d 234 ACRES OF OPEN SPACE a 440 ACRES OF OPEN SPACE r e 1. Pennington Biomedical il m Research Center 1 2. Baton Rouge Clinic 3. Our Lady of the Lake College 6 FUTURE CREEK TRAIL 4. LSU Health Sciences Center 5 Baton Rouge Branch PE RK 4 5. Our Lady of the Lake Regional 1 I E NS N R A Medical Center D L 3 N E S 7 6. Mary Bird Perkins Cancer Center S E 7. Ochsner Medical Center — 2 Summa / Bluebonnet 8. OLOL Children’s Hospital (future) 9. Baton Rouge General Medical Center 8 —Bluebonnet Campus Partners Located outside District Core: 9 Woman’s Hospital Blue Cross Blue Shield of LA E V A T LA Department of Health and Hospitals E N N O Louisiana State University B E PERKINS ROAD U L The Neuromedical Center B COMMUNITY PARK FUTURE PASSENGER RAIL Baton Rouge Orthopaedic Clinic 52.2 ACRES OF OPEN SPACE STATION (LOCATION TBD) Surgical Specialty Center of Baton Rouge BATON ROUGE HEALTH DISTRICT The District core is car-oriented and suffers from heavy traffic congestion 1. Pennington Biomedical Research on its main arterials. It lacks sidewalks and pedestrian connections between Center destinations. 2. Baton Rouge Clinic 3. Our Lady of the Lake College There is limited access to the remarkable open-space amenities located within 4. LSU Health Sciences Center walking distance. The district core has a large concentration of pillar healthcare Baton Rouge Branch institutions, as well as many private practices, physicians’ groups and other 5. Our Lady of the Lake Regional businesses, both health-related and more general. Medical Center 6. Mary Bird Perkins Cancer Center INTERSECTION DENSITY AVERAGE DAILY TRAFFIC 7. Ochsner Medical Center - Summa/Bluebonnet 8. OLOL Children’s Hospital (future) 9 intersections 42,690 9. Baton Rouge General Medical Center —Bluebonnet Campus are located within cars per day on major 93 Partners Located outside District Core a square mile in arterials in the area • Woman’s Hospital • Blue Cross Blue Shield of LA the district core (a (compared to 21,800 • LA Department of Health and Hospitals walkable environment cars on Brookline Ave, • Louisiana State University • The Neuromedical Center that supports transit a similar main arterial • Baton Rouge Orthopaedic Clinic • Surgical Specialty Center of use typically has 25- serving the medical Baton Rouge 30 per square mile93). district in Boston, MA). 54

As upsetting as the current situation Prevalence is, a potential for significant improvements have been identified. of Chronic The proximity of a number of leading health care providers as well as their Disease commitment to creating a health- supportive environment will be crucial In Louisiana, as elsewhere across the in the prevention of chronic disease. nation, the slow pace of change does The CDC has identified environmental not reflect the urgency of the health change as one of the 4 key factors in needs in the broader population. chronic disease prevention99. These The prevalence of obesity—a root factors are: cause for many preventable chronic • Epidemiology and surveillance to diseases—has doubled since 1990 monitor trends and track progress; in Louisiana and currently stands at • Environmental approaches to 33.1%: one of the highest rates in promote health and support healthy the nation91. At the current rates of behaviours; increase, the number of obese adults • Healthcare system interventions to in Louisiana is expected to double by improve the effective delivery and 203097. use of clinical and other high-value preventive services; and The prevalence of diabetes in • Community programmes linked to Louisiana has also increased steadily clinical services to improve and from 6.6% in 2000 to 10.3% in sustain management of chronic 2010. Lower socio-economic status conditions. is correlated with a significant increase in disease risk: close to 20% of residents in the lowest tier of income had diabetes as opposed to 6% among the highest tier. In 2013, 11.6% of Louisianans had diabetes, with only Alabama, Mississippi, and West Virginia having higher percentages90. East Baton Rouge is one of 644 counties located in the CDC- identified “Diabetes Belt”89, which extends from Louisiana towards the East Coast (Fig 12).

Diabetes and obesity in Baton Rouge amount to $1.5 billion in healthcare costs annually98. Creating a health- supportive physical environment is one of the key practices to prevent chronic disease as identified by the CDC99. Health + Mobility 55

WA ME

MT ND VT MN NH OR WI NY MA ID SD MI CT RI WY IA PA NJ NE OH IN NV IL DE UT WV MD CO VA DC CA KS MO KY NC TN OK SC AZ NM AR GA MS AL

TX LA

FL over 35% AK 30-35%

25-30%

20-25 %

Fig 11: Prevalence of self-reported obesity among adults, by State, 201391 HI

WA ME

MT ND VT MN NH OR WI NY MA ID SD MI CT RI WY IA PA NJ NE OH IN NV IL DE UT WV MD CO VA DC CA KS MO KY NC TN OK SC AZ NM AR GA MS AL

TX LA

over 10% FL 9.0% - 9.9% AK 8.0% - 8.9%

7.0% - 7.9%

6.0% - 6.9%

Fig 12: Prevalence of Diagnosed Diabetes (Type 1 and 2) amongHI adults, by State, 201392 56

communities where walking is not with the objective to make the Sprawling only unsafe, but often impossible100. city more walkable. The code, as The Baton Rouge Unified Development it currently stands, is a significant Development Code (UDC), while adopted in 1995, barrier to orderly development that builds on the legacy of car-centric builds a sense of place and a vibrant, A large percentage of the 1,000+ acre zoning codes. pedestrian-friendly public realm. study area for the District is zoned C2—Heavy Commercial District, which The city-parish has sought to specifically permits the construction address the need for walkability by of laboratories, offices, and other adding urban design districts to the research facilities in addition to a wide zoning code. These include stricter variety of other uses ranging from development requirements intended gas stations to townhomes. There is to build a sense of place and a unified also a number of residentially-zoned public realm. parcels although the majority of the District’s residential plots are located One of the primary recommendations in commercially-zoned areas. of FuturEBR, the comprehensive plan for East Baton Rouge Parish, was the Like elsewhere in the US, zoning was revision of the UDC to enable mixed- established in Baton Rouge to protect use buildings and districts, shared the health, safety, and welfare of parking facilities (such as surface lots the community. A growing body of and structures which are managed research shows that zoning codes and used jointly by multiple private of this era may have contributed to entities), and to promote pedestrian- the obesity epidemic in the nation oriented, compact development. by promoting the development of The City-Parish is taking steps to use-segregated and car-oriented overhaul the UDC in the near term101,

Parcel Boundary Zoning District Boundary BLUEBONNET General Office Districts

PERKINS Commercial Districts Residential Districts Light Industrial Districts STARING Planned Unit Developments Hospitals Study Area Boundary

Fig 13: Zoning categories currently in use in the Health District Health + Mobility 57

disconnected street network102. Boulevard—which also carry large Inefficient volumes of regional traffic (Fig 14). As a result, most people drive to work On any given day at rush hour, these Transport and make additional vehicular trips on two main arterials serving the District a daily basis for necessities. are clogged with bumper-to-bumper Network traffic moving at extremely slow The sprawling land use pattern speeds. For much of the low-income and combined with lack of investment at-risk population in Baton Rouge, in transportation infrastructure has appropriate care can also be physically created significant traffic challenges, difficult to access. Traffic issues, lack which are experienced most acutely in of transportation options, and poor the Health District103. appointment availability during non- work hours can become barriers that Insufficient mobility infrastructure disproportionately impact residents (including roads and other options) without the access to a car. and a general reliance on the car contribute to a gridlock situation in The Baton Rouge metropolitan area the District. has developed in a way that makes living without car virtually impossible. The highway, Ward’s Creek and A 2014 study supported by the Kansas City Southern Railroad, all of National Institutes of Health (NIH) which run east-west across this area, and the Ford Foundation found Baton limit access into the core District. Rouge to be one of the most sprawling With most drivers trying to enter metro areas in the nation due to or exit the highway, District traffic its segregation of urban functions, is channelled into two regional low density of development, and arterials—Essen Lane and Bluebonnet

JEFFERSON

BLUEBONNET

ESSEN

Highway Arterials

KCS RR Railroad Creek Local Streets Access Points Hospitals DAWSON Points of Congestion*

STARING PERKINS Neighbourhood Cut-throughs (routes on local streets to by-pass arterial intersections)*

*reported by public meeting participants

Fig 14: The current road network in the District 58

Lack of EXISTING DISTRICT STREET NETWORK Alternative to the Car

The car-oriented development of the Health District contributes to congestion and prevents people from choosing to walk—sometimes to destinations as close as 1,000 feet (four minute walk) - due to a fear of crossing streets. The focus on the car also limits the use of buses, which are often stuck on the same roads and are unable to deposit pedestrians at locations where it is safe to walk. Even if residents were to choose to EXISTING SIDEWALK NETWORK walk, today only 22% of streets in the District have sidewalks.

Even though the design of District streets is poor, it is actually rather lack of them that makes walking virtually impossible. Street connectivity (measured by the number of intersections) is one of the key determinants of walkability93. The District fares poorly from this perspective: it has, on average, almost a tenth of the connectivity of Downtown Baton Rouge. Even in areas that have a grid of connected streets, the long block sizes reduce the potential for through-movement. The typical block size in the Calais office EXISTING BICYCLE NETWORK park subdivision is 400 feet by 1,300 feet.

The average Walk Score - a number between 0 and 100 that measures the ability to walk to various destinations from a given location - within the district is 48. Health + Mobility 59

Bicycle facilities within the District leveraged within the Health District are also in short supply - there are to make it a viable transportation no designated cycle lanes, shared means for those without a car and streets, or multi-use sidewalks. The an alternative to potentially reduce District’s only bicycle facility is the 0.5 overall vehicular use. mile trail along Kenilworth Parkway. The Baton Rouge Health District is By increasing the mobility options located next to a globally-recognised within and to the District, there is a outdoor museum, a regional children’s huge opportunity to connect with destination for adventure sports, and a green and recreation spaces nearby. creek with historical significance that Aside from the well-known benefits is gaining new life with active trails. of fresh air, research also shows Yet, it has surprisingly weak pedestrian significant psychological benefits of and bicycle connections. Data analysis physical and visual access to natural by Strava, a website and mobile app environments104. Natural open spaces used to track athletic activity via GPS, also provide opportunities for active shows that runners and cyclists in the recreation: doctors around the U.S. community largely avoid the District are using “park prescriptions” to with the exception of streets where encourage their patients, especially sidewalks are present. children, to spend time exercising outdoors105. The Capital Area Transit System (CATS) provides service to the Health District. This system needs to be better

Fig 15: Snap shot of the district from Strava’s Global Heatmap. Activity levels are indicated by blue to red lines, with red indicating the highest level of use for routes. 60

Physical Scenarios

The Baton Rouge Health District Because the district is looking at both The primary physical prescriptions Plan is not meant to be a definite improving existing infrastructure for the District are outlined on the master plan; rather it sets a series and creating new elements, following pages. of goals and solutions that can be recommendations consider both implemented in a number of different aspects of the determinants of health ways as the district evolves. As part of as laid out in the Design Protocol. the planning process, the design team These include the quantitative aspects tested a number of physical scenarios of transport infrastructure, such as to understand the impacts, positive whether there are sidewalks on both and negative, of various design sides of the street, linear units of cycle solutions. lanes and direct access to open spaces as well as the more qualitative aspects The outcome of the scenario that may change behaviour, such as testing process is an illustrative, frequency of transit, perceived safety demonstration physical framework, of a street and improved intersection including a new street network, a conditions. new and enhanced network of parks and open spaces, and new infill The scenario testing at this stage of development. While specific locations the process has been focused on the for infrastructure such as streets availability and design intent of future and cycle lanes may change, the infrastructure, rather than testing prescriptions laid out in the document specific final design solutions. To fully will help the district administrators support the desired health outcomes, guide future development in order to a similar type of testing should meet the specific health (and other) happen for the final design of each of goals identified at the outset of this these elements. process.

Design Protocol Indicators

WALKING CONDITION CYCLE-ABILITY ROAD • Positive association/perception • Bicycle Hire Scheme: Implement • Traditional Grid: Build a Street with the built environment: Adopt bicycle and car share programmes Framework - reconnect/distribute District Street Design Guidelines • Number of cycle lanes: cycle traffic • Pedestrian Safety Islands: lanes on priority cycle corridors Medians - on larger streets • Proximity to cycle paths: build provide pedestrian refuge the Health Loop Trail; complete a bicycle trail network; add rail WALKABILITY crossings • Presence of a Sidewalk - Adopt District Street Design Guidelines PUBLIC TRANSPORT • Pavement Continuity - Manage • Access to public transport and Access on Arterials destinations: Build a multi-modal • Access to Facilities +Amenities: transit center Coordinated Development; connect to the Burden Campus PUBLIC TRANSPORT AVAILABILITY • Connectivity/Land Use Mix: • Increase transit routes: add a Coordinated Development district funded shuttle route Health + Mobility 61

BURDEN MUSEUM AND GARDENS I-10

DIJON

OLOL HENNESSY SUMMA

MIDWAY

BLUEBONNET

BRITTANY

ESSEN DIJON

O'DONOVAN BRG MANCUSO PICARDY

MALL OF LOUISIANA PENNINGTON BATON ROUGE BIOMEDICAL CLINIC RESEARCH PERKINS RD STARING CENTER KENILWORTH COMMUNITY PERKINS PARK

Fig 16: A potential future road network for the Baton Rouge Health District District Study Area Existing Street Proposed Street Existing Rail Corridor Proposed Frontage Road BUILD THE DISTRICT STREET ADOPT STREET DESIGN GUIDELINES Existing Multi-use Trails and Cycleway Proposed Multi-use Trails and Cycleway NETWORK The plan lays out non-prescriptive Existing Creek An important short-term priority for best practice treatments for the Existing Railroad Underpass or Bridge over Creek the district is to implement an arterial various street types anticipated in Proposed Rail Underpass or Bridge over Creek Existing Open Space street network, moving the area from the district, addressing the different Proposed Open Space reliance on a single arterial road to a elements found in each of the street Existing Water Body system of multiple arterials that will, types. Included are: in time, connect to a robust network • Pedestrian Zone of major local streets. Completion of • On-Street Parking this network will not only allow (and • Bicycle Lanes encourage) more infill development • Travel Lanes in the district, but it will also help • Medians. improve air quality by dispersing traffic, and will provide more options IMPLEMENT CAR AND BICYCLE for pedestrians and cyclists travelling SHARING through the district. Baton Rouge has already taken initial steps toward bicycle share ADD RAIL CROSSINGS implementation. There are good Key to the success of vehicular, cycling, examples from institutional and and pedestrian improvements will corporate campuses; when combined be the addition of rail crossing in key with the trail system, it will provide a locations (3 are identified in the plan). viable alternative to private vehicles Reducing time spent waiting for trains and help facilitate behavioural change. to pass will reduce traffic congestion, with a positive impact on air quality, and also make cycling and walking more attractive by creating more direct routes. 62

ENHANCE TRANSIT OPTIONS IN THE DISTRICT

In addition to encouraging and ESSEN facilitating modal shift to get more people walking and biking, a key aspect of reducing traffic congestion HENNESSY and encouraging transit use is to provide more ways to access existing PICARDY and planned public transit. The plan recommends that the District funds a circulator service to allow more people access to the District through public transit.

Current CATS Route Proposed Core Circulator Route Auxiliary Service Existing Hospitals Planned Hospital

Fig 17: Proposed Circulator Shuttle Route

BUILD A MULTI-MODAL TRANSIT CENTER Conceptual service proposals for rail in the region include a stop in the Baton Rouge Health District, potentially

linking the District directly with ESSEN New Orleans. The plan recommends including this station in all final build out models, and explores three N O potential future locations. A more P direct connection to New Orleans and other destinations in the region will help ease reliance on private vehicles travelling to and within the district, MIDWAY BLUEBONNET potentially having a positive effect on air quality as well as walking and other alternate modes of transport.

Transit Station Location N West of Essen Lane O East of Essen Lane P East of Midway Blvd

Fig 18: Baton Rouge Health District Multi-modal Passenger Terminal Location Options Health + Mobility 63

BUILD A BICYCLE TRAIL NETWORK JEFFERSON A priority project within the proposed

BLUEBONNET bicycle trail network is the Health ESSEN Loop Trail, a 7.4 mile (12km) loop around the District. This trail would be an extension of an existing trail, and would provide key infrastructure for walking and biking as both commuting and leisure activity. Critical to the success of this trail is the creation of a new creek crossing at the Our Lady of the Lake Regional Medical Center, reducing to 3 minutes what is now a 15 minute walk from the hospital to the trail head and making walking and cycling a much more attractive KCS RR possibility for those who live, work, and seek treatment in the District.

STARING PERKINS

Urban Forest Existing Trail Active/Sports Park Proposed Trail Agricultural Fields Creek Botanical Gardens Lake District Signature Park Proposed Future Street Network

Fig 19: Baton Rouge Health District Landscape Framework Plan: The Network of Existing and Proposed Open Spaces and Connecting Corridors 64

Fig 20: Potential build-out option for the District.

OUR LADY OF THE LAKE RMC Regional destination for nature, farming, and horticulture MARY BIRD PERKINS CANCER CENTER

A calming walk in nature A welcoming, tree- lined boulevard An attractive campus environment

Happy neighbours

PENNINGTON BIOMEDICAL RESEARCH CENTER

Fun places for students to live

A nationally-recognised A regional destination BATON ROUGE CLINIC Diabetes and Obesity Center for active sports

Train to New Orleans Health + Mobility 65

MALL OF LOUISIANA FUTURE OUR LADY OF THE BATON ROUGE GENERAL RMC LAKE CHILDREN’S HOSPITAL

Safe residential OCHSNER MEDICAL neighbourhoods CENTER - SUMMA

Happy neighbours A health and wellness village

Walkable neighbourhoods

Lots of places to A new linear park and boulevard cycle or walk to lunch 66

Follow Up

DESIGN CHECK-UP Check-Up • Intersection density • Sidewalk coverage Metrics • Transit coverage • Diversity of land uses In order to ensure the success of the • Access to public open space. prescriptions outlined, the Treatment Plan calls for regular check-ins and BEHAVIOUR AND HEALTH adjustments to the prescriptions laid BENCHMARKS out above. • Traffic volume on arterials • Employee travel behaviour survey As the District evolves, the leadership • Prevalence of obesity and diabetes group will work with community for people living and working in the groups, healthcare providers, and District. local and regional authorities to • Mortality rates collect data about how infrastructure • Community needs indices is being used, how and if behaviour • Transit access to hospitals is changing, and the personal, district • Pedestrian and bicycle accidents level, and regional health outcomes in • Average daily traffic the area. • Parking demand.

The database created for this purpose In order to get the most meaningful is integral to the Treatment Plan and data, the leadership group along with will be added to an on-going basis as the consultant group is working with assessments occur. local healthcare providers and the State of Louisiana to access a finer Additionally, follow-up testing of the grain of health data. recommendations in the Treatment Plan and the data it collects can be an The District is now established as invaluable means to detecting other a non-profit organisation and has issues. If other diagnoses are hired its first executive director. As confirmed, additional treatment plans part of the on-going mission of the will be necessary. This Treatment Plan Baton Rouge Health District, the serves as a template for continuous leadership group will track key metrics delivery of care for the District. The at a regular interval. Part of the goal is to not only make the District a recommendations of the Plan include healthy place, but to make it a place a digital dashboard for access to that is proactive about and a model of progress metrics at the district scale. health far into the future. Current health information is available only at the census tract scale, which is useful for regional trends but not as informative when tracking the impact of infrastructure and built form changes at a local level. This additional information should allow the leadership group to make more powerful, meaningful decisions for the district. Health + Mobility 67

STRONG OPPORTUNITIES FOR POSITIVE CHANGE Design Protocol Current conditions make it difficult for people to use mobility options other than private vehicles, but the Summary creation of a strong coalition of partners (including health care providers) and a health-supportive environment make positive change in the district very possible. Baton Rouge

BENCHMARKING OPPORTUNITIES & CONSTRAINTS

DISTRICT SYMPTOMS CHALLENGES • Low intersection density (per 1/4 mile): 9 in the • Lack of coordinated planning and focus on individual district core vs 25-30 in a walkable environment buildings and car throughput (vehicles/hour) • High volumes of traffic (cars per day): 42, 690 on • Lack of alternatives to the car Essen Lane vs 21,800 in a similar district in Boston • Minimal street connections. • High numbers of Medicare beneficiaries with diabetes (%): 29% in Baton Rogue vs 16% as the OPPORTUNITIES lowest rate among states • Mortality and disease rates are regional issues • High rates of potentially preventable mortality. but can be addressed very locally through a few interventions KEY VITAL SIGNS FOR SUCCESS • The coalition of health care providers leading the • Decrease traffic, increase connectivity and Treatment Plan process is committed to positive walkability health outcomes • Decrease rates of preventable mortality and • The amount and quality of green space surrounding diabetes. the District is a strong framework.

SCENARIO TESTING

DESIGN GOALS • Adopt street design Guidelines • Priority: implement arterial network to • Implement car and bicycle sharing disperse traffic and increase connectivity • Enhance transit options in the District • Priority: health loop trail • Build a multi-modal transit centre • Build the District street network • Build a bicycle trail network • Add rail crossings • Connect to open space.

FOLLOW UP DESIGN CHECK UP POST-IMPLEMENTATION CHECK-IN • Design review check-ins to ensure proposals • Health outcomes - diabetes and preventable meets goals of plan (check against mortality. prescriptions and related benchmarks). • Mobility behaviour survey: work with providers • Connectivity, adherence to guidelines, for more granular level data to examine health enhanced access to transit. impacts at the District scale. 68

5 Way forward Health + Mobility 69

How can the health and mobility agenda be taken forward? 70

USING THE DESIGN PROTOCOL IN The data from the benchmarking Way forward YOUR PROJECT stage can inform a discussion about Whether you are an urban planner, the causes of health challenges infrastructure provider or architect, in the community and how these there are lessons from this design can be improved through transport Designing for health protocol that you can apply to your and mobility infrastructure. This work to improve health through introduces the opportunities and through mobility transport. Some strategic decisions constraints stage and is probably best about new transport infrastructure will seen as a stakeholder engagement in your project and impact communities for decades and activity (or several) where inputs can possibly centuries. Other decisions be gathered from different agencies further research areas will have a shorter duration but could and the community. still have a big impact. The important principles in the design protocol can The design and engineering teams be applied at any project scale. The can then work with this information to protocol can be a useful checklist to develop different options. These are ensure decision-makers consider the taken through the Scenario Testing opportunities and potential impacts stage through client meetings and of the project holistically, at the community engagement activities earliest possible stage. The healthier as appropriate for the scale of the option does not necessarily have to intervention. It may also be possible cost more, and it will be cheaper in to model predicted impacts from the long run. Prevention is cheaper different design options using the data than cure! There are several examples gathered in the benchmarking stage. in this publication to support the business case. When consensus is achieved and a particular design is taken forward it The benchmarking stage of the is important to set measures which protocol identifies how an area is will allow ongoing monitoring and currently performing and could evaluation. This could be through data be aided by national or local data from service providers or possibly sources. In the USA, the Department sensors, surveys or smartphones. of Transportation and the Centers for The important point is to ensure that Disease Control and Prevention have the follow up stage is integrated developed the new Transportation and into project plans and not forgotten. Health Tool which provides data via There could be very minor changes indicators about how transport and required which could ensure that mobility infrastructure affect health88. the infrastructure meets the original Many cities have started to make objectives. cross-departmental data available online in an open access format. At the benchmarking stage it would be useful to collect data about transport and environment (such as traffic congestion, air quality and mode share) alongside health data (such as physical activity levels, obesity and disease prevalence). In the UK, this type of health data is available through Public Health England’s Health Profiles with interactive mapping and reporting functions107. Health + Mobility 71

Complete Streets Policy - New York City, USA

The New York Department of • 90 miles of new bicycle lanes Transportation and New York City alongside a reduction of parking Transit adopted a series of policies spaces. to create streets that accommodate cyclists, pedestrians and public Since implementing the Complete transport users, along with motor Streets programme, usage of the bus vehicles, including: service increased by 9% and speeds • Bus-only lanes and transit signal improved by 15-18%. Due to the priorities; Green Light for Midtown project, • Complete street roadway design in injuries to motorists and passengers many key locations within the city; decreased by 63% and to pedestrians • ‘Green Light for Midtown’ plan to by 35%. Finally, cycling has been reduce traffic congestion and to increased by 35% annually since the improve safety and public spaces; bicycle lanes were added. • A public plaza programme to create new open spaces and a sense of community; and

FURTHER RESEARCH AREAS Cities and infrastructure providers are makers (see ‘Appendix A. Existing There is a large body of research increasingly releasing open data as tools and methodologies’ for an covering the impacts of transport part of the smart cities movement and existing tool for walking and cycling on health internationally. Beyond the desire to fuel new technological infrastructure). The impact of transport the references cited throughout solutions to urban challenges. on health is a complex system linked this report, there are many This data can now be coupled with to wider social and economic context. additional sources of information for real-time data from sensors or This makes it difficult to predict practitioners and policy-makers. In smartphones to provide low-cost the influence of a single piece of the USA, the Active Living Research and accurate information about how infrastructure on specific health programme helps move research people are moving about a city and outcomes. However, systems thinking into practice, with a specific set of how this impacts health. Planners and modelling should help multi- resources on transportation108. In and designers can begin using this to disciplinary research teams develop Europe, the WHO Regional Office for evaluate new infrastructure options. tools that can aid design teams in Europe has a number of transport and This is likely to become increasingly creating urban transport environments health publications, tools and research sophisticated and automatic through that support multiple outcomes for networks to disseminate research and cloud-based tools that feed real-time multiple users. best practice109. data from multiple sources and allow layers to be mapped spatially and In the literature review for this interrogated for a number of different report we also identified a range of priorities. This is not currently widely existing tools and resources which available, but there are a number can be used in the urban design of tools which are moving in this process to integrate healthy transport direction. and mobility options. These are summarised in ‘Appendix A. Existing More accurate information about tools and methodologies’ and may the costs and benefits of new be a useful resource to help readers infrastructure should be integrated implement the design protocol. into data driven tools to aid decision- 72 Health + Mobility 73

Glossary

BMI: NMT: VMT: Body Mass Index, is a measure of Non-Motorised Travel, including Vehicle Miles Travel, usually to body fat based on the height and pedestrian and walking travel that is reference the distance for all travel weight (mass) that applies to adult derived. via motorised means (e.g., auto, men and women. BMI is a method of motorcycle, or transit). screening for weight category such NON-COMMUNICABLE DISEASES: as underweight, normal or healthy Non-communicable diseases (NCD) weight, overweight and obesity. is a medical condition or disease that is non-infectious or non- DESIRE LINES: transmissible. The four main types of An informal trail or path worn down non-communicable diseases include by often foot traffic to create a shorter cardiovascular diseases (like heart distance between two points rather attacks and stroke), cancers, chronic than taking a formal or set route such respiratory diseases (such as asthma) as a footpath. and diabetes.

GVA: OBESITY: Gross value added is a measure of the A medical term for a person who is contribution to an economy of an area, very overweight with excess body fat. industry or sector. The BMI is commonly used to help classify overweight and obesity in HEALTH: adults. The state of complete physical, mental and social well-being and not merely OVERWEIGHT: the absence of disease or infirmity11. Overweight is having extra body weight from muscle, bone, fat and/or LOS: water. The BMI is commonly used to Level of Service models aim to provide help classify overweight and obesity a common rating system for facilities in adults. used by cyclists and/or pedestrians. PMT: MOBILITY: Person Miles Travel, used to refer to The ability of people to move between the distance for all travel, regardless places and the ease with which they of mode. reach their destinations. PPM: MOBILITY INFRASTRUCTURE: Parts per million is a unit of measure The physical environment built by for volume and is often used to humans, that includes bridges, roads, measure particle concentration in air railways and transit hubs, together pollution. with the natural environment which support mobility of people. PRIORITY PEDESTRIAN CROSSING: A place designated for pedestrians MODAL SPLITS/SHARE: to cross a road where the pedestrian The percentage of travelers or has priority over other transportation number of trips of a particular type of modes. transportation mode. 74

Appendix Health + Mobility 75

A. Existing tools and methodologies

The first stage of this project was Assessment (HIA) as ‘a means of and transport infrastructure supports a rapid review of bibliographic assessing the health impacts of walking, cycling and accessing public databases and Google Scholar using policies, plans and projects in diverse transport. These tools could be a search concepts related to health, economic sectors using quantitative, useful input to the design protocol. transport and benchmarking. The qualitative and participatory purpose of this review was to ensure techniques.’112 Transport service WALK SCORE, BIKE SCORE AND that the outputs of the project build providers may be required to produce TRANSIT SCORE on existing evidence, methods and an HIA when proposing transport In the US, Canada, Australia and New best practice. infrastructure which requires Zealand residents, policy/decision- planning permission, or they may makers and planners can make use The findings from the review showed choose to produce an HIA for their of Walk Score, Transit Score and that there has been multiple models own purposes. HIAs are undertaken Bike Score to understand how well developed to test the impact of by consultants and are not currently a city, neighbourhood or particular potential transport infrastructure automated processes. Design teams location caters for these activities. projects on health and wellbeing could use HIAs from similar projects Walk Score is used by academic using modelling and GIS-based tools. or within the same city to mine useful researchers and has received grants There is not a consistent and widely data or recommendations. The HIA from the Rockefeller Foundation and accepted approach for all aspects consultant would be a valuable person the Robert Wood Johnson Foundation of such modelling. Some areas are to include in the design protocol to ensure the method’s algorithms more accepted than others, such as outlined in the main report. work with the latest research findings. measuring ‘walkability’. Many projects Walk Score is also used on real estate have adapted previous models and HEALTH EFFECTS AND RISKS OF listings in the US as research shows appear to be continually evolving TRANSPORT SYSTEMS (HEARTS) that homebuyers, tenants and certain methods in this area, especially in HEARTS is a WHO model of the health businesses place a high value on relation to GIS-based models. Several effects of road traffic. The tool informs walkability71. well-known and publicly accessible an integrated health risk assessment tools and methods are summarised that allows users to compare policy PEDESTRIAN AND CYCLING below. or development options and their ENVIRONMENT REVIEW SYSTEM associated risks. This includes The UK’s Transport Research HEALTH ECONOMIC ASSESSMENT ‘exposure to air pollution, noise and Laboratory has developed two TOOL (HEAT) FOR WALKING AND road accidents and the associated software tools to aid in the CYCLING health risks in relation to road assessment of pedestrian and cycling The HEAT tool was developed by WHO traffic.’113 The research team further environments. The parameters used to to measure the economic value of developed a GIS-based software tool, evaluate the pedestrian environment health benefits achieved from reduced STEMS, which incorporates a set of include114: surface quality, lighting, mortality from walking and cycling110. integrated steps and models based conflict with traffic, pedestrian The tool can be used internationally on extensive review of the evidence facilities, obstructions, cleaning, and requires some data input from on the health effects of air pollution, drainage, crossing type, deviation from the user. The assessment allows noise and road accidents. The HEARTS the desired route at crossing, crossing transport planners and other users system runs at two levels, as described refuge quality, rest points, public to benchmark the current situation in the report: 1) ‘the city-wide long- spaces, permeability, road safety and and compare the impact of potential term level using the proportions public transport waiting areas such as or proposed transport infrastructure. of time spent in different micro- bus stops and taxi ranks, public spaces There are limitations about who the environments and’ 2) ‘the detailed and interchange spaces. results apply to within a population level using individualized space–time– and which data can be used. However, activity patterns.’113 Other walkability and street the tool is regarded as the best assessment tools include: estimate available for non-health ACTIVE TRANSPORT ASSESSMENT • Walkonomics experts, such as transport planners111. TOOLS • Walkability app The following tools do not measure • RateMyStreet HEALTH IMPACT ASSESSMENT health impacts but rather they focus The WHO defines a Health Impact on how well the built environment 76

B. Data sources

The data sources listed here are freely available. This list is not intended to be comprehensive but a starting point of data available to support analysis.

OFFICE OF NATIONAL STATISTICS DEPARTMENT FOR ENVIRONMENT THE STATE OF OBESITY ONS is UK’s largest independent FOOD & RURAL AFFAIRS: AIR The State of Obesity provides producer of official statistics and QUALITY information on the obesity epidemic its recognised national statistical The DEFRA’s website includes data within the United States. It includes institute. ONS is responsible for from automatic air quality monitoring state level data on obesity rates collecting and publishing statistics stations measuring oxides of nitrogen by age, gender and race alongside related to the economy, population (NOx), sulphur dioxide (SO2), ozone (O3) ranking and trends from 1990. and society at national, regional and and particles (PM10 and PM2.5). http://stateofobesity.org/ local levels. This includes the Index http://uk-air.defra.gov.uk/interactive- of Multiple Deprivation. Census is map collected every 10 years in England Other and Wales. Data is available on LSOA level. USA EUROSTAT www.ons.gov.uk The Eurostat is the statistical office https://census.ukdataservice.ac.uk/ UNITED STATES CENSUS BUREAU of the European Union and aims to The Census Bureau provides data provide statistics at a European level PUBLIC HEALTH ENGLAND: HEALTH and statistics around the economy, to enable comparisons between PROFILES population and society at national, countries and regions. Data topics is Health Profiles is a programme to state and local levels. The Census wide ranging including demographics, improve availability and accessibility Bureau hosts a number of data and industry, transport, environment and for health and health-related visualisation tools. The census is economics in a format that is easily information in England. The profiles collected every 10 years. comparable with other countries and give a snapshot overview of health for http://www.census.gov/ regions in the EU. each local authority in England. Health http://ec.europa.eu/eurostat/web/ Profiles are produced annually. CENTERS FOR DISEASE CONTROL main/home www.healthprofiles.info AND PREVENTION (CDC) The CDC is part of the Department of OPENSTREETMAP NOMIS: LABOUR MARKET STATISTICS Health and Human Services. The CDC OpenStreetMap is a crowd-sourced Nomis is a service provided by the provides data and statistcis on various mapping website which is used ONS dedicated to providing detailed specific health and disease related and supported by amateur and and up-to-date UK labour market topics including physical activity, life professional mappers to create a high- statistics from offical sources. Data expectancy and heart disease. resolution dataset of buildings, roads includes employment, qualifications, http://www.cdc.gov/ and other topographical features. Data earnings, benefit claims and can be accessed as spatial information businesses. HEALTH INDICATORS WAREHOUSE using GIS programs. www.nomisweb.co.uk (HIW) https://www.openstreetmap.org/ The HIW is maintained by the CDC’s LONDON DATASTORE National Center for Health Statistics The London DataStore is a free and and provides access to high quality open data-sharing portal enabling data to understand a community’s anyone to access data relating to health status and determinants. the city. Datasets is wide ranging Indicators include chronic disease and including environment, housing, conditions, demographics, behaviours. transport, education, planning and Data that is provided is on National, safety. The datasets range in scale, State, County and hospital referral scope and format. region level. http://data.london.gov.uk/ http://www.healthindicators.gov/ Health + Mobility 77

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Biographies

LYDIA COLLIS XENIA KAREKLA INGRID STROMBERG ARCHITECT AND URBAN DESIGNER, RESEARCH ASSOCIATE, CIVIL, KNOWLEDGE MANAGER, PERKINS + PERKINS + WILL ENVIRONMENTAL AND GEOMATICS WILL Lydia works on a number of large scale ENGINEERING DEPARTMENT, UCL Ingrid works closely with practitioners urban design and planning projects in Xenia has a transport engineering around the world to keep the Cities the UK, Europe, and abroad. Focusing background and, since joining UCL, + Sites group on the cutting edge on complex mixed-use development, has been working on various projects of innovation. A seasoned urban research and innovation districts, as targeting improvements on the bus designer, Ingrid brings a strong well as urban infrastructure for public and metro systems of London. Her practical foundation to internal and and private clients, Lydia works to PhD research studied the level of external research initiatives around bring together the complex moving accessibility of London double-decker the built environment and health, pieces of a city to create unique buses. mobility, resiliency, and advancing vibrant urban environments that [email protected] sustainable communities. foreground environmental, social, and [email protected] economic sustainability and resiliency. IKUMI NAKANISHI [email protected] PROJECT MANAGER, ARUP LAURENS TAIT Ikumi is a strategic planner and PROJECT DIRECTOR, ARUP DAVID GREEN urban designer with a key interest Laurens is an Associate Director PRINCIPAL, PERKINS + WILL in creating better designs and cities responsible for leading Arup’s David is the Global Practice Leader for through evidence-based decision Planning and Computation team based Cities + Sites and in this position his making and community engagement. in Amsterdam. Laurens’ expertise is work and research focus on issues of Ikumi’s recent work with Arup has in transport infrastructure projects urban development and the creation seen her work across disciplines and the mobility aspects of large of strategies for sustainable cities. and internationally on large scale developments and has been involved This includes aspects of public policy, spatial data analysis, data harvesting, in metro, high speed rail, highway, implementation of development integrated land use and transport airports and port developments in controls, and strategic infrastructure planning, infrastructure master Europe, Asia and the Middle East. More implementation, with a particular planning, precinct and site wide recently, Laurens has been involved focus on research, education and analysis and design, design principles in various studies to determine links health districts. development, and digital engagement. between human health and transport [email protected] [email protected] infrastructure. [email protected] PAUL GROVER HELEN PINEO, MRTPI ASSOCIATE DIRECTOR, ARUP ASSOCIATE DIRECTOR FOR CITIES, PROFESSOR NICK TYLER Paul is a chartered town planner and BRE CHADWICK CHAIR OF CIVIL certified economist who is the Arup Helen is responsible for leading ENGINEERING, UCL UK lead for Urban Wellbeing. Paul the development of BRE services Nick’s research is about the future of draws on his extensive experience to help cities grow while achieving cities as a way to improve the quality in the management of strategic and the best outcomes for people, place of life and wellbeing, including the site specific projects to advise both and the planet. She is leading BRE’s health impacts of urban design. private and public sector bodies on Healthy Cities programme and is a [email protected] regeneration strategies, strategic PhD candidate at University College economic studies, integrated London, researching the use of urban infrastructure plans, spatial plans, health benchmarking systems by impact assessments and planning policy and decision-makers. consents. [email protected] [email protected]