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JULY / AUGUST 2012 :: 73(4)
Promoting Healthy and Sustainable Communities

This issue explores collaborations to improve the health of communities across the state, which are paramount to a healthy population, workforce, and economy. The policy forum includes articles highlighting various state departments' visions for healthy communities, as well as articles on planning, health impact assessments, local food systems, and efforts to strengthen the built environment. Original research includes an evaluation of the North Carolina Violent Death Reporting System and Medicaid coverage cost for the uninsured. A farewell and welcome to NCMJ editors in chief and a perspective on the challenge for health policy are also included.

INVITED COMMENTARY

The North Carolina Division of Public Health’s Vision for Healthy and Sustainable Communities

Cathy Thomas, Lori K. Rhew, Ruth Petersen

N C Med J. 2012;73(4):286-289.PDF | TABLE OF CONTENTS



The North Carolina Division of Public Health is working to improve access to physical activity through changes in the built environment by participating in the Healthy Environments Collaborative and by leading the state’s Communities Putting Prevention to Work project and the Shape Your World movement.

Prevention is critical if we are to curb the steady increase in health care costs that is greatly affecting our state. In 2010, an estimated $14 billion in medical costs and lost-productivity costs in North Carolina were attributable to 3 preventable risk factors: tobacco use, physical inactivity, and low dietary intake of fruits and vegetables [1]. Prevention is necessary to decrease demand for limited health care resources, to decrease health care costs, and most important of all, to increase the health and quality of life of North Carolinians, especially those affected by health disparities. Advancing health through prevention will require continued improvement of and support for the provision of health care services, as well as a new emphasis on making changes with respect to environmental influences on health. These changes include improving air quality, decreasing exposure to secondhand smoke, decreasing exposure to lead and other potential toxins, assuring continued access to safe drinking water, and designing the built environment to improve access to physical activity. The built environment consists of human-made resources and infrastructure designed to support human activity, such as buildings, sidewalks, parks, stores, and roads [2]. Increasing access to safe places to be physically active makes it more likely that individuals will engage in physical activity, which is associated with decreased risk of developing heart disease, type 2 diabetes, stroke, and some cancers [3].

Research shows that the built environment affects physical activity levels. A cross-sectional study was recently conducted to examine the effect of light rail transit (LRT) on body mass index (BMI) and physical activity levels in Charlotte. Individuals living within a 1-mile radius of a new LRT line were surveyed by telephone 8 to 14 months before the line was operational and again 6 to 8 months after it began operating. When the people who used LRT were compared with similar individuals who did not use it, a significant association was found between LRT use and reductions in BMI over time. LRT use was also associated with reduced odds of becoming obese. In addition, the study found that people who reported a more positive perception of their neighborhood had a lower BMI, were less likely to be obese, and were more likely to engage in the recommended amount of physical activity (20 minutes of vigorous activity 3 times a week, or 30 minutes of walking 5 times a week) [4].

Putting Prevention to Work
Affecting change in the built environment will require new partnerships, and to this end the Physical Activity and Nutrition (PAN) Branch of the Division of Public Health (DPH), North Carolina Department of Health and Human Services has expanded its strategic approach to increasing access to physical activity across the state. With an understanding that decisions made outside of the public health and health sectors affect the health of the population by improving or limiting access to physical activity, the DPH has aligned strategically with other state agencies. Understanding the interconnectedness of the different agencies that shape the community and how their decisions affect health is critical to achieving good health for the population. “Health in all policies” is an approach to the decision-making process that acknowledges that many decisions made outside of the health sector affect the health of the population. Including health benefits and impacts as a part of the decision-making process ensures that health is considered along with economics, commerce, transportation, safety, environment, education, and other factors.

Since 2006, the North Carolina Departments of Transportation (DOT), Environment and Natural Resources (DENR), Commerce, and Health and Human Services (specifically DPH) have been working together through the Healthy Environments Collaborative (HEC) to address areas of intersection between the environment, the economy, and health. This work was accelerated in 2010, when DPH became one of only 13 state health departments to receive Communities Putting Prevention to Work II (CPPW II) funding. This funding, provided through the 2009 American Reinvestment and Recovery Act, was awarded to state health departments that could demonstrate a readiness to implement special large-scale, statewide policy, or environmental change initiatives that affect population groups rather than individuals. One of the stated goals of the funding was to reduce health care costs through prevention.

The PAN Branch of DPH partnered with the Department of Health Behavior and Health Education of the Gillings School of Global Public Health at the University of North Carolina at Chapel Hill (UNC-Chapel Hill) on the design and implementation of the CPPW II project. The UNC-Chapel Hill partners brought innovation and expertise in policy analysis to the project, and the PAN Branch had a strong working relationship with the HEC. Working together, the team designed and implemented a project to create environments that support active living. Strategies include working with the HEC to integrate health concerns into projects involving transportation, the environment and natural resources, and commerce; working with municipalities to inform state-level work by providing information on barriers and facilitators to creating active living environments at the local level; and creating a communications campaign to help people understand how the environment around them affects their health and to let them know how they can become involved in making changes in their local communities to support active living.

Using an approach that involves state-level partners, community-level partners, and community members was critical in creating change across the state. The state-level partners in the HEC reviewed their practices, policies, and planning processes that have an impact on physical activity. They considered ways to increase support for and alignment around these activities. One unique example that arose from this project was the space allotment required at the local level for greenways. Partners at the DOT and the DENR discovered that the DOT’s space requirements for local greenways differed from DENR’s requirements. Once they became aware of this discrepancy, the 2 departments were able to resolve it, and requirements no longer hinder approval for proposed greenway projects.

Through a competitive application process, 11 municipalities—the cities of Gastonia and Wilmington, and the towns of Midland, Eden, Mount Gilead, Carrboro, Ashokie, Lumberton, Sparta, Banner Elk, and Waxhaw—received funding to identify barriers to active living in their communities, create action plans, and engage in projects to promote active living. The projects included updating comprehensive land use and transportation plans, adopting a resolution in support of the DOT’s Complete Streets Policy (which intends to make streets useable by all types of users including pedestrians, bicyclists, transit riders, motorists, and individuals of all ages and capabilities), implementing bike routes by adding signs and creating maps showing the routes, and initiating new programs. In addition, the municipalities informed the HEC of the barriers they encountered and engaged in dialogue about potential solutions.

Conclusion
As a result of the CPPW II project, the HEC partnership has strengthened and increased its focus on active living, and each partner has found ways to align its efforts with those of other state agencies. For example, the DOT is integrating public health considerations into the long-range transportation planning process, the statewide bicycle and pedestrian plan, and the Complete Streets design guidelines; the North Carolina Department of Commerce hopes to incorporate “access to physical activity” criteria into the worksite certification program; and the DPH has begun work on increasing joint-use agreements between communities and facilities offering green space and playground access as part of public health interventions. The HEC state agencies are collaboratively looking at how to increase the inclusion of health considerations in comprehensive planning with an understanding of the connections between health and land use planning, transportation planning, environmental equality, and economic development.

The participation of state-level partners, community-level partners, and community members in the CPPW II project has been essential to its success. The HEC partnership has played a critical role in helping each individual agency understand how state departments could align and integrate efforts to support active living. Municipalities have been able to inform state partners of barriers they experience in their communities as a result of state practices and policies. Local community partners and community members have been able to better understand how the built environment can help or hinder their ability to make healthy choices.

In the end, we all win when North Carolina communities become healthier through increased access to physical activity. This requires collaboration between local community members, health officials, the public health community, parks and recreation organizations, regional planners, decision makers, and local and state agencies. The DPH is incorporating this vision in planning its work. Adding input from the medical and public health communities will facilitate success in these efforts and set us on a path to lower the demand for medical treatment, decrease health care costs, and improve the quality of life and the level of wellness for the entire population.

Acknowledgment
Potential conflicts of interest. All authors have no relevant conflicts of interest.

References
1. Tipping the Scales: The High Cost of Unhealthy Behavior in North Carolina. Be Active North Carolina 2012 Report. http://www.beactivenc.org/wp-content/uploads/2011/08/Tipping-the-Scales-Final_2012.pdf. Accessed May 9, 2012.

2. County Health Rankings and Roadmaps. University of Wisconsin Population Health Institute. http://www.countyhealthrankings.org/health-factors/built-environment. Accessed June 29, 2012.

3. Task Force on Community Preventive Services. Recommendations to increase physical activity in communities. Am J Prev Med 2002;22 (4S):67-72. http://www.thecommunityguide.org/pa/pa-ajpm-recs.pdf. Accessed June 29, 2012.

4. MacDonald JM, Stokes RJ, Cohen DA, Kofner A, Ridgeway GK. The effect of light rail transit on body mass index and physical activity. Am J Prev Med. 2010;39(2)105–112. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2919301/. Accessed May 11, 2012.


Cathy Thomas, MAEd, CHES head, Physical Activity and Nutrition Branch, North Carolina Division of Public Health, North Carolina Department of Health and Human Services, Raleigh, North Carolina.
Lori K. Rhew, MA, PAPHS manager, Physical Activity Unit, Physical Activity and Nutrition Branch, North Carolina Division of Public Heath, North Carolina Department of Health and Human Services, Raleigh, North Carolina.
Ruth Petersen, MD section chief, Chronic Disease and Injury Prevention, North Carolina Division of Public Heath, North Carolina Department of Health and Human Services, Raleigh, North Carolina.

Address correspondence to Ms. Cathy Thomas, Physical Activity and Nutrition Branch, NC Department of Health and Human Services, 5505 Six Forks Rd, Raleigh NC 27699 (Cathy.Thomas@dhhs.nc.gov).