6
Current State of Knowledge

Understanding how the built environment may affect physical activity is a relatively new but rapidly expanding field of inquiry. The literature comes primarily from two fields: urban planning (travel behavior) and public health (physical activity).1 The former has focused largely on automobile travel but has also explored walking and cycling as modes of travel. The physical activity literature has focused on the personal and social determinants of physically active behavior and on the intensity and the amount of physical activity, with less attention to the type or location of that activity (Handy 2004). Neither field has had a long history of examining the role of the built environment as a determinant of physical activity (Handy 2004).

In this chapter, the empirical evidence on the relationship between the built environment and physical activity is reviewed. The chapter begins with an overview of the literature and then summarizes the evidence by drawing on studies from both the travel behavior and physical activity fields. Where possible, the results are further analyzed to highlight the role of sociodemographic factors, geographic scale, and such mediating variables as safety and security and time. The studies reviewed are primarily cross-sectional, but the results of a few studies whose research designs are more conducive to drawing causal inferences are also discussed. The final section summarizes knowledge gaps revealed by this review.

1

This chapter draws heavily on a literature review and paper commissioned by the committee (Handy 2004).



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Does the Built Environment Influence Physical Activity? Examining the Evidence - Special Report 282 6 Current State of Knowledge Understanding how the built environment may affect physical activity is a relatively new but rapidly expanding field of inquiry. The literature comes primarily from two fields: urban planning (travel behavior) and public health (physical activity).1 The former has focused largely on automobile travel but has also explored walking and cycling as modes of travel. The physical activity literature has focused on the personal and social determinants of physically active behavior and on the intensity and the amount of physical activity, with less attention to the type or location of that activity (Handy 2004). Neither field has had a long history of examining the role of the built environment as a determinant of physical activity (Handy 2004). In this chapter, the empirical evidence on the relationship between the built environment and physical activity is reviewed. The chapter begins with an overview of the literature and then summarizes the evidence by drawing on studies from both the travel behavior and physical activity fields. Where possible, the results are further analyzed to highlight the role of sociodemographic factors, geographic scale, and such mediating variables as safety and security and time. The studies reviewed are primarily cross-sectional, but the results of a few studies whose research designs are more conducive to drawing causal inferences are also discussed. The final section summarizes knowledge gaps revealed by this review. 1 This chapter draws heavily on a literature review and paper commissioned by the committee (Handy 2004).

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Does the Built Environment Influence Physical Activity? Examining the Evidence - Special Report 282 OVERVIEW OF THE LITERATURE The literature review conducted for this study encompassed 22 studies from the fields of urban planning/travel behavior and 28 studies from the fields of public health/physical activity (Handy 2004). It drew heavily on recently published reviews of studies supplemented with additional studies known to the committee or Handy or published more recently. International studies were included, although the committee recognizes that the social and environmental determinants of physically active behavior may not be fully comparable with nor the results transferable to the situation in the United States. The committee acknowledges the contribution of international scholars and the importance of international collaboration on research linking the built environment and physical activity. At the same time, it cautions the reader that the policy relevance of the experience in other countries for the United States should be examined with care. Differences in land use and transportation patterns (e.g., lower densities, lower transit use, and greater reliance on the automobile in most U.S. metropolitan areas) and dissimilar regulatory and institutional arrangements (e.g., local rather than central control over land use and zoning policies) may limit the applicability of international experience to the United States (TRB 2001). For example, the experience of Australia and Canada, where land use densities and travel patterns are more similar to those of the United States, may have more relevance and transferability than the experience of many more densely populated and transit-oriented European countries. Handy’s (2004) selection of studies for review in her commissioned paper reflects her subjective assessment of the suitability and relevance of the research. She notes that a detailed evaluation of the quality of execution of each study, using criteria such as those employed by the Task Force on Community Preventive Services, was beyond the scope and resources of the review (Handy 2004).2 2 The reader is directed to the following references for a thorough discussion of the evidence-based methods used in preparation of the task force’s Guide to Community Preventive Services: Briss et al. 2000 and Carande-Kulis et al. 2000.

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Does the Built Environment Influence Physical Activity? Examining the Evidence - Special Report 282 In fact, a task force review of environmental interventions to promote physical activity is under way but has not yet been completed.3 The findings and conclusions presented in this chapter reflect the committee’s judgment, although, with few exceptions, that judgment agrees with Handy’s assessment. The vast majority of the studies reviewed use a cross-sectional design; that is, they examine outcomes (i.e., levels of physical activity) at a particular point in time as a function of explanatory variables (i.e., characteristics of the built environment that vary by neighborhood or region). As discussed in Chapter 5, this design enables researchers to draw correlations between variables of interest and isolate those that are statistically significant but not to demonstrate causality. The review in this chapter should not be viewed as exhaustive but as illustrative of the research completed and under way to date. The field is growing rapidly, more interdisciplinary work is being conducted, and new studies and research results are emerging. REVIEW OF FINDINGS Findings from the Travel Behavior Literature The focus of these studies is on destination-oriented walking trips and nonmotorized travel rather than on walking and cycling for recreation and exercise. As noted, nearly all the studies are cross-sectional, and many control for socioeconomic variables—household size, income, automobile ownership, age, gender, race, employment status—drawn primarily from travel diary data. Two studies incorporate attitudinal factors as control variables, including attitudes about transportation and lifestyle preferences (Kitamura et al. 1997; Bagley and Mokhtarian 2002). Measures of the built environment include population and employment density, 3 Part of the review that deals primarily with work site interventions (e.g., industrial plants, universities, and federal agencies) and related informational outreach programs has been completed (Kahn et al. 2002), and the results are discussed in the subsequent section under “Building or Site Level.”

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Does the Built Environment Influence Physical Activity? Examining the Evidence - Special Report 282 land use mix or diversity of land uses, and design (e.g., shade, scenery, presence of attractive stores and houses), features that have been characterized as the three D’s of land use—density, diversity, and design (Cervero and Kockelman 1997). Other measures include transportation infrastructure (e.g., presence and continuity of sidewalks), street pattern (e.g., grid, cul-de-sac) and connectivity, presence of bicycle paths, neighborhood type (e.g., traditional versus suburban planned unit development), and accessibility (e.g., distances to destinations or numbers of destinations within a specified distance). Although it is difficult to summarize the results of these studies in view of the breadth of measures considered, inspection of the study findings (see Handy 2004, Table 3-4, and Table 6-1, pp. 174–189 in this report) suggests that certain measures are positively (or negatively) correlated with walking or cycling for travel.4 Land use correlates include a few density measures—population, employment, and retail density—and diversity of land uses. All are positively correlated with nonmotorized travel (i.e., the greater the density of population, employment, stores, and mix of land uses, the greater is the number of walking and other nonmotorized trips). Predictably, access (i.e., distance to nearest destination), another land use measure, is negatively correlated with nonmotorized travel in several studies. A grid street network and presence and extent of sidewalks are the primary transportation-related correlates, both being positively correlated with nonmotorized travel. Design features, with the exception of those of commercial areas, are insignificant, but only four studies examine the effect of such features. Certain neighborhood types—traditional,5 transit-served, and walkable—are positively correlated with walking and nonmotorized travel. The results are difficult to interpret, however, because of the lack of specificity about the characteristics of these neighborhoods. 4 The pluses and minuses in the tables represent results that are statistically significant. The level of significance (e.g., 5 percent, 1 percent) varies from study to study and is not noted. 5 Traditional neighborhoods are characterized by a people-oriented, small-town scale with such features as sidewalks and front porches, which have been emulated in neotraditional or new-urbanist developments.

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Does the Built Environment Influence Physical Activity? Examining the Evidence - Special Report 282 Findings from the Physical Activity Literature The focus of these studies is on walking, primarily for exercise and recreation; other types of physical activity (e.g., vigorous or moderate-intensity exercise, leisure-time physical activity other than walking); and total physical activity (distinguishing between those who are active and inactive or who do and do not meet recommended levels of physical activity). Measures of the built environment used in these studies cover a breadth of variables that differ considerably from those used in the travel behavior literature. They often include perceptual characteristics—perceived safety, aesthetics and other neighborhood characteristics, and accessibility—rather than objective measures. Where objective measures are used, they fall into many of the same categories as in the travel behavior literature, such as accessibility, design, neighborhood type, and infrastructure for nonmotorized transportation. However, the destinations are most often trails, bicycle paths, or recreation centers rather than the more utilitarian destinations in the travel behavior literature (e.g., shopping, transit stations). Drawing on ecological models, many of these studies include information about individual attitudes and intentions regarding physical activity (e.g., self-consciousness about appearance) and about the social as well as the physical environment (e.g., club membership, engaging in physical activity with another). Thus, these studies are able to assess the relative importance of all these factors in the decision to be physically active. Most of the studies also control for more typical socioeconomic variables, such as age, gender, race, ethnicity, educational level, marital status, employment status, and income level. With regard to effects of the built environment, the study results reveal that a few measures are significantly correlated with physical activity (see Handy 2004, Table 3-7, and Table 6-2, pp. 190–209 in this report). For example, subjective measures of accessibility are positively correlated with several types of physical activity in a number of studies. Likewise, neighborhood characteristics, identified by both subjective and objective measures such as presence of sidewalks, enjoyable scenery, and seeing others exercising, are

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Does the Built Environment Influence Physical Activity? Examining the Evidence - Special Report 282 positively correlated with walking and total physical activity. The importance of subjective perceptions of neighborhood characteristics is not surprising in view of trip purpose in these studies, which is often for leisure or recreation rather than for destination-oriented travel. Notably absent, however, are strong associations between measures of perceived safety, design, and diversity of land uses and physical activity. Summary Assessment The existing literature approaches the relationship between the built environment and physical activity from a broad range of perspectives, areas of expertise, and measures of the variables of interest. The study results provide a growing body of evidence that shows an association between the built environment and physical activity. That having been said, it is difficult—perhaps because of the diversity of the literature—to sort out which characteristics of the built environment have the strongest association. Nevertheless, the study results reveal some patterns that suggest opportunities for further investigation. Land Use Population, employment, and land use density and mix/diversity are positively correlated with walking in the transportation literature. In the physical activity literature, fewer studies were found that examine land use measures. Land use diversity (one study) was positively correlated with walking, and density of pay and free facilities (one study) was positively correlated with total physical activity levels. The characteristic of land use density is a good example of the complexities involved in linking the design of the built environment to travel behavior, such as walking in the neighborhood or walking to access transit. Several studies, for example, explored the link between transit use, development density, and urban design (Pushkarev and Zupan 1977; Messenger and Ewing 1996; Frank and Pivo 1994). They found that as density increased at both trip origin and destination, transit use rose, access by walking increased, and automobile use declined. Other analyses have shown that, although

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Does the Built Environment Influence Physical Activity? Examining the Evidence - Special Report 282 more compact development supports more walking and transit use, automobile ownership and travel patterns also reflect differences in the household characteristics and income of persons living at different density levels (Dunphy and Fisher 1996; Schimek 1996). When these factors are controlled for, the independent effect of density becomes far less robust. Moreover, the density thresholds needed to support transit are reached only in the most heavily populated central cities of U.S. metropolitan areas (TRB 1995). Density may well be a proxy for other variables, such as demographics, distance, car ownership levels, and transit service quality (Boarnet and Crane 2001). In her literature review for the committee, Handy (2004) notes that in studies that tested the significance of measures of both density and accessibility, the latter were significant, while the former were not. Indeed, density may serve as a proxy for accessibility, which provides a more direct explanation for travel behavior. Accessibility Typically measured as distance from destinations or facilities, accessibility is significantly correlated with physical activity in studies from both the travel behavior and physical activity literatures. In the former, distance from the nearest destinations, such as stores, bus stops, and parks, emerges as a significant correlate of non-motorized trips in general and of shopping and school trips in particular. Longer distances discourage all travel, but especially nonmotorized. In the physical activity literature, both perceived and objective measures of proximity and convenience of facilities, ranging from exercise equipment at home, to bicycle paths and trails, to parks, to local shopping and transit stops, are significantly and positively correlated with walking, other forms of exercise and recreation, and total physical activity. The importance of good access to and convenience of facilities and destinations in the decision to be physically active is certainly plausible from a theoretical perspective. As discussed in Chapter 4, reducing the cost of a desired behavior—in this case by increasing the closeness and convenience of trip destinations—helps encourage the desired behavior.

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Does the Built Environment Influence Physical Activity? Examining the Evidence - Special Report 282 Design The evidence for a correlation of design features and aesthetic characteristics of neighborhoods with physical activity is more limited. Design variables, such as neighborhood aesthetics and enjoyable scenery, emerge most strongly in the physical activity literature as significant correlates of physical activity, particularly walking. The one statistically significant result in the travel behavior literature is the positive correlation of design variables with walking trips for shopping. Handy et al. (1998) found that positive perceptions about shade, scenery, traffic, people, safety, and walking incentive and comfort were positively correlated with numbers of walking trips to neighborhood commercial areas. These limited findings about the importance of design could reflect either the small number of studies that examined these variables, particularly in the travel behavior literature, or poorly specified measures of design. They could also signal the lack of a significant relationship between design and physical activity, or a relationship that may depend on the particular type of physical activity involved. Handy (2004) suggests the latter and concludes that design measures may be a more important influence on walking for recreation and exercise than on destination-oriented travel. Indeed, another review of the literature, drawing on a different set of studies, arrived at much the same conclusion (Humpel et al. 2002). Both reviewers, however, conclude that more research is needed to determine which aspects of design may matter and how they are related to different types of physical activity. Transportation Infrastructure The presence of sidewalks emerges in both literatures as a significant correlate of walking and nonmotorized travel. Other correlated transportation infrastructure measures include the proportion of streets with sidewalks and the percentage of the road network having a grid pattern. Some additional evidence exists that the condition of sidewalks is important to physical activity (Sharpe et al. 2004; De Bourdeaudhuij et al. 2003; Hoechner et al., in press). Senior citizens, in particular, may find uneven and cracked sidewalks barriers to walking because of the risk of falls (Loukaitou-Sideris 2004).

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Does the Built Environment Influence Physical Activity? Examining the Evidence - Special Report 282 Attitudes and Motivation The limited number of studies that included individual and interpersonal factors found them to be more important than the physical environment in explaining levels of walking and other forms of physical activity (Kitamura et al. 1997; Bagley and Mokhtarian 2002; Giles-Corti and Donovan 2002b). For example, Handy (1996a) and Moudon et al. (1997) found high levels of walking in suburban areas even though these areas had been rated relatively low in terms of walkability. Thus the built environment may not be that important to those who are highly motivated to walk (Handy 2004). At the other end of the spectrum, a more appealing physical environment may not make a difference to those who have little motivation to walk or engage in other forms of physical activity. For many who fall between these two extremes, however, the built environment can facilitate or constrain physical activity. Handy (2004) concludes, and the committee concurs, that a supportive built environment alone is not sufficient to influence physical activity; nevertheless, it can play a facilitating role. ANALYSIS OF FINDINGS Effects of the Built Environment on Different Socioeconomic Groups Data on physical activity levels of the adult population from the large public health surveys discussed in Chapter 2 indicate that activity levels decrease with age and are lower among women, ethnic and racial minorities, those with less education and low income levels, the disabled, and those living in the southeastern region of the United States (CDC 2003). The committee had hoped to examine the results of the literature review conducted for this study according to various socioeconomic groups to understand how characteristics of the built environment may affect the propensity of these groups to be physically active. Very little could be gleaned on this question, however. This is not surprising given that the results for the general population, with some exceptions, show little consistency in the effects of the various environmental characteristics studied.

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Does the Built Environment Influence Physical Activity? Examining the Evidence - Special Report 282 An examination of the results of the physical activity literature from the perspective of demographic differences is a good case in point. Of the 28 studies in this literature reviewed by Handy (2004), only nine describe the relationship between the built environment and physical activity separately for some demographic characteristic. Few coherent patterns emerge from the analyses. Seeing others exercising was positively associated with physical activity for African Americans, Hispanics, and rural women (King et al. 2000; Eyler et al. 2003; Wilcox et al. 2000). Physical activity was lower among racial and ethnic minorities who perceived their neighborhood to be unsafe and among older men and women (aged ≥65 years) (CDC 1999). Gender differences are more difficult to interpret. For example, walking and moderate activity among women were positively correlated with diversity of land use, ease of walking to a transit stop, access to local shopping, and emotional satisfaction with a neighborhood, but not with presence of sidewalks or satisfaction with neighborhood services (De Bourdeaudhuij et al. 2003). Effects of the Built Environment at Different Geographic Scales The role of the built environment can affect the propensity to be physically active at many geographic scales (the building or site level, the neighborhood, and the region) (see Figure 1-2 in Chapter 1). In general, the issue of geographic scale is underexamined in the recent literature (Boarnet 2004). Building or Site Level Little is known about how the design of buildings and their sites may influence physical activity (Zimring et al. 2004), which is why the committee did not focus more of its investigation at this scale. Yet most Americans spend the majority of their day in and around buildings—at home, work, or school. This suggests that these locations can provide important opportunities to be physically active. The form of buildings and sites is thought to affect physical activity at several spatial scales. These include building elements, such as the layout of stairs and exercise rooms; overall building design; and site selection and design, which comprise connectivity be-

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Does the Built Environment Influence Physical Activity? Examining the Evidence - Special Report 282 tween buildings, connectivity of buildings to the edge of the site, and proximity to off-site amenities (Zimring et al. 2004). Very limited data could be found on physical activity at home. Two studies included in Handy’s (2004) review found that having home exercise equipment was positively correlated with vigorous exercise (De Bourdeaudhuij et al. 2003; Sallis et al. 1989). Workplaces are another important but understudied location for physical activity. Stair use provides a low-cost way to integrate physical activity into the daily routine, and there is some limited evidence that interventions to increase workplace stair use (e.g., motivational signs and music in the stairwell) can be effective, although the duration of the effect is unclear (Kerr et al. 2004). Other, more costly interventions, mainly at work sites (e.g., equipment in fitness centers or community centers, creation of walking trails), in conjunction with informational programs, were found to be effective in increasing physical activity (Kahn et al. 2002). The workplace can also be an important base for walking trips, depending on the location of the building and the site layout. An analysis of trip linkage patterns, for example, found that the highest percentage of non-work-related trips involving physical activity are accounted for by walking to and from the workplace before, during, and after work (Wegmann and Jang 1998). Connectivity between buildings and shelter from the elements, placement of parking, and availability of amenities (walking or running trails in suburban, campuslike office complexes and presence of stores and other desirable destinations near urban office buildings) could encourage more such walking trips (Zimring et al. 2004). Company interest in promoting physical activity can pay off because a healthy workforce reduces health care costs (see Chapter 2). Neighborhood Level To date, most of the literature has focused on environmental determinants of physical activity at the neighborhood level, and this is appropriate. The neighborhood provides opportunities for all types of physical activity. Indeed, in a recent survey of U.S. adults—the U.S. Physical Activity Study—approximately two-thirds of respondents identified neighborhood streets as the setting where they

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Does the Built Environment Influence Physical Activity? Examining the Evidence - Special Report 282 Study Sampling Survey Physical Activity Variable   BRFSS sampling plan sectional survey (based on moderate activity and vigorous activity) NOTE: ANOVA = analysis of variance; BMI = body mass index; BRFSS = Behavioral Risk Factor Surveillance System; MAREPS = Methodology for the Analysis of the Rationality and Effectiveness of Prevention and Health Promotion Strategies; NHANES = National Health and Nutrition Examination Survey; SES = socioeconomic status. aSociodemographic and geographic variables only; many studies include other individual measures and social environment measures. bResults of multivariate analyses reported when available. cIncluded in Humpel et al. 2002.

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Does the Built Environment Influence Physical Activity? Examining the Evidence - Special Report 282 Controls/Confoundersa Built Environment Variables Resultsb   able scenery, frequently see others exercising, high levels of crime Safe to walk or jog alone during the day (5-point scale) Barriers (5-point scale): lack a safe place to exercise, poor weather  

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Does the Built Environment Influence Physical Activity? Examining the Evidence - Special Report 282 REFERENCES Abbreviations BR&S Belden, Russonello & Stewart CDC Centers for Disease Control and Prevention EPA U.S. Environmental Protection Agency NCSA National Center for Statistics and Analysis NHTSA National Highway Traffic Safety Administration TRB Transportation Research Board Bagley, M. N., and P. L. Mokhtarian. 2002. The Impact of Residential Neighborhood Type on Travel Behavior: A Structural Equations Modeling Approach. Annals of Regional Science, Vol. 36, No. 2, pp. 279–297. Ball, K., A. Bauman, E. Leslie, and N. Owen. 2001. Perceived Environmental Aesthetics and Convenience and Company Are Associated with Walking for Exercise Among Australian Adults. Preventive Medicine, Vol. 33, No. 5, pp. 434–440. Berrigan, D., and R. P. Troiano. 2002. The Association Between Urban Form and Physical Activity in U.S. Adults. American Journal of Preventive Medicine, Vol. 23, No. 2S, pp. 74–79. Black, C., A. Collins, and M. Snell. 2001. Encouraging Walking: The Case of Journey-to-School Trips in Compact Urban Areas. Urban Studies, Vol. 38, No. 7, pp. 1121–1141. Boarnet, M. G. 2004. The Built Environment and Physical Activity: Empirical Methods and Data Resources. Prepared for the Committee on Physical Activity, Health, Transportation, and Land Use, July 18. Boarnet, M. G., and R. Crane. 2001. Travel by Design: The Influence of Urban Form on Travel. Oxford University Press, New York. Boarnet, M. G., K. Day, C. Anderson, T. McMillen, and M. Alfonzo. 2004. Urban Form and Physical Activity: Insights from a Quasi-Experiment. Presented at the Active Living Research Annual Conference, Del Mar, Calif., Jan. 30. Boarnet, M. G., and S. Sarmiento. 1998. Can Land-Use Policy Really Affect Travel Behavior? A Study of the Link Between Non-Work Travel and Land-Use Characteristics. Urban Studies, Vol. 35, No. 7, June, pp. 1155–1169. Booth, M. L., N. Owen, A. Bauman, O. Clavisi, and E. Leslie. 2000. Social-Cognitive and Perceived Environmental Influences Associated with Physical Activity in Older Australians. Preventive Medicine, Vol. 31, pp. 15–22. Briss, P. A., S. Zaza, M. Pappaioanou, J. Fielding, L. Wright-De Agüero, B. I. Truman, D. P. Hopkins, P. Dolan Mullen, R. S. Thompson, S. H. Woolf, V. G. Carande-Kulis, L. Anderson, A. R. Hinman, D. V. McQueen, S. M. Teutsch, and J. R. Harris. 2000. Developing an Evidence-Based Guide to Community Preventive Services—Methods. American Journal of Preventive Medicine, Vol. 18, No. 1S, pp. 35–43.

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