In the final session of the workshop, four panelists discussed potential opportunities for action gleaned from the earlier presentations and discussions.1 The panelists were Janet Fulton, chief of the Physical Activity and Health Branch in the Division of Nutrition, Physical Activity, and Obesity at the CDC; Steve Lavrenz, technical programs specialist for the Institute of Transportation Engineers; Patricia Smith, senior policy advisor for the Reinvestment Fund; and Ken Wilson, a principal and design director of interiors in the Washington, DC, office of Perkins and Will.
“We want to think about what we can do, how we can take our work to the next level, and what steps we could take together to focus on leveraging built environment opportunities to prevent obesity,” said the panel’s moderator, Monica Hobbs Vinluan, senior program officer at the Robert Wood Johnson Foundation. The remarks of the panelists are organized thematically in this chapter to highlight the potential actions they suggested for communities and organizations.
1 The information summarized here reflects the knowledge and opinions of individual panelists and should not be seen as a consensus of the workshop; the Roundtable on Obesity Solutions; or the National Academies of Sciences, Engineering, and Medicine.
Several members of the final panel raised the topic of understanding the needs of specific communities—from rural environments to large cities with diverse populations—and ensuring that solutions address those needs.
Fulton began by emphasizing a point made by several of the earlier presenters: understanding the needs and opportunities of communities at the local level may be useful for achieving large-scale impact. She highlighted the importance of meeting communities where they are and approaching them by asking questions about their needs. Doing so, she asserted, can result in strategies that differ from community to community and region to region, including communities and regions that are disadvantaged or in which obesity rates are highest.
On this point, Smith emphasized the importance of being sensitive to cultural heritage. “We must, as we think about planning and land use,” she said, “not overlook those long traditions of culture and heritage and what that means to [a] community. The way you get at that is by having community voice and decision making at that table.” She noted that the Reinvestment Fund, with the support of the Robert Wood Johnson Foundation, has been working in small and midsized cities and towns on an initiative called Invest Health.2 The capacities of these places are very different from those of large cities with respect to resources, skill sets, and access to information, she observed. For that reason, she said, the Reinvestment Fund has been acting in a convening and facilitative role to share information and data to which officials may otherwise not have access. She added that leadership teams include a public-sector official, a representative of a hospital or university, a community organizer, and someone focused on development, and that creating such teams facilitates collaboration and cross-sector thinking.
Lavrenz pointed out that taking action at the local level often requires personalizing issues that would otherwise remain abstract. He explained, for example, that the Institute of Transportation Engineers has been emphasizing to its members that transportation need not be improved just for transportation’s sake; rather, it can be tied to the idea of more livable communities and the specific ways in which people work and play.
For many communities, he continued, improvements to the built environment are also economic development opportunities. The construction of bicycle infrastructure offers a particularly high rate of return by attracting new residents and businesses, he observed. “Not only are you making the space more welcoming and safer for the people using the transportation system,” he said, “but you are revitalizing a lot of those communities. That
2 More information about the program is available at https://www.reinvestment.com/initiatives/invest-health (accessed November 30, 2017).
is a message that resounds strongly with practitioners, whether they are in transportation or public health or other policy areas.”
Lavrenz also pointed out that many of the members of the Institute of Transportation Engineers are from smaller and more rural communities. In those communities, he argued, large-scale and expensive design solutions, such as separated bike paths, may not make sense. Rather, he suggested, smaller and simpler measures, such as slowing down traffic through pavement markings or making roads more amenable to multiple modes of travel, may be preferable. “Being sensitive to context is important,” he stressed.
Smith made the point that new models are exciting but that innovation also involves costs. She asked: “How do you finance it? What [funding] is needed to make sure that it is carried out and implemented in a great way? Is that the role of philanthropy? Is that the role of government? Whose job is it to pay for innovation and new concepts?” In response to this point, Wilson observed that many new best practices, such as health and wellness rating systems or Leadership in Energy and Environmental Design (LEED) ratings3 for buildings, cost relatively little now that they are more common or mandated by code. He added that organizational policies also can make businesses and workplaces more healthy and active, such as by reducing access to sugar-sweetened beverages. People spend more than 90 percent of their time indoors, he noted, and “minor improvements in the quality of the indoor environment—whether it is air quality, natural light, views to the outside, being able to get up and walk around, take the stairs—things like that can have a huge value [to a worksite].”
Fulton observed that implementing programs is essential, “but we need to show that they work.” For that reason, she noted, evaluation can be built into programs to establish a foundation of evidence. “We need to build on it,” she said. “We need to use it as we go out and try to change the world.”
Practitioners need to think ahead of time about what they want to show, she continued. “What successes do we want to see in our investments?” She stressed that planning for data gathering, analysis, and dissemination has to take place “up front,” and the objective should be “not just data for data’s sake, but data that matter and data that can help improve the lives of the people we are trying to affect.” As an example, she cited the displacement of people and businesses as a complex issue that demands advance thought. “Those kinds of issues need to come front and center when we think about working in disadvantaged [or low-resourced] communities,” she argued.
Smith suggested that for practitioners, demonstrating impact can help
as they advocate for resources. “That is the first question you are usually asked,” she said. “What difference does it make, and how can you prove it?” Good evaluation sometimes requires questioning assumptions, she added: “If the evidence is starting to indicate that our original assumptions are not playing out, don’t be afraid to question them.”
Engineers thrive in a data-rich environment, Lavrenz pointed out. He observed that “the more that we, as a community of transportation professions and stakeholder groups, can collect data and tie it to particular performance measures in health and transportation—to measurable outcomes—[the greater the] level of adoption and buy-in from stakeholders within the transportation profession.”
Several of the panelists suggested that the role of the built environment in advancing obesity solutions can be conveyed to a variety of stakeholders.
Vinluan noted that different things resonate with different types of decision makers, including transportation engineers, architects, or the general public.
Fulton emphasized the importance of telling “really good stories.” She added that accounts of success and opportunity can be tailored to the targeted audience: “It can be decision makers. It can be parents. It can be kids themselves. But [tell] those stories with emotion—and also [try] to bring in the data that matter to them. . . . I heard a lot in this room about the great things that are happening. I would love to see those stories translated to key audiences in emotionally compelling ways.”
Lavrenz stressed that framing messages correctly is critical when facilitating healthier communities. For example, he observed that when communities are hit by natural disasters, the process of rebuilding can be framed in terms of healthy, safe, and resilient communities. For example, he said, “as horrible as hurricanes are, they do provide a good opportunity to have some of those conversations about that larger scale of rebuilding.”
Smith cautioned, however, that the complexity of the issue confounds the task of communicating messages to audiences. “We are a society of sound bites,” he noted. “Quick and simple is what you are under pressure to do.”
The importance of partnerships was another point highlighted by many of the presenters and echoed by several members of the final panel. Building partnerships requires good communication, Fulton pointed out, which in turn requires listening as well as communicating. “What does transporta-
tion need?” she asked. “What do decision makers need? What do parents need? If we enter those conversations in that way, we will be able to form those cross-sectoral collaborations in a better way.” To illustrate this point she cited support by the CDC for a training program that brings together professionals from different sectors (e.g., transportation and planning, business, and public health) to develop an action plan for their communities. She described this as “a great model to think about as we move forward to develop effective partnerships.” She added that many of the partners who need to be involved are not among what she called “the usual suspects”; for example, real estate developers are major influences in the built environment, yet they are not often involved in these conversations. “We have to open up the tent and really look beyond the usual suspects,” she argued. “It might not be easy to invite people into our room,” she acknowledged, “but we certainly can go into others, like conferences and meetings and opportunities to meet with other [potential partners]. I am talking about the developers, the bankers, and the business owners.” She emphasized as well the importance of including young people as partners: “They are also not among the usual suspects. Getting and bringing in their voice is very important.”
Wilson observed that because obesity is a complex problem, no one strategy or one sector can completely address the issue. Rather, he asserted, “it is really multiple strategies that will get you where you want to go.” Vinluan made a similar point. Because of the complexity of the problem, she said, advancing obesity solutions requires considering a “whole bundle of problems and solution sets that can address all those strategies.”
Finally, the panelists discussed some of the many barriers communities may face in addressing the issue of obesity through changes in the built environment. Smith cited funding as one significant barrier. “Having worked for a local government,” she said, “and currently trying to advocate for resources to improve access to healthier foods, . . . it is always the issue of cost and who pays for it.” The way to overcome this barrier, she continued, is to create political will, which can be accomplished in multiple ways—through community action, through the ballot box, or by bringing the business community to the table as a partner. Another way to create political will, she suggested, is by bringing the story of an investment’s impacts on individuals to a wide audience. “One of the most moving experiences I had,” she said, “was when we took a young man to Harrisburg at the beginning of the Pennsylvania Fresh Food Financing Initiative to talk about what that job meant to him—and not only to him but to his younger brother, to be able to see him get up every day and go to a job and come
home and not be dealing drugs. People get that. It touches [in particular] policy makers and elected officials.”
Lavrenz cited as another barrier not having a holistic view of policy and how changes in policy can ripple through multiple domains. He explained, for example, that transportation has historically emphasized straight roads, wide lanes, and clear zones on the sides. He observed that this makes the roadway a safer environment for drivers, but it also tends to increase speed, which has safety and psychological impacts for people using other modes of travel. “Those kinds of policy implications were never considered or given significant weight until recently,” he said, noting that at the local level, decision makers set much of the design and overall planning policy that influences these systems. He argued that “simply providing education can go a long way toward demonstrating how all those different moving pieces interact with one another and what some of those trade-offs are.”
Fulton stressed the importance of greater understanding of why some policy options are not being implemented in particular communities or regions of the country. She suggested that the similarities among such places are of interest. She noted, for example, that about a quarter of municipalities have adopted Complete Streets policies, and said she wonders about the characteristics and motivations of the other 75 percent of municipalities. Smith referenced a point made by Shiriki Kumanyika in the third workshop session (see Chapter 4)—that one factor may be the aftereffects of legal segregation or other inequities that have been powerful forces in U.S. history. “It is easy to overlook people who have been overlooked and often are not in the position to make their voices heard,” she said.
At the end of the session, Vinluan invited the panelists to share their thoughts on particular action steps that workshop participants can implement in their own communities and organizations.
Fulton suggested four potential action steps: First, collect the data that matter. For example, she said, while policies in many communities call for increasing walkability, there is no system for comprehensively and cost-effectively measuring the walkability of communities in the United States. Second, form partnerships at all levels, from the federal to the local, because “we should all [work] together on these issues.” Third, think beyond the health benefits of improvements to the built environment: “How do these changes affect economic vitality or social cohesion? What are the other benefits that are being affected that sell to different audiences?” Finally, make the changes simple—“People will be more likely to do them if they perceive them as simple. . . . Making temporary bike lanes. Inviting the
mayors to take a bike ride with you. How can we do more of those simple things that show people that these types of easy changes do have benefit?”
Smith focused on rural communities, particularly since her organization is seeking to work more in rural communities around issues of access to healthy foods. She explained, “What we are learning is that the issue of access is incredibly different in places like Montana or in places like Appalachia where geography can play a major role. It is not just about the built environment, but also other types of infrastructure like transportation and how does a truck of food or fresh produce get to places over long distances.”
Vinluan added that the Robert Wood Johnson Foundation has a long history of dedicating resources to changing the built environment and creating optimally healthy communities, and it is now looking at how it can leverage assets in communities, especially in rural areas, to increase economic pathways that would also benefit health. “All of these are connected issues,” she said.
Lavrenz cited two potential action steps. First, a transportation and health task force at the Institute of Transportation Engineers has been developing short-, medium-, and long-term action items and goals. The conversation at the workshop, he said, “can help to inform that.” Second, he suggested, health can be linked more explicitly to safety, noting, “The two go hand in hand.” He added that one way to make the connection is through case studies that highlight the linkage for the Institute’s members so they can more easily have conversations with health professionals.
Wilson noted that designing for health and wellness is a core value of his practice at Perkins and Will. “We need to practice what we preach,” he said. He added that his firm is participating in the Fitwel Champions program, which includes a rating system that provides a roadmap for designing interior spaces that support wellness.4 “Health and wellness can be taught at the workplace,” he argued, stating, “If your organization has a policy that supports that, people learn about it and then they take it home and tell their friends.”
Finally, Bill Purcell asked all the workshop participants to ask themselves what they and their organizations can do to change the built environment in such a way as to promote health. “What is your next step? How will you put into practice what you learned today? . . . There are definitely things that all of us can do . . . to create more healthy and equitable environments.”
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