A Research Roadmap for Transportation and Public Health (2019)

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4 The following sections highlight health-related research needs and opportunities within five specific contexts for transportation decision-making (also shown in Figure 1): policy making; planning; capital programs, projects, and implementation; monitoring and evaluation; and data improvement and integration. Policy Making There are many forms of policy making in transportation, both formal and informal, that can affect health outcomes. Transportation policies related to design, processes, activities, spending, and articulation of agency values can set a broad vision for a transportation agency or provide specific direction for decision-making. In addition, transportation agencies adopt policies for measuring and tracking long-term progress, such as safety performance targets. Other forms of transportation policies include rules and guidance that determine how funding and activities should take place, frequently decided by mode, context, or project type. Organizations such as the CDC have called for transportation officials to establish policies that create positive community health outcomes. Common examples of transportation policies that address health include Vision Zero, Health in All Policies, Complete Streets design guidance, spending targets, and performance metrics. See the contractor’s final report for more discussion on these. When transportation officials draft policy, they weigh the interests of the public with available resources. Partnering with health agencies can bring new stakeholders, informa- tion, and perspectives into transportation activities, helping improve transportation-related policies and processes. Transportation policy making may require participation by health agencies in all phases of the development of the transportation network, and policies may also establish the expectation that transportation and health officials will meet and collaborate on a routine basis. Research Gaps and Needs 1. Gap: Limited knowledge about the application of land use, travel pricing, transit, and other travel demand management tools and the extent to which these have been evaluated in relation to health and equity outcomes. a. Need: Synthesis of practice and research to describe the following: i) Frequency of use of pricing (e.g., parking pricing, cordon pricing, congestion pricing); ii) Transportation Demand Management (TDM) tools; C H A P T E R 2 Transportation Agency Processes

Transportation Agency Processes 5 iii) Strategies for curtailing single occupant vehicle use that draw upon the larger litera- ture of human motivation and decision-making (e.g., opinion leadership, intrinsic motivation, reactance theory, social behavioral theory, etc.); and iv) The resulting health impacts. b. Need: Synthesis of practice to describe how federal, state, and/or local entities are aligning policy goals related to travel demand and travel performance metrics (such as vehicle miles traveled) in order to advance health and equity (building upon the guidance provided by Malekafzali, 2009). This should include case studies from urban and rural contexts. c. Need: Research to describe the following: i) The degree to which state and local transportation agencies—and related societal sectors such as chambers of commerce, school districts, public health agencies, legislative bodies, etc.—are implementing the guidance from prior research; ii) The degree to which existing resources have identified specific policies to support health across a variety of domains (e.g., safety/injury prevention, active travel, envi- ronmental health, access, etc.); iii) Documentation of the barriers and challenges to implementation; and iv) Recommendations to support more rapid diffusion of best practices. 2. Gap: Lack of quality research on the effects of policies at various stages of transportation agency activities (planning, design, project delivery, maintenance, spending, and other procedural policies) on short- and long-term health and equity outcomes. a. Need: Robust, longitudinal policy evaluations to examine the short- and long-term impacts of transportation policies on various domains of health and equity outcomes, including impacts through intermediate community characteristics such as land use and economic development. b. Need: Research to provide a clear understanding of who experiences positive or negative health outcomes as a consequence of transportation policy making (including the severity and duration of health outcomes) and the degree to which these outcomes lead to health disparities. c. Need: Research to develop and apply a systems approach (such as systems dynamics and agent-based models) to understand time lags, bidirectional effects, and nonlinear impacts of transportation policies on travel behaviors and health outcomes. d. Need: Population level (i.e., county, region, or state) natural experimental/observational studies on the economic impacts (e.g., transportation and health costs) of transportation policy changes intended to support health, to complement the large body of less rigorous evaluations and simulation studies that exist. 3. Gap: Lack of research on effective methods for policy development and adoption that are the most impactful to health, are sustainable, and are transferrable across agencies and disciplines. a. Need: Synthesis and evaluation of existing health-oriented transportation policy develop- ment processes, gauging longevity, clarity of purpose, impact in changing transportation procedures and practices, and replicability in other states or agencies. b. Need: Synthesis and evaluation of the use of health-related performance metrics that have been effective in guiding transportation decision- and policy making and that can be replicable across states and regions. c. Need: Research on the use of collaboratively-developed conceptual models to identify key policy levers and case studies of opinion leaders taking a systems or holistic approach to policy making. d. Need: Research to describe the role of public engagement and grassroots support in the adoption of health-related policies and documentation of agency practices and processes to support inclusive and equitable engagement. Related to this is the need to study how

6 A Research Roadmap for Transportation and Public Health to effectively frame and communicate health issues. This could also include the study of how a public that is more engaged around health can influence decision-makers. 4. Gap: Lack of knowledge related to how transportation agency policies around “resiliency” incorporate short- and long-term health issues. a. Need: Synthesis research to identify examples of transportation policies related to resiliency and disaster planning and how they account for and are related to health impacts. b. Need: Synthesis research to identify transportation policies designed to adapt to or mitigate impending health effects of flooding, urban heat island effects, and drought. Planning Transportation planning is the foundation to creating sustainable and efficient networks and systems for people to travel to work, services, shopping, recreation, home, and other destina- tions. Long-range transportation plans consider needs over a 20- to 40-year horizon, incorporate community preferences for mode of transportation, and make assumptions about technology advances and mobility options. These long-range plans require data about current and expected land development, trip origin and destinations, forecasts for future travel demand, and estimates for mode share. Transportation plans may be developed for a specific mode of transportation or for all modes of travel. Plans may be created for specific purposes, such as air quality conformity, safe access to schools or transit, accessibility, disaster management, or freight movement. Plans are developed at the statewide, regional, city-wide, corridor-level, or neighborhood scale. The data require- ments for a transportation plan will often depend on the physical scale or extent of the study area. For instance, a corridor plan may require detailed crash analysis, traffic counts, and speed data. Larger-scale plans may build from a regional travel demand model based on household travel surveys, annual traffic data estimates, and growth projections. Health and transportation equity may be considered in any of these planning activities. The quality and availability of public input and data are key factors for integrating health. Regional transportation plans, such as those developed by an MPO, can provide better estimates of future travel demand if they have a more complete picture—across many years—of who is traveling and how (e.g., by including pedestrian and bicycle counts and/or trip information). They can make more informed investments if they have information on the possible health impacts of various growth scenarios. In addition to improving data for planning-related decision-making, health practitioners can also help with public engagement in ways that are less familiar to transportation planners. For example, health practitioners working with community members may identify community stressors such as air pollution, noise, or lack of access to job sites that can have a transportation- related origin. More broadly, public health officials can help engage community groups, using grassroots or formal approaches, in the transportation planning process, and they can share information about social determinants of health to help identify populations impacted by transportation plans and decisions in the community. A transportation plan that can integrate health considerations in measurable ways is the Transportation Improvement Program (TIP). TIP is a schedule of future transportation projects and funding for a four to ten-year period, including all modes of transportation. It contains project prioritization policies, which can explicitly require health measures of a project. All states and MPOs must have current and coordinated TIPs, also allowing for public input, which may be channeled through an MPO. Each step in developing a TIP provides an oppor- tunity for raising health considerations and discussing underlying community values and needs and how those align with the TIP project prioritization process.

Transportation Agency Processes 7 Sections 2.3 to 2.7 in the contractor’s final report describe many more specific planning applications where health considerations are being integrated in current practices and research studies. Research Gaps and Needs 1. Gap: Lack of available data and research methods for planning/forecasting active travel and the exposures that result from it. a. Need: More robust tools for travel demand modeling, in particular around estimating pedestrian, bicycle, and transit travel demand, as well as demand for walking to transit, in various contexts. b. Need: Research to compare existing models of assessing health impacts, validate models and underlying assumptions, enhance model specificity, better incorporate equity mea- sures, document and assess model usage, and develop more comprehensive or comple- mentary tools. c. Need: Studies to assess objective data collection techniques for use in measuring physical activity and travel behaviors (such as with mobile device Bluetooth tracking) and where they take place, and to develop guidance on how to derive pedestrian and bicycle counts from existing technologies. For example, studies are needed to validate mobile device trackers with calibrated bicycle and pedestrian counters and identify and adjust for sources of bias (underrepresented groups, etc.). d. Need: More localized, granular public health and traveler behavior data at the census tract level to support assessment of health performance in small areas and support planning efforts at that scale. This includes, for example, morbidity data by age group (including traffic safety), as well as more localized data on air quality and noise to mea- sure exposure among active travelers. These data can be complemented with existing methods, such as EPA’s Smart Location Database, that inventory current community supports and barriers for active travel (such as vehicular traffic, population density, and land use mixtures). e. Need: Guidance for adjusting available health data sources to support transportation planning or modeling [e.g., using Integrated Transportation Health Impacts Model (ITHIM) or Health Economic Assessment Tool (HEAT) tools], building on the case studies provided by Wu et al. (2018). 2. Gap: Lack of guidance on how travel surveys can integrate health questions. a. Need: Systematic research on states and cities/regions that integrate health questions into travel surveys; the development of a health question “bank” (or other resources and guidance) that would make travel surveys easier to conduct and the use of comparable questions across surveys more likely. Information on the validity and reliability of ques- tions, when available, should be included. This could build upon prior efforts to create an archive of household travel surveys. 3. Gap: Lack of guidance on best practices in public involvement during planning efforts. a. Need: Research to support the development of tools/resources for framing health issues in ways that motivate policy-makers and the public to get involved in transportation decision-making processes (also described as a need in the policy section). b. Need: Research that describes the role of public engagement/grassroots activities in the adoption of health-related plans, documents agency planning practices to support inclusive and equitable engagement, and defines opportunities to use public support to get decision maker buy-in. 4. Gap: Lack of research on equity considerations and outcomes in planning processes. a. Need: Research to explore how transportation agency structures and programs (such as allocation of new infrastructure projects across a community or state) affect health

8 A Research Roadmap for Transportation and Public Health equity outcomes and guidance on the role of agencies, public involvement practices, and state/local coordination in planning new facilities. b. Need: Synthesis and guidance on how equity indicators are being used in planning/ forecasting tools and models. 5. Gap: Lack of guidance on opportunities to integrate health considerations during priori- tization, programming, and pre-scoping processes. a. Need: Synthesis of practices where MPOs or state DOTs included health indicators in transportation project prioritization criteria. b. Need: Survey of MPO and state DOT interest in incorporating health into project priori- tization and programming decisions, and expressed barriers in doing so. c. Need: Summary of transportation agencies who collect and review health data for potential impacts as part of project screening. d. Need: Case studies or documentation of the use of health department representation in transportation planning processes, such as boards or advisory committees. 6. Gap: Lack of research to evaluate and refine key decision-making tools and support implementation. a. Need: Research to assess available modeling/forecasting tools (such as ITHIM and HEAT) to determine the following: i) What the frequency is of application/adoption and implementation challenges; ii) What the incorporation is of those tools into routine agency practices; iii) How such tools account for self-selection bias, non-linearity, system feedback, and the relationship between regular physical activity and travel-related physical activity (each step in developing a TIP provides an opportunity for raising health consider- ations and discussing underlying community values and needs and how those align with the TIP project prioritization process); and iv) How to develop recommendations and refined approaches to address research and implementation challenges. b. Need: Research to develop a model or other complementary tools (such as spreadsheets or tables) that can be used by practitioners to provide a comprehensive overview of health impacts for different kinds of transportation projects. The model should allow for scenario planning (i.e., testing the impact of different transportation and/or land use changes against the baseline health data). Capital Programs, Projects, and Implementation There are many processes and substeps related to capital programs, projects, and implementa- tion. This section covers identified gaps in research on health integration in three major areas: 1) project development and design, 2) public involvement, and 3) construction, maintenance, and operations. Project Development and Design: Transportation projects scheduled for implementation are developed into preferred alignments, preliminary designs, right-of-way acquisition plans, construction drawings, and financial agreements. This process is often determined by state or federal laws that require documentation of potential impacts to important resources or populations, and these documents detail mitigation strategies or commitments in response to expected impacts. Health impacts can be evaluated and documented as a project is developed. This process requires clear indicators of community health resources; criteria for identifying populations whose health, property, or access may be disproportionately affected by transporta- tion projects; and strategies or tools for improving health and access through the transportation project. These elements are dependent on detailed data sets and descriptive metrics of health. For instance, agencies will often produce a community impact assessment (CIA) for projects, but CIAs often lack health metrics.

Transportation Agency Processes 9 Public Involvement: Public involvement is required for most publicly-funded projects. Health partners can improve public outreach efforts for specific projects, if involved in the project development process. During public meetings or presentations, transportation officials display proposed plans or preliminary designs. Public input can be enriched by effective visual aids or illustrations to simulate the user’s experience. Visualization tools may also help describe the trade-offs or options for integrating facilities for pedestrians, cyclists, and transit. Construction, Maintenance, and Operations: After final design and regulatory materials have been completed, transportation agencies acquire right-of-way, develop construction documents, and construct projects. Transportation agencies may minimize health impacts by continuing an open dialogue with affected property owners to ensure fair compensation and access. Construction activities can produce emissions and noise that produce potential health impacts and should be mitigated. While work-zone-related detour plans are customarily made for drivers, many agencies fail to provide safe alternate routes and information for pedestrians, bicyclists, and people using wheelchairs during construction. Transportation agencies produce maintenance agreements and asset management plans for the ongoing upkeep of the transportation system. Maintenance activities, such as roadway resurfacing, require coordination between state and local agencies, as well as adjacent property owners. These activities facilitate access for travel and may incorporate improvements to further improve public health and roadway safety. Transportation agencies create asset management plans to evaluate, prioritize, and maintain the physical condition of the transportation network. These plans consider criteria such as pavement and fleet condition but can also consider equity and health in project decisions. While opportunities to integrate health appear to exist in the processes outlined above, the contractor’s final report was not able to document many actual practices being deployed or documented in the literature reviewed. Research Gaps and Needs 1. Gap: Lack of guidance for addressing health as part of a project’s environmental document. a. Need: Examples of projects where public health officials were included in transportation project scoping or project initiation discussions. b. Need: Method for estimating the health impact(s) or benefits of recommended future improvements, as part of a Purpose and Need statement. c. Need: Examples of actions that the environmental document may evaluate as responses to health impacts. d. Need: Research to identify how health impact assessment processes can be implemented without becoming another burden to existing regulations. e. Need: Research to examine the role of Planning and Environmental Linkages (PELs). 2. Gap: Lack of data and methods for assessing short- and long-term health impacts and associated economic evaluation. a. Need: Research to support guidance on improving the accuracy and consistency of efforts to measure health impacts. b. Need: Examples and research of rigorous economic evaluations that account for the health impacts of projects. c. Need: Studies to review existing evidence and provide concrete guidance on the preferred project stage at which to conduct health assessments, the scope and time frame of the assessment, and the ways to communicate findings including estimated effects and uncertainty. d. Need: A synthesis of research and methods for examining the relationship between transportation projects and housing affordability, displacement, and change in access to healthcare or other services.

10 A Research Roadmap for Transportation and Public Health 3. Gap: Lack of guidance and data visualization tools (e.g., estimators and mapping tools) to support public engagement. a. Need: Guidance for engaging the public—during project development—to identify and respond to community concerns about potential health impacts. b. Need: Examples of transportation agencies working with public health officials to conduct outreach to communities affected by projects. c. Need: Research to detail how communities are funding, using, and maintaining online mapping or data visualization platforms as well as other innovative experiential ways of community involvement (e.g., from temporary pop-ups to virtual reality) and how new data are being integrated into transportation practices and public engagement. 4. Gap: Lack of guidance describing how project impact assessments can evaluate health impacts. a. Need: Guidance on whether and when it is appropriate to use a health impact assessment (HIA) or other form of health assessment in a community impact study to assess the health impacts of a project. b. Need: Investigation into institutional arrangements and interagency partnerships to provide technical support and expertise in overseeing the consideration of health impacts as part of community impact studies or reports. c. Need: Checklists for data sources that can be used to generate performance measures around health and wellness per the scale of transportation project impact. 5. Gap: Lack of information about health considerations as part of transportation opera- tions and maintenance activities. a. Need: Research on population health impacts incurred during routine transportation maintenance activities (e.g., road salting, resurfacing). b. Need: Guidance for including health metrics as part of safety evaluations for maintenance and operations activities. c. Need: Guidance about the relationship between maintenance and operation activities and health. Monitoring and Evaluation Federal and local regulations require that agencies monitor for conformity with environmental standards for air and water quality. When levels are not in agreement with standards, the transportation agency may be required to change plans and project priorities. Safety monitoring and crash reporting are required as well, and failure to meet safety targets carries implications for future funding sources. Ongoing evaluation of the performance of the transportation system can be an opportunity to integrate health outcomes. Transportation agencies can include mea- sures to mitigate health and environmental impacts. To evaluate their prior or potential actions, programs, and projects, agencies require data and models calibrated to describe future change scenarios and possible outcomes. See also Chapter 3 in this Research Roadmap for research needs regarding how agencies identify and set performance measures. See the contractor’s final report for an expanded discus- sion of the research needs that follow. Research Gaps and Needs 1. Gap: Lack of detailed, disaggregate morbidity data needed for health and injury monitoring. a. Need: See data gaps/needs described in the planning section. b. Need: Research to explore state practices in consistently reporting non-fatal crashes and other morbidities and develop recommendations on how to collect nationally comparable morbidity data, such as non-fatal injuries sustained by people using active travel modes.

Transportation Agency Processes 11 2. Gap: Lack of detailed data and wide coverage area for use in environmental quality and resiliency monitoring. a. Need: Research to examine the quality of data (and calibration/validation practices) from permanent and portable air quality monitors used to enforce the National Ambient Air Quality Standards, coverage of near-road areas, and the role of coordination between DOT officials and the parties responsible for monitor placement. b. Need: Disaggregated data for regional or small area air quality analysis are needed in order to more closely examine health equity concerns related to air quality. c. Need: Development of a methodology or simulation model to forecast long-term health impacts of heat island effects and impervious surface-induced local flooding related to land use decisions, parking policies, and roadway expansion efforts. 3. Gap: Lack of tools and performance measures for plan evaluation. a. Need: Research to develop performance measures (PMs) and/or evaluate the effects of PMs on plans or policies related to health. b. Need: Provide research basis for new PMs, including those related to equity as well as emerging issues and modes of travel (such as automated vehicles). c. Need: Develop standards or guidance to improve the consistency of incorporating inter- vention (e.g., roadway facility/countermeasure, or policy change) costs into evaluations. d. Need: Research to develop/test implementation of health and equity PMs (at the state level). Data Improvement and Integration Data improvement and integration, beyond application in the specific processes above, is itself a process for many agencies. There are both routine and ad hoc mechanisms for data improvement programs. Every state, for example, has guidelines for assessing the impact of transportation project alternatives on communities, the environment, and transportation system performance. Transportation practitioners use data to measure impacts of each alter- native according to guidance or best practices. Some states have begun to collect data across a wide spectrum of disciplines to help automate screening projects for potential impacts. For example, the North Carolina Department of Transportation initiated Project ATLAS (Advancing Transportation through Linkages, Auto- mation, and Screening) and is compiling and creating GIS-based data to assist with project devel- opment and program delivery. Each dataset has a purpose to project development. Section 2.4 of the contractor’s final report describes data sources, quality, integration, and future research needs in more detail. Research Gaps and Needs 1. Gap: Lack of integrated data needed for systematic monitoring of transportation and health outcomes. a. Need: Efforts to improve data coverage/quality for a variety of data sources related to health, including variables that can be used to link across data sets. This may involve synthesis research to identify and showcase best practices and develop guidance or recommendations on ways to improve data quality, data completeness, granularity (e.g., census tract, sub- county level), and specificity for various applications. b. Need: Guidance and training/capacity building for state and local agency staff on how to institutionalize collection and integration of key data sources (such as active travel mea- sures or pedestrian and bicycle counts). This may include guidance for data formatting, standardization, and aggregation.

12 A Research Roadmap for Transportation and Public Health c. Need: Research to develop a “database of data” that will enable agencies to examine the effects of transportation projects at various geographic scales and develop strategies for sharing data across policy sectors. d. Need: Research to identify, test, and recommend methods to link or overlay key national data sets, such as National Household Travel Data and American Time Use Survey, to better contextualize trips and health behaviors. e. Need: Guidance and examples on how to integrate public health data collection into existing transit data collection and management practices. 2. Gap: Lack of documentation of best practices in data collection, improvement, integra- tion, and application. a. Need: Research to assess innovations in collecting data that supports health integration. b. Need: Research to detail how communities are or could/should be funding, using, and maintaining data visualization tools and platforms (also noted as a need in the planning section.)