A Research Roadmap for Transportation and Public Health (2019)

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20 The previous chapters of the Research Roadmap articulate a diverse set of research gaps and identified needs, which could easily fill the next decade’s worth of research funding. The following research problem statements provide an expanded commentary on six priority research areas. For details on the process used to select these topics, see Appendix A of the con- tractor’s final report. These problem statements can be put forward to key TRB and/or AASHTO committees to consider for advancement to funded research projects. See Appendix A: Research Communications and Implementation Plan in this document for details on how research problem statements can be developed into funded projects. Collectively, these topic areas cover a range of health domains and relate to various transportation agency processes and practices, as illustrated in Table 1. C H A P T E R 5 Research Problem Statements Research Problem Statement Domain or Pathway to Health Agency Process or Practice A cti ve T ra ve l A cc es s Co m m un ity En vi ro nm en t Re si lie nc y Sa fe ty Co m m un ity E ng ag em en t an d D at a In te gr ati on Po lic y M ak in g Pl an ni ng Ca pi ta l P ro gr am s, P ro je ct s, an d Im pl em en ta tio n M on ito ri ng a nd E va lu ati on #1: Synthesis of Best Practices for Including Health Outcomes in Transportation Project Prioritization X X X X X X #2: Data Sources for Establishing Health Outcome Performance Measures for Transportation Projects X X X X X X X X #3: Practices and Recommendations in Reporting and Integrating Pedestrian and Bicycle Non-Fatal Injury Data Systems X X X X X X #4: A Guidebook for Considering the Public Health Impacts of Public Transportation Decisions X X X X #5: Effect of Demographic Change on Travel Behavior and Health X X X X #6: Evaluating and Integrating Emerging Data Sources to Support Transportation and Health Planning and Operations X X X X X X Table 1. Relationship of research problem statements to key health domains and agency practices/processes.

Research Problem Statements 21 Problem Statement #1: Synthesis of Best Practices for Including Health Outcomes in Transportation Project Prioritization I. PROBLEM NUMBER To be assigned by NCHRP staff. II. PROBLEM TITLE Synthesis of Best Practices for Including Health Outcomes in Transportation Project Prioritization III. RESEARCH PROBLEM STATEMENT NCHRP Project 20-112 identified, among several important research topics, the need for examples of how transportation agencies use data and health indictors to select and develop transportation projects. According to the Centers for Disease Control and Pre- vention (CDC), Americans spent $10,348 per capita on national health expenditures in 2016 (“Health, United States, 2017–Data Finder,” 2019). This sums to $3.3 trillion, or approximately 17.9 percent of the total gross domestic product. It is well established that “transportation is an important part of the built environment and significantly influences physical activity and well-being, safety, and the ability of community members to access destinations that are essential to a healthy lifestyle” (Lyons et al., 2012). Therefore, transportation systems and individual projects can contribute to negative and positive health outcomes, such as changes in healthcare expenditures. Despite the understanding that transportation systems have an impact on pub- lic health outcomes, few standardized tools are available to metropolitan planning organizations (MPOs) or state departments of transportation (DOTs) to analyze and quantify health as part of the transportation project development and prioritization process. In December 2012, the John A. Volpe National Transportation Systems Center (Volpe Center) of the U.S. DOT Research and Innovative Technology Administration published “Metropolitan Area Transportation Planning for Healthy Communities” for the FHWA (Lyons et al., 2012). This white paper identified four MPO case studies (Puget Sound Regional Council and Partners; Nashville MPO; Sacramento Area Council of Governments; and San Diego Association of Governments) and their efforts to integrate health into transportation planning. In April 2014, the Volpe Center published “Statewide Transportation Planning for Healthy Communities” for FHWA (Lyons et al., 2014). This white paper identified five state DOT case studies (California, Iowa, Massachusetts, Minnesota, and North Carolina) and their efforts to integrate health into transportation planning. Relevant literature includes best practices and policies from a few MPOs and state DOTs, but there are more than 400 other MPOs and 45 other state DOTs that may have integrated health into transportation planning and project prioritization since recent publication (2012 and 2014, respectively). This proposed research is intended to address the urgent need for guidance and recommendations for agencies seeking to integrate healthy community design methodologies into existing planning and priori- tization processes with respect to improving health outcomes. IV. LITERATURE SEARCH SUMMARY The NCHRP 20-112 project team searched for, gathered, and screened potentially relevant studies and agency reports to identify research that was conducted and to

22 A Research Roadmap for Transportation and Public Health document research needs relative to this research problem statement. This included peer-reviewed research articles, grey literature prepared by agencies, and TRB research needs statements. There are many known examples of MPOs that have integrated health consid- erations into project prioritization. There is an opportunity to identify additional best practices that have not previously been published through this research topic. In addition to the 2012 Volpe Center report cited above, Transportation for America provided a series of case studies on how regional entities, including Portland, Oregon, and communities in Tennessee, Texas, North Carolina, Minnesota, Oklahoma, Ohio, and California are prioritizing and evaluating projects through the health lens (Carpenter and Zaccaro, 2018). The literature review suggests that a limited number of state DOTs have adopted health considerations into project planning and development phases. There is an opportunity to include health-related data and metrics into transportation project scoping, selection, and evaluation. Environmental and safety considerations have been well-established in state DOT practices; other domains of health—such as active transportation, access, and community—are less often considered as key to DOT functions (Litman, 2017). Another study examining inclusion of active transportation plans among DOTs found low levels of support in design and planning (Dill, Smith, and Howe, 2017). Other references related to this research topic identified in the NCHRP 20-112 contractor’s final report include the following: • Carpenter, Rochelle. Measuring What We Value: Policies to Prioritize Public Health and Build Prosperous Regions. Transportation for America. 2017. • Carpenter, Rochelle, and Heather Zaccaro. Building Healthy and Prosperous Communities: How Metro Areas Are Implementing More and Better Bicycling and Walking Projects. Transportation for America. 2018. • Casey, Colleen, Stephen Mattingly, Jianling Li, and James Williams. Developing Public Health Performance Measures to Capture the Effects of Transportation Facilities on Multiple Public Health Outcomes. Transportation Research Center for Livable Communities. 2016. • Dill, Jennifer, Oliver Smith, and Deborah Howe. “Promotion of Active Transporta- tion Among State Departments of Transportation in the U.S.” Journal of Transport & Health, 5 (2017): pp. 163–171. doi:10.1016/j.jth.2016.10.003. • Meehan, Leslie A., and Geoffrey P. Whitfield. “Integrating Health and Transporta- tion in Nashville, Tennessee, USA: From Policy to Projects.” Journal of Transport & Health, 4 (2017): pp. 325–33. Despite this research, there is a lack of agency guidance on opportunities to integrate health consideration during prioritization, programming, and pre-scoping processes. V. RESEARCH OBJECTIVE The primary objective of this research is to develop the means for state DOTs, MPOs, and local agencies to effectively plan, implement, and evaluate the use of health indicators and metrics during project planning and prioritization. The research will not focus on specific tools or software but will review commonly used methods— and tools used to implement those methods—to build upon existing practices. The research should ideally present recommended methodologies and measurable success stories (i.e., project case studies with health data over time).

Research Problem Statements 23 While the research problem statement describes initial efforts to identify MPOs and state DOTs that include health in project evaluation criteria, the objectives of the research will also address the following questions: • Have additional MPOs and state DOTs adopted policies or procedures to consider health in the transportation planning process? • What are the Planning and Environmental Linkages considered during project prioritization? • Have additional MPOs and state DOTs modified their project prioritization and funding processes to include health considerations? • Which best practices for integrating health considerations during prioritization, programming, and pre-scoping processes can be used effectively by all MPOs and state DOTs? The anticipated outcomes or deliverables of the research are a guidebook and training materials that provide clear standards for how to involve health professionals in transportation planning, project development and prioritization, and documented case studies with measurable outcomes. The steps or tasks involved with this research may include the following: • Review published literature to identify existing best practices for integrating health into transportation planning and project prioritization. • Form an MPO working group to share lessons learned and best practices. • Form a state DOT working group to share lessons learned and best practices. • Partner with state departments of health to identify readily accessible health metrics to be incorporated in transportation project evaluation criteria. • Provide guidance for transportation agencies to modify their project prioritization process for the Long-Range Transportation Plan/Metropolitan Transportation Plan, Five Year Capital Plan, or other capital improvements plans. VI. ESTIMATE OF PROBLEM FUNDING AND RESEARCH PERIOD Recommended Funding: $75,000–125,000 Research Period: 18 months VII. URGENCY, PAYOFF POTENTIAL, AND IMPLEMENTATION Transportation agency plans often include generic statements about the importance of public health and improved health outcomes in transportation. However, agencies need specific data sources, standards, and metrics for how to incorporate health considerations into roadway design handbooks, planning resources, and project priori- tization programs. Traditional metrics for transportation planning focus on volume over capacity (V/C) ratios, level of service (LOS) standards, and other motor vehicle performance metrics. These measures are often used to score and select projects for funding, not considering non-drivers or public health outcomes. By changing the way transportation projects are prioritized by including health in evaluation criteria, there is an opportunity to increase the development of multimodal projects (such as transit, Complete Streets, and bicycle/pedestrian-oriented projects) that promote active transportation, safety, and improved health outcomes. The Nashville

24 A Research Roadmap for Transportation and Public Health MPO, as described in the Volpe Center report, modified its project prioritization process to give greater weight to projects that contributed to better health outcomes. As a result, the region increased its sidewalk mileage by 57 percent, bikeway mileage by 19 percent, and greenway mileage by 36 percent between 2009 and 2014. The intended outcome of this research is to provide all MPOs and state DOTs with the tools needed to evaluate projects from a health perspective (quantitative and qualitative) and make appropriate changes to existing processes. VIII. PERSON(S) DEVELOPING THE PROBLEM NCHRP 20-112 Project team: UNC Highway Safety Research Center, VHB, APA, and consultants. IX. PROBLEM MONITOR TO BE DETERMINED X. DATE AND SUBMITTED BY TO BE DETERMINED Problem Statement #2: Data Sources for Establishing Health Outcome Performance Measures for Transportation Projects I. PROBLEM NUMBER To be assigned by NCHRP staff. II. PROBLEM TITLE Data Sources for Establishing Health Outcome Performance Measures for Transportation Projects III. RESEARCH PROBLEM STATEMENT NCHRP Project 20-112 built upon the body of literature, strategic agendas, and research needs connecting health to transportation to provide a list of gaps and needs to support decision-making in funding research over the next ten years that can lead to greater consideration of health issues in transportation contexts. NCHRP Project 20-112 concluded that it is important to understand how agencies are incorporating health into transportation performance measures and discussed whether this understanding will increase overall integration of health into transporta- tion outcomes. Establishing and monitoring progress toward performance measures is strongly tied to federal funding and project selection due to the Moving Ahead for Progress in the 21st Century (MAP-21) legislation [and supported by the more recent Fixing America’s Surface Transportation (FAST) Act] that established national perfor- mance goals for the federal-aid highway program in seven areas. This is a major shift for many DOTs as well as some MPOs, and they are still trying to navigate the new requirements and understand how decision-making is impacted. Many of the performance measures relate directly and indirectly to health impacts, leading agencies to seek guidance in how to set targets and report on their progress.

Research Problem Statements 25 Quality performance measures, and research/evidence to guide implementation, are also important for planning efforts—such as Strategic Highway Safety Plans, Vision Zero, or related safety initiatives—that have clear connections to health and offer important opportunities to bring new partners and data to the table. While there are several health-related data sources, guides, and resources available for states, MPOs, and local agencies, there is a lack of guidance for addressing health as part of project development, implementation, and most specifically a project’s envi- ronmental document. Furthermore, there is a lack of data, lack of an understanding of how data sources relate to health outcomes, and lack of methods for assessing short- and long-term health impacts and associated economic evaluation. This proposed research is intended to address the urgent need for guidance and recommendations for agencies seeking to develop checklists of the data sources that can be used to generate performance measures around health and wellness. Ultimately, practitioners will use this information to develop health and wellness performance measures as an outcome of transportation projects. IV. LITERATURE SEARCH SUMMARY The NCHRP 20-112 project team searched for, gathered, and screened potentially relevant studies and agency reports to identify research that was conducted and to document research needs relative to this research problem statement. This included both peer-reviewed research articles, grey literature prepared by agencies, and TRB research needs statements. The team identified a large body of evidence regarding transportation and safety performance, likely in part due to the recent federal require- ments. Research to date focused primarily on existing guidance on health performance measures and research and evaluation of performance measures. Existing health performance measure resources included FHWA’s Guidebook for Developing Pedestrian and Bicycle Performance Measures (Semler et al., 2016), The League of American Bicyclists’ Bicycling and Walking in the United States: 2018 Benchmarking Report (McLeod and Herpolsheimer, 2018), APA’s Metrics for Planning Healthy Communities (Ricklin and Shah, 2017), and Transportation Research Center for Livable Communities’ Developing Public Health Performance Measures to Capture the Effects of Transportation Facilities on Multiple Public Health Outcomes (Casey et al., 2016). Despite the number of health indicators and measures included in the guidebooks and toolboxes, they are limited by their lack of specific values, lack of generalizability to all geographies, and minimal guidance on the values and ranges for indicators. NCHRP Project 20-112 also considered research synthesis and studies that evaluated effectiveness of existing tools. The research revealed limitations to the health-related performance measures and components in long-range regional transportation plans; broad, non-prescriptive metrics that do not provide guidance on what values/ranges to aim for within each indicator; an inconsistency of evaluation in terms of performance measures used and time horizons for application; and a focus on the inclusion of health or health-related aspects in them rather than their impact on population health. There is a need to develop performance measures or studies that evaluate the effect of such plans or policies on health outcomes such as physical activity, obesity, environ- mental exposure, equity, and quality of life. However, more information is needed for developing scoring tools and checklists that provide a structured method for considering key elements of health during critical stages of transportation infrastructure planning and design. The proposed research addresses the limitations of the previous research and

26 A Research Roadmap for Transportation and Public Health provides guidance on standardizing the application of performance measures to help communities select, develop, or use the measures that best suit their context. Specific literature or research that supports these findings include the following: • McLeod, Ken, and Sean Herpolsheimer. Bicycling and Walking in the United States: 2018 Benchmarking Report. League of American Bicyclists. 2018. • Casey, Colleen, Stephen Mattingly, Jianling Li, and James Williams. Developing Public Health Performance Measures to Capture the Effects of Transportation Facilities on Multiple Public Health Outcomes. Transportation Research Center for Livable Communities. 2016. • Grasser, Gerlinde, Delfien van Dyck, Sylvia Titze, and Willibald J. Stronegger. “A European Perspective on GIS-Based Walkability and Active Modes of Transport.” European Journal of Public Health 27, no. 1 (2017): pp. 145–51. doi:10.1093/eurpub/ ckw118. • Maiden, Kristin M., Marina Kaplan, Lee Ann Walling, Patricia P. Miller, and Gina Crist. “A Comprehensive Scoring System to Measure Healthy Community Design in Land Use Plans and Regulations.” Preventive Medicine 95, Suppl (February 2017): pp. S141–S147. doi:10.1016/j.ypmed.2016.09.031. • Ricklin, Anna, and Sagar Shah. Metrics for Planning Healthy Communities. American Planning Association. 2017. • Semler, Conor, Adam Vest, Karla Kingsley, Susan Mah, Wayne Kittelson, Carl Sundstrom, and Kristen Brookshire. Guidebook for Developing Pedestrian and Bicycle Performance Measures. Federal Highway Administration. 2016. • Singleton, Patrick A., and Kelly J. Clifton. “Considering Health in U.S. Metro politan Long-Range Transportation Plans: A Review of Guidance Statements and Performance Measures.” Transport Policy 57 (2017): pp. 79–89. doi:10.1016/j.tranpol.2017.02.003. • Steedly, Ann, Teresa Townsend, Leigh Lane, Brandy Huston, and Chris Danley. “Connecting Transportation & Health: A Guide to Communication & Collabora- tion: Contractor’s Final Report.” Part of NCHRP Project 25-25 Task 105. 2019. V. RESEARCH OBJECTIVE The objective of this research is to develop checklists that transportation agencies can use to identify what data sets may help to determine the health impacts of trans- portation projects. The research will not focus on developing new data sources or tools but will review commonly used data sources, data needs, and health definitions. The research should ideally provide practitioners a comprehensive overview of health impacts for different kinds of transportation projects and the associated data sources for tracking performance. Possible tasks to be completed as part of this research may include the following: 1. Establish and clearly define performance measures that enhance analysis and provide a better understanding of the connection between transportation and health. Potential foci include measures to evaluate equity, measures to quantify impacts of transportation funding decisions, and measures of resiliency and envi- ronmental change. 2. Identify the data requirements to support the performance measures with a check- list of existing data sources available to transportation agencies. The checklist should detail software requirements, costs, and user knowledge/skills. 3. Convene a multi-disciplinary group to establish working or standard definitions of health and wellness performance measures and impacts of transportation.

Research Problem Statements 27 4. Develop data and methods for assessing short- and long-term health impacts and the associated economic evaluation to emphasize the return on investment. 5. Develop guidance for addressing/understanding health as part of a project’s envi- ronmental document. NCHRP Project 20-112 identified numerous existing health-related research questions in the TRB Research Needs Statements database. It is suggested that this effort be coordinated with questions previously submitted to determine what this current research could answer to support future research efforts. VI. ESTIMATE OF PROBLEM FUNDING AND RESEARCH PERIOD Recommended Funding: $150,000 Research Period: 15 months VII. URGENCY, PAYOFF POTENTIAL, AND IMPLEMENTATION This proposed research will allow agencies to more effectively establish performance measures and track transportation project impacts on health outcomes. Ultimately, agencies will be able to better allocate funding to projects that will have the greatest health impacts or benefits. Using an appropriate performance measure and best evaluation technique will also help in effective policy making because it will translate the reality more accurately. Immediate implementation of this research among state DOTs, MPOs and local municipalities can be expected following the conclusion of the project. VIII. PERSON(S) DEVELOPING THE PROBLEM NCHRP 20-112 Project team: UNC Highway Safety Research Center, VHB, APA, and consultants. IX. PROBLEM MONITOR TO BE DETERMINED X. DATE AND SUBMITTED BY TO BE DETERMINED Problem Statement #3: Practices and Recommendations in Reporting and Integrating Pedestrian and Bicycle Non-Fatal Injury Data Systems I. PROBLEM NUMBER To be assigned by NCHRP staff. II. PROBLEM TITLE Practices and Recommendations in Reporting and Integrating Non-Fatal Injuries and Morbidity Data for Active Travel Modes

28 A Research Roadmap for Transportation and Public Health III. RESEARCH PROBLEM STATEMENT NCHRP Project 20-112 built upon the body of literature, strategic agendas, and research needs connecting health to transportation to provide a list of gaps and needs to support decision-making in funding research over the next ten years that can lead to greater consideration of health issues in transportation contexts. The project final report stated, “Quality data are integral for transportation and health, used to support research and agency decision-making at all levels.” While data on fatal crashes is, for the most part, a health outcome related to transportation that is consistently and routinely collected across the U.S., practices vary more widely when it comes to collecting data regarding morbidity. Morbidity can be defined as any medical problem, illness, disease, or the symptom of such. Diabetes, cardio- vascular disease, obesity, traumatic brain injury or any other non-fatal injury, and chronic obstructive pulmonary disease (COPD) are morbidities most frequently associated with transportation in the existing literature. Of these, non-fatal injuries resulting from interactions with other road users are most directly in the purview of state DOTs. For all-cause morbidity beyond the transportation sector, the Global Burden of Disease database has been used to estimate disease burden. The National Electronic Injury Surveillance System (U.S. Consumer Product Safety Commission, 2019) is another source of data on injuries related to non-motorized road users. Improved transportation-sector-specific morbidity/non-fatal injury data is needed in order to provide an input to key modeling and scenario planning tools in order to be able to assess the broader health impacts of transportation projects and policies. For example, as described in the NCHRP 20-112 contractor’s final report, “Widespread usage of the HEAT is limited by lack of data for several factors, including lack of morbidity data, the nonlinear relationship between mortality and active transportation, lack of data on the long-term health effects of active transportation on children, health effects of active travel by gender and age group, and non-fatal crash data” (Kelly et al., 2014). Given the continued need to support and evaluate facilities for active transportation, there is an important need for research regarding the injury data monitoring/surveillance systems in place and opportunities to further enhance these systems’ abilities to document health and safety outcomes, particularly for active travel modes. IV. LITERATURE SEARCH SUMMARY The NCHRP 20-112 project team searched for, gathered, and screened potentially relevant studies and agency reports to identify research that was conducted and to document research needs relative to this research problem statement. This included peer-reviewed research articles, grey literature prepared by agencies, and TRB research needs statements. NCHRP Project 20-112 identified several recent or ongoing projects aimed at linking police reported crash/injury data with hospital data sources in order to better understand non-fatal injuries and underreporting trends. These include the following: • Stutts and Hunter produced a seminal piece in 1999, one of the first studies to document police underreporting of pedestrian and bicycle injuries, utilizing linked hospital data. The most recent presentation (led by Sarah Doggett at the 2019 TRB Annual Meeting) provided an updated take on this issue: “Evaluating Research on

Research Problem Statements 29 Data Linkage to Assess Underreporting of Pedestrian and Bicyclist Injury in Police Crash Data” (Doggett et al., 2018). • A recent University Transportation Centers (UTC) report, Completing the Picture of Traffic Injuries: Understanding Data Needs and Opportunities for Road Safety, describes the strengths and limitations of traditional data sets as well as many com- plementary data sets that can provide a more complete picture of road safety and identifies opportunities and methods for data integration (Cherry et al., 2018). • CDC’s Assessment of Characteristics of State Data Linkage Systems found reporting lag time to be the primary barrier to data linkage across agencies. Other major issues in linking data included capable staff, data quality, and lack of unique identifiers (Milani, Kindelberger, and Bergen, 2015). Above all, the organizational structure of most state, regional, and local agencies may lead to siloed efforts that can be difficult to combine for a variety of reasons. • An ongoing study in North Carolina by Waller et al., “Linking Health Outcome Data with Police Crash Report Data” (Carolina Center for Health Informatics, 2019), produced a series of publications on demonstration projects linking pedestrian and bicycle police reported crash data with other sources. A key finding was that crash and injury data quality and completeness, both from police and hospital sources, had a major impact on the ability to link cases and confidence in linkage methods. These studies may offer a baseline of literature reviews, methods, and lessons learned from which future studies can benefit. V. RESEARCH OBJECTIVE The objective of this research is to assess the state of the practice regarding pedestrian and bicycle injury reporting and integration systems, critically examine existing methods, demonstrate best practices, and identify future data improvement needs. Possible tasks to be completed as part of this research may include the following: 1. State of the practice scan: a. Perform a systematic scan of states (and possibly select regions/cities) to determine: i. To what degree states are aware of and adhering to the “Consensus Recom- mendations for Pedestrian Injury: Surveillance” (Safe States Alliance, 2017) and using similar or standard and comparable definitions of pedestrians, bicyclists, and wheelchair users for non-fatal injury reporting? For emerging travel modes where standard definitions do not exist (such as e-scooters and other forms of micro-mobility), what definitions are being used to track non-fatal injury reporting? ii. What methods and data sources, if any, are states and cities using to measure injuries that are not reported in police crash report systems, including falls and crashes not directly involving vehicles that occur in the right-of-way and could be attributable to the built environment or used for safety and health planning purposes? iii. To what degree are states or cities linking different data sources (such as police reported crashes with emergency department, trauma registry, or EMS data) in order to establish more integrated reporting systems, and what linkage methods are used? iv. To what degree do state-level incentives, agency or project requirements, or legislation drive reporting practices and can help explain differences across states?

30 A Research Roadmap for Transportation and Public Health 2. Validation/critical examination of practice: a. Perform data program assessments and/or actual data analyses to determine the extent to which existing data collection and linkage practices and data sources can accurately capture non-fatal injuries among pedestrians and bicyclists. In particular, identify practices that may lead to disparities in the data (e.g., under- reporting among people of varying ethnicities, languages, birthplaces of origin, housing status, age). It is possible that this research project could also lead to the development of methods to adjust for underreporting. 3. Demonstration of best practice: a. Create a case example of a leading agency practice around non-injury data monitoring and linkage that demonstrates the value in investment in data linkage and highlights how agency practices leverage data improvements for various purposes. Acknowledge the limitations and challenges identified in Task 2 and make recommendations for future advancements. Note: The USDOT Safety Data Initiative (SDI) held a forum in April 2019 in which linked data systems and improved reporting of non-fatal injuries were key themes and recommended future areas of research. Any advancements in this research problem statement should be coordinated with staff involved with the SDI. VI. ESTIMATE OF PROBLEM FUNDING AND RESEARCH PERIOD Recommended Funding: $200K–400K, depending on scope and robustness of data validation Research Period: 24–36 months VII. URGENCY, PAYOFF POTENTIAL, AND IMPLEMENTATION For every state Highway Safety Improvement Program, safety projects are priori- tized using a formula that incorporates the number of crashes experienced or predicted along a roadway. Pedestrian and bicycle projects are systematically under-valued in these processes when, as prior research indicates, more than half of all pedestrian and bicycle injuries are unreported in the police data systems used by state safety programs. Improved data to measure non-fatal injuries will vastly enhance the validity of the tools applied by state DOTs to prioritize their safety investments. Linking and integrating data has been identified as a key goal of TRB’s Health and Transportation Committee for a number of years, and this research problem state- ment builds upon a prior research need statement that was submitted in 2012 and has yet to be funded (Estimating the Benefits of a More Complete Pedestrian Injury Reporting System, produced by the Pedestrian Committee, ANF10). This research will identify states that are creating model programs, critically exam- ine successes and challenges in collecting and linking data to capture pedestrian and bicycle morbidities, and develop new methods and/or recommendations for enhanced, integrated data systems that can measure morbidity impacts for active travelers. It can be used immediately by agency decision-makers that fund research regarding data collection and data quality improvement programs, both in state DOTs and state highway safety offices. Local agencies and hospitals may also support data-collection system and integration improvements and applications in plan and project evaluations.

Research Problem Statements 31 VIII. PERSON(S) DEVELOPING THE PROBLEM NCHRP 20-112 Project team: UNC Highway Safety Research Center, VHB, APA, and consultants. IX. PROBLEM MONITOR TO BE DETERMINED X. DATE AND SUBMITTED BY TO BE DETERMINED Problem Statement #4: A Guidebook for Considering the Public Health Impacts of Public Transportation Decisions I. PROBLEM NUMBER To be assigned by NCHRP staff. Could also be cross-listed with TCRP. II. PROBLEM TITLE A Guidebook for Considering the Public Health Impacts of Public Transportation Decisions III. RESEARCH PROBLEM STATEMENT NCHRP Project 20-112 built upon the body of literature, strategic agendas, and research needs connecting health to transportation to provide a list of gaps and needs to support decision-making in funding research over the next ten years that can lead to greater consideration of health issues in transportation contexts. This research needs statement (RNS) is one of the outcomes of the NCHRP project. Public transportation is key to providing access to critical destinations such as schools, work, grocery stores, health care, and other community services. Public transportation is also closely associated with walking and bicycling travel; it reduces automobile travel and can be an effective tool in addressing transportation-related inequities and supporting aging-in-place approaches. Even though transit service can reduce health risk factors such as motor vehicle crashes, air pollution, and physical inactivity, transit planning and operational decisions are often made without giving consideration to the health impacts. Stakeholders interviewed for NCHRP Project 20-112 indicated that transit was an often overlooked or underconsidered opportunity to incorporate health considerations. Research and guidance on how the health impacts of transit are being achieved and communicated can broaden our understanding of the far-reaching impacts of transit and strengthen support for improved integration of health considerations into transportation practice. Linking transit improvements to larger public health goals can underscore the importance of public transportation for economic develop- ment, livability, quality of life, and well-being goals. In addition, there is a need for demonstrating how agencies are linking land use, built environment, and pedestrian improvements to transit ridership and coordinating with other entities to share knowl- edge, data, and coordinate communications with the public.

32 A Research Roadmap for Transportation and Public Health IV. LITERATURE SEARCH SUMMARY There is growing evidence about the importance of public transportation for indi- vidual and community health. A recent review of transportation policies singled out several transit-related policies with potential positive effects on health, primarily those that improve transit service and overall accessibility to destinations (Khreis et al., 2017). Several studies have shown a relationship between transit investments and transit service planning decisions and the ability of transit riders to meet physical activity goals, reduce the risk of chronic diseases, or access transit by active modes of travel (Besser and Dannenberg, 2005; Lachapelle and Frank, 2009; Durand et al., 2016; MacDonald et al., 2010; Brown et al., 2017; Miller et al., 2015), sometimes in concert with complementary strategies like changes to the built environment (Mansfield and Gibson, 2016). Other studies have focused specifically on the health benefits of enhancing transit service to particular destinations such as healthcare providers (Battista et al., 2015; Mattson, 2011), parks (Transit to Trails programs in the Los Angeles region), and targeting transit affordability for particular groups. Some of these findings further indicate that minority and lower-income populations benefitted the most from walking to and from transit. In addition to research studies, several health impact assessments (HIAs) on specific transit projects have been conducted. HIAs have been successful at advancing land use, transportation, and development practices as mechanisms to promote community health. They bring community voices into public decision-making, raise awareness, and provide opportunities for agency collaboration and increased capacity. Dannenberg et al. (2014) examined selected HIAs that had been used to analyze a variety of transit projects around the country, highlighting the diversity of types of projects on which HIAs have been applied. For example, positive health effects were estimated for a proposed fourteen-mile long Red Line Light Rail project in Baltimore. At the state level, reports have summarized efforts to include health considerations in state DOT processes (Lyons et al., 2014). For example, at Iowa DOT, the Office of Public Transit and the Office of Systems Planning are focusing on healthcare access and active transportation, the health objectives most relevant to each office’s role in the statewide multimodal system. At the regional level, Portland, Oregon’s MPO incentivizes transportation projects that are likely to increase walking and biking trips and provides funding specifically for active transportation and transit-oriented projects (Carpenter, 2017). The agency collaborates closely with the Oregon Public Health Institute, Upstream Public Health, Enders in Action, and other organizations concerned with health and social equity to participate in community engagement and to evaluate project design criteria. In a separate report, Transportation for America provided a series of case studies on how MPOs and RPOs, including Portland, Oregon, and communities in Tennessee, Texas, North Carolina, Minnesota, Oklahoma, Ohio, and California are prioritizing and evaluating projects through the health lens (Carpenter and Zaccaro, 2018). Despite the fairly well-understood impacts of transit on health, most decision-making around large transit investments often fails to include key health impacts associated with transit. For example, guidance from 2002 (TCRP Report 78: Estimating the Benefits and Costs of Public Transit Projects: A Guidebook for Practitioners) identified a number of health-related outcomes that should be considered, but physical activity was not one of them. Moreover, recently issued (2018) USDOT guidance on conducting a cost–benefit analysis for applications to discretionary funding programs also omits physical activity, despite its beneficial effects on morbidity and life expectancy.

Research Problem Statements 33 V. RESEARCH OBJECTIVE This research aims to provide a comprehensive overview of the health impacts of transit decisions and to develop a conceptual framework that will enhance the ability of transit agencies to consider health outcomes in transit planning and decision-making. The objective is to address the knowledge and action gap in regards to how health is consid- ered when transit investment decisions are made. Specifically, the study would address gaps in identifying the scope and measuring the overall health impacts of transit and identify ways in which transit agencies can proactively incorporate health consider- ations into evaluation and decision-making. This research will result in the following: • A research synthesis of the impacts of transit and health, written in non-technical language to facilitate engagement of multiple transit-focused stakeholders with an interest in health. • A practice guidebook that presents a suggested framework for incorporating health considerations into transit decision-making, including key success factors such as committed leadership, dedicated and skilled team members, the ability to support diverse priorities, and a strong ability to engage diverse stakeholders. The guidebook would include examples highlighting the ways in which different types of transit decisions have successfully accounted for health considerations and how this was achieved. The guidebook would be written in a compelling, accessible manner to highlight the connections between the transit decisions being assessed and health. • Dissemination of synthesis and guidebooks across transit agencies, MPOs, and DOTs. VI. ESTIMATE OF PROBLEM FUNDING AND RESEARCH PERIOD Recommended Funding: $120,000–150,000 Research Period: 18 months VII. URGENCY, PAYOFF POTENTIAL, AND IMPLEMENTATION Major progress has been made in understanding the usefulness and importance of incorporating health into transportation decisions. The urgency is to identify who will be included and how and when health considerations will be included. Because transit agencies are in charge of billions of dollars of capital investments every year—in addition to operational and service decisions that influence millions of current and potential users—the proposed work (synthesis and guidebook) can have an immediate applicability and use. Effective and engaged dissemination of project results among transit agencies, state DOTs, and MPOs is likely to be critical to the success of the project. VIII. PERSON(S) DEVELOPING THE PROBLEM NCHRP 20-112 Project team: UNC Highway Safety Research Center, VHB, APA, and consultants. IX. PROBLEM MONITOR TO BE DETERMINED X. DATE AND SUBMITTED BY TO BE DETERMINED

34 A Research Roadmap for Transportation and Public Health Problem Statement #5: Effect of Demographic Change on Travel Behavior and Health I. PROBLEM NUMBER To be assigned by NCHRP staff. II. PROBLEM TITLE Effect of Demographic Change on Travel Behavior and Health III. RESEARCH PROBLEM STATEMENT Changing demographics influence travel/commute behavior and health (both mental and physical). We will have a greater number of people age 65 and over in the coming years than we have now. Initial demographic projections suggested that the aging population will move to urban areas and younger people will move to suburbs; however, recent trends indicate otherwise. The older generation (especially baby boomers) are not moving to urban areas, and thus millennials have been either staying in urban areas or moving to exurbs. More research is needed to understand the direct impact of this trend on transportation and health. Many urban areas are experiencing gentrification due to the relatively booming housing market and increasing income of millennials. The gentrification is thought to be leading to displacement, which affects the mental health of the displaced people. Displacement also brings an additional transportation cost burden on low-income families and people of color, which leads to deteriorating quality of life and health (“Getting Home: Transportation Equity and Access to Affordable Housing,” 2011; Lucas, 2012; Boniface et al., 2015; National Academies of Sciences, Engineering, and Medicine et al., 2017; Jeekel and Martens, 2017). The effect on health is most severe in places that do not have well-connected public transit systems. This may contribute to increasing health disparities between low, middle, and high-income communities. Innovative policies that encourage investment while not excluding some residents in all facets of a community need to be explored and advanced. Additionally, research suggests that younger generations have different travel behaviors and are less dependent on personally-owned automobiles than generations before them. This affects travel demand and transportation systems. While auto depen- dence and ownership may be decreasing in some urban areas, most people moving to exurbs remain highly automobile dependent and drive long distances to work. This has a negative impact on the environment and health. Moreover, as the population in the suburban and rural areas have a greater proportion of older adults, questions remain as to whether demand on the rural transportation system will meet their health needs, including access to healthcare, long-term care, and social services. IV. LITERATURE SEARCH SUMMARY The population makeup in the United States is changing. The trend is different than what was predicted by traditional transportation planning models and theory. With more older people living in suburbs and younger people living in urban areas, there is a change in travel demand and behavior. Research on aging populations and driving cessation finds that driving cessation is associated with several poor health outcomes, including a doubling of risks of depressive symptoms. Traffic-related safety is also an issue. Safety-related studies have shown mixed results; while a number of studies have

Research Problem Statements 35 documented that older adult drivers (and pedestrians) are more cautious and less likely to be involved in crashes, older adults account for a growing percentage of the fatal vehicle–vehicle and vehicle–pedestrian crashes. Some studies have provided evidence that older adults have slower reaction times and more limited mobility (such as head turning movements, required to avoid a crash). They also have more challenges in surviving and recovering from traumatic forces caused by motor vehicles. Regarding younger generations, studies show a steady decrease in automobility among millennials, which is producing a marked shift in travel demand. Research contends that while their travel patterns may show fewer trips made by this group today, their travel patterns may shift once they reach new life milestones. Government has an opportunity now to set policy which will shape the form of their future mobility. Another factor of changing urban landscapes is rising housing values, displacement, and gentrification, all identified as a concern in multiple studies looking at implemen- tation of major transportation infrastructure. V. RESEARCH OBJECTIVE Overall, the objective of this research effort would be to conduct research to improve the transportation field’s understanding of the impact of recent and future demographic changes on transportation and health. Research can focus and compare either type of age groups (e.g., millennials, baby boomers) or type of communities (e.g., urban, suburban, exurban, rural). The purpose of the research that centers on the age groups would be to analyze the impact of the demographic change on transportation/transit infrastructure and health. A nation-wide quantitative study could use this information to predict future transportation needs of each age group and could be useful to regional and state transportation agencies, community planners, and public health departments. While urban and rural areas are both facing the realities of a shift in demographics, the urban areas are relatively better equipped to address these changes. Other types of communities, on the other hand, are not well-resourced or well-equipped to meet the challenges. The objective of this research effort would be to help rural and suburban communities tackle issues such as lack of access to facilities (such as healthcare) and increasing crashes among elderly and children. A mixed method study would focus on how to design a rural or suburban community to encourage transit use, active living, and safe roadways; this study could be useful to communities all around the country. In addition, a feasibility study that analyzes the viability of transit that connects the rural community with the urban areas is needed. VI. ESTIMATE OF PROBLEM FUNDING AND RESEARCH PERIOD Recommended Funding: $150,000 Research Period: 24 months VII. URGENCY, PAYOFF POTENTIAL, AND IMPLEMENTATION The changes in the demographics are happening now, and the effects of these changes are going to be evident in the next five to ten years. It is crucial that we undertake this research now so that we are equipped to implement policies and strategies that would accommodate the changing demography. Implementing appropriate policies would

36 A Research Roadmap for Transportation and Public Health lead to improved health outcomes and reduce fatalities. Rural communities are in need of more explicit focus on their unique and changing transportation needs. This would help planners and transportation agencies to distribute the capital improvement funds or other funding according to the needs of the communities. VIII. PERSON(S) DEVELOPING THE PROBLEM NCHRP 20-112 Project team: UNC Highway Safety Research Center, VHB, APA, and consultants. IX. PROBLEM MONITOR TO BE DETERMINED X. DATE AND SUBMITTED BY TO BE DETERMINED Problem Statement #6: Evaluating and Integrating Emerging Data Sources to Support Transportation and Health Planning and Operations I. PROBLEM NUMBER To be assigned by NCHRP staff. II. PROBLEM TITLE Evaluating and Integrating Emerging Data Sources to Support Transportation and Health Planning and Operations III. RESEARCH PROBLEM STATEMENT Big data can be defined as extremely large data sets, often gathered by machine or sensor technologies. There are a growing number of big data sources that can give key insights into travel behaviors that affect health (such as active travel trip-making) and can be used for planning (such as identifying preferred routes or quantifying usage or examining equity concerns) as well as operations (such as real-time monitor- ing of intersections and corridors for travel demand management or deployment of emergency response resources). Increasingly, big data from traffic camera footage, cell phone data, or personal apps collecting travel data are being used to differentiate travel modes (vehicles vs. pedestrians vs. bicyclists) and quantify trips at discrete locations. While these data may offer a rich source of information, current applications are limited by lack of research to calibrate and validate these data, to determine when and how much they over- or underestimate trips or other outcomes being measured, and what populations may be under-represented in these data sources. For example, a recent USDOT pilot study comparison of Waze users’ reported incident data against real-time police-reported incident data found that Waze data provided quality estimates in large urban regions during peak daytime commute hours (due to widespread app usage) but was less accurate and reliable in predicting night-time crashes (“Safety Data Initiative Pilot Projects,” 2019). Research is needed to evaluate the various emerging, big data sources and to identify sources of bias and error—particularly in relation to vulnerable road users,

Research Problem Statements 37 pedestrians and bicyclists, and historically underserved populations—in order to develop adjustments or recommendations for improvements that would further support transportation planning and operations to improve equity, opportunities for active travel, and safety. IV. LITERATURE SEARCH SUMMARY As described in the NCHRP Project 20-112 contractor’s final report: There are many emerging data sources that hold potential to improve the ability of practi- tioners and researchers to capture health determinants and outcomes, in particular accessibility, active travel, and environmental exposures. These include GIS data gathered from app-based sensing technology (such as Strava and Waze) that can track individuals and aggregate the travel behaviors and routes of some populations. Some, such as Google Fit, are also capable of inte- grating travel and health data. A 2015 report describes the technologies and methods by which pedestrian and bicyclist activity data can be crowdsourced to support research and planning. The report describes four different types of crowdsourced data (in situ, thematic, thumbtack, and spatial inventory data), and provides various applications and examples (A. Smith, 2015). Since that report, many new technologies have continued to emerge. V. RESEARCH OBJECTIVE This research could take a variety of approaches to address one or more of the following aims: • Summarize big data sources and passive data collection techniques, as well as health-related data that can be captured by these sources and methods. • Describe how emerging data sources are being used by researchers, states, or regional agencies to advance health in transportation, in particular through improved measurement of active travel behaviors and trends. • Identify sources of bias in the data, such as GPS accuracy and coverage; describe the ways in which biased data may contribute to equity issues, such as by systematically under-representing/weighting certain populations in the data sources; and discuss implications for planning or correcting data biases. • Perform studies to validate or “ground truth” data (such as Strava, cell phone, or app-based measures of pedestrian and bicycle activity) against count-based or other methods. • Identify practices or provide guidance to agencies on how to integrate emerging data with traditional data sources to improve estimation and other applications. • Identify model or noteworthy practices regarding data sharing and public-private collaboration, data usage agreements, and data governance models needed to support cost-effective and sustainable acquisition, storage, and usage of data that may originate from proprietary sources. Ultimately, this research would advance the state of practice in improving and apply- ing big data sources to support active travel, equity considerations, and transportation decision-making. VI. ESTIMATE OF PROBLEM FUNDING AND RESEARCH PERIOD Recommended Funding: $200–400K Research Period: 24–36 months

38 A Research Roadmap for Transportation and Public Health VII. URGENCY, PAYOFF POTENTIAL, AND IMPLEMENTATION Cell phone data is becoming more widespread, robust, and available for research and analysis, and it has become more common for transportation agencies to purchase data from communication companies and data-processing companies to describe real-time travel patterns. To date, most of the prevailing research has been applied to study motor vehicle traffic, missing key opportunities to improve our understanding of pedestrian and bicycle travel patterns and safety needs. As big data storage, manage- ment, security, and analytic practices evolve, there is a timely opportunity to harness these data sources for health and transportation research opportunities and improve the methods needed to evaluate their quality and make adjustments to correct for inherent biases in the data sources. Big data offer real opportunities for better predicting pedestrian and bicycle behav- iors, including route choice and exposure to risk. They may become an increasingly important source of information to use in scenario planning, performance evaluation and monitoring trends over time, as well as safety studies if researchers and practitioners have confidence in the data. However, it is not yet clear how well big data sources represent all pedestrian and bicycle trips and populations and how using data that has not been corrected for these limitations can exacerbate equity concerns. VIII. PERSON(S) DEVELOPING THE PROBLEM NCHRP 20-112 Project team: UNC Highway Safety Research Center, VHB, APA, and consultants. IX. PROBLEM MONITOR TO BE DETERMINED X. DATE AND SUBMITTED BY TO BE DETERMINED