Prevention Agenda 2013-2018: Promote a Healthy and Safe Environment Action Plan
Focus Area 3: Built Environment
- Goals and Objectives
- Goal #1: Improve the design and maintenance of the built environment
- Goal #1: Interventions by Levels of Health Impact Pyramid
- Goal #2: Improve the design and maintenance of home environments
- Goal #2: Interventions by Levels of Health Impact Pyramid
- Interventions by Sector
Defining the Problem
The 'built environment' includes homes, schools, workplaces, public and commercial buildings, transit systems, multi-use trails, roadways, streetscapes and parks.18 How the built environment is designed and maintained can affect human health through the products and materials used and through land use, zoning, economic development and infrastructure decisions that affect access to nutritious food and opportunities for physical activity.19,20
At the neighborhood level, sidewalks, cross-walks, multi-use trails, safe streets, "complete streets," inter-connected streets and trails and public transportation are associated with physical activity,21,22 energy usage23 and the risk of being overweight or obese, especially among children, adolescents and the elderly.24,25 These factors are also associated with decreased risks of heart disease, hypertension, stroke, Type-2 diabetes, colon and breast cancer, falls, metabolic syndrome.26 Many low-income communities and communities of color have disproportionately less access to public transportation, green and open space, recreational facilities, safe streets and healthy foods. These communities also experience elevated rates of obesity, diabetes, cardiovascular disease and mortality.27,28,29 Additionally, many neighborhoods and buildings aren't designed to accommodate the needs of the elderly and disabled.
The way we arrange the different land uses listed above - in relation to transportation systems, the natural environment, and one another – also determines the degree to which residents can engage in physical activity. Thus, safe and comfortable streets must be matched with proper land use, zoning and development that bolsters and complements active living. In this regard, 'smart growth' planning offers several planning and design principles that support this goal – including, strategically-targeted density; mixed land uses; inter-connected street and trail networks; and safe, accessible and well-maintained public spaces.
"Traffic-calming" measures can integrate transportation improvements and land use design to support physical activity. The Institute of Traffic Engineers defines traffic-calming as follows: Traffic calming is the combination of mainly physical measures that reduce the negative effects of motor vehicle use, alter driver behavior and improve conditions for non-motorized street users. 30 Examples include: landscaped medians that force drivers to slow down and allow safer mid-street havens to pedestrians to cross; well-designed raised cross-walks; buildings close to the sidewalk matched with on-street parking and sidewalk landscaping – this provides safe enclosures for pedestrians to travel and congregate; well-designed traffic circles and rotaries ('round-abouts'); narrower vehicle lanes, which slows, but does not congest, traffic; and human-scaled traffic signs, signals and lighting structures, among others.
At the building level, the use of toxic products, structural issues, inadequate ventilation, heating and cooling systems, and deferred maintenance can create health and safety hazards. Many housing-related issues can pose a threat to human health, including carbon monoxide, peeling and chipping lead-based paint, fire and electrical hazards, mold, radon, poor indoor air quality, pests and pesticides.31 These hazards can result in health effects including poisoning, fall and fire related injury and death, and lung diseases such as asthma and cancer.32 Housing is an especially important part of the built environment because some of the most vulnerable populations (e.g. children, elderly, and infirmed) spend the most time in their homes. Four key housing-related health issues are asthma, childhood lead exposure, fire-related injuries and carbon monoxide poisoning.
A number of housing-related hazards, such as mold, cockroaches and environmental tobacco smoke can trigger asthma. Asthma affects an estimated one in eleven New Yorkers (1.3 million adults and 475,000 children). Asthma prevalence among adults increased from 6.3 percent in 1999 to 8.7 percent in 2008. Asthma prevalence, ED visits and hospitalization rates are higher in New York State than nationally. Children in New York State miss more than 1.9 million days of daycare, pre-school or school due to asthma each year. In 2008, adults with asthma reported approximately 7.6 million days when they were unable to work or carry out usual activities because of asthma.33 Although not all asthma is housing-related, asthma control programs focused on improving the home environment (e.g., environmental assessment; education; use of mattress and pillow covers; use of HEPA vacuums and HEPA air filters; smoking cessation and reduction in environmental tobacco smoke; cockroach and rodent management; minor repairs, and intensive household cleaning) have been shown to have health and financial benefits.34,35,36
Childhood lead poisoning is another preventable housing-related condition. New York consistently ranks high on key risk factors associated with lead poisoning, including childhood poverty, a large immigrant population, and an older, deteriorated housing stock. Although the overall incidence of newly diagnosed cases of lead poisoning among New York State children under age six has steadily declined over the past four decades, thousands of children are still at risk. In 2008, over 3000 children under age six were newly identified with blood lead levels (BLLs) 10 micrograms per deciliter (µg/dL) and above; 80 percent resided in just 13 of the States' poorest counties with the oldest housing stock.37
Residential fires are among the leading causes of injury and death among children and the elderly.38 A primary risk factor in residential fire injuries and deaths is the absence of a working smoke alarm. Residential smoke alarm legislation has been shown to be effective in increasing the prevalence of working smoke detectors in a home.39 When a fire occurs in a residential setting, a working smoke alarm can reduce fatal injuries by 40 to 50 percent.40 Carbon monoxide (CO) poisoning is another potential housing-related health problem, especially following severe weather events that result in power outages and can lead to improper use of portable generators.41,42 As an example, one early-season storm in 2006 resulted in 14 percent of the emergency department visits for non-fire-related CO poisoning in NYS for that year.43 Each year, approximately 200 people in New York are hospitalized due to accidental CO poisoning. About one-third of poisonings result from fires and two-thirds result from fuel-burning equipment and appliances.44 CO poisoning is preventable with safe use of generators, boiler maintenance, and installation and maintenance of CO alarms; and prompt treatment if overexposure occurs. Delayed treatment can result in neurological problems.45
Climate change (e.g., extreme weather episodes, increased coastal flooding and storms) contributes to adverse health impacts of the built environment. For example, storms and subsequent power outages increase the risk of CO poisoning46; and extreme heat episodes disproportionately impact the poor and elderly population, who may be unable to afford the additional cost of air conditioning.47
Built environments that discourage physical activity can also increase energy consumption, and thus contribute to adverse climate impacts and decreased air quality. For example, lack of access to public transit and lack of safe, well-lit streets promotes driving over more sustainable forms of transportation. Children who live in neighborhoods without safe access to spaces for recreation spend more time in front of the television (TV) and computer (PC).48 TV and PC use are significant sources of increased home energy consumption.49
Finally, half of the top ten risk factors for chronic disease in high income countries (including the US) are influenced by the built environment: overweight and obesity, ranks third; physical inactivity, ranks fourth; low fruit and vegetable intake, ranks seventh; exposure to urban air pollutants, ranks eighth; and occupational risks, ranks tenth.50 The priority areas for intervention are improving the design and maintenance of home environments and improving the transportation infrastructure.
Goals and Objectives for Action
The Built Environment Focus Area Committee identified the following goals and objectives for action as well as sector level interventions to implement the identified goals and objectives:
Goal #1: Improve the design and maintenance of the built environment to promote healthy lifestyles, sustainability and adaptation to climate change.
- Objective 1a:
- By December 31, 2018 c, increase the percentage of the population that lives in a jurisdiction that adopted the Climate Smart Communities pledge by 20% from 26.7% to 32.0%
- (Year: 2012; Data Source: NYS DEC Program Tracking, available, State and County).*
- Objective 1b:
- By December 31, 2018, increase the proportion of people who commute using alternate modes of transportation, i.e., public transportation, carpool, bike/walk, telecommute, by 10% from 44.7% to 49.2%.
- 2007-2011 5-yr. estimate; Data Source: US Census, American Community Survey; Data Availability: State, county) *
- Objective 1c:
- By December 31, 2018, improve access to affordable fruits and vegetables among low-income NYS residents by decreasing the percentage who live greater than 1 mile from a supermarket or grocery store in urban areas, or greater than 10 miles from a supermarket or grocery store in rural areas, by 10% from 2.49% to 2.24%. (Year: 2010; Data Source: US Department of Agriculture Food Environment Atlas; Data Availability: State, county) *
- Objective 1d:
- By December 31, 2018, reduce the number of crash-related pedestrian fatalities by 10% from 1.4 (2007-2009) to 1.25 per 100,000 people.a (Data Source: NYS Vital Statistics)
- Objective 1e:
- Improve pedestrian and bicycling infrastructure by addressing financial and other barriers to investing in pedestrian and bicycling networks, especially in low-income communities.
- Objective 1f:
- Integrate active transportation network to increase accessibility to destinations, such as grocery stores, schools, shops, and restaurants.
- Objective 1g:
- Increase access to bike paths, hiking trails, open green spaces, recreational facilities, particularly among low-income communities.
- Objective1h:
- Reduce health impacts associated with extreme weather incidents, especially among vulnerable populations.
- Objective 1i:
- Increase the percent/number of buildings that meet the US Green Building Council's LEED (Leadership in Energy and Environmental Design) green building and neighborhood standards, or any other comparable set of standards.
d This objective and its target are consistent with a similar one in the NYS DOT Strategic Highway Safety Plan, although the NYS DOT goal year for achieving the objective is 2014.
Goal #2: Improve the design and maintenance of home environments to promote health and reduce related illness.
- Objective 2a:
- By December 31, 2018, increase the percentage of homes in vulnerable neighborhoods that have fewer asthma triggers during Healthy Neighborhood Program home revisits by 55% from 12.9% to 20%.
- (Data Source: NYS DOH, Healthy Neighborhoods Program Tracking; Data Availability: select counties)*
Late 2015 the target was modified and a new 2018 target was developed for this objective to 25%, along with a new baseline.
(Data Source: NYS DOH, Healthy Neighborhoods Program Tracking) (Baseline: 26.3, Years: 2008-2011; Data Availability: Selected counties) - Objective 2b:
- Reduce by 20% the number of non-fire-related carbon monoxide poisonings resulting in hospitalizations. (Baseline: 125/year)
- Objective 2c:
- Reduce the incidence of elevated blood lead levels among children in high-risk neighborhoods and from populations and by 10%.
- Objective 2d:
- Increase the number of housing units that contain at least one functional smoke and one functional carbon monoxide detector.
*Objectives that are in bold font are Prevention Agenda Dashboard Tracking Indicators.
Goal #1: Interventions by Levels of Health Impact Pyramid
| Goal #1: Improve the design and maintenance of the built environment to promote healthy lifestyles, sustainability and adaption to climate change | |
|---|---|
| Levels of Health Impact Pyramida | Interventionsb |
| Counseling and Education |
|
| Clinical Interventions |
|
| Long-Lasting Protective Interventions |
|
| Changing the Context to Make Individuals' Decisions Healthy |
|
| Socioeconomic Factors |
|
b Frieden T. "A Framework for Public Health Action: The Health Impact Pyramid". American Journal of Public Health. 2010; 100(4): 590-595.
b Interventions in boldface type have been proposed for prioritization.
Goal #2: Interventions by Levels of Health Impact Pyramid
| Goal #2: Improve the design and maintenance of home environments to promote health and reduce related illness | |
|---|---|
| Levels of Health Impact Pyramida | Interventionsb |
| Counseling and Education |
|
| Clinical Interventions |
|
| Long-Lasting Protective Interventions |
|
| Changing the Context to Make Individuals' Decisions Healthy |
|
| Socioeconomic Factors |
|
a Frieden T. "A Framework for Public Health Action: The Health Impact Pyramid". American Journal of Public Health. 2010; 100(4): 590-595
b Interventions in boldface type have been proposed for prioritization
Interventions by Sector
Changes can be made across the sectors identified below to improve health outcomes related to the built environment. Below are examples of how your sector can make a difference.
Healthcare Delivery System
- Goal #1:
- Promote healthy lifestyles, sustainability and adaptation to climate change.
- Provide targeted education on the impact of the built environment on health (e.g., clinicians, patients, teachers, employers, property owners, local planning and zoning boards). (Objectives 1a-1g)
- Conduct patient assessments on the impact of the built environment. (Objectives 1b)
- Goal #2:
- Improve home environment.
- Provide targeted information on home related hazards to patients. (Objectives 2a-2d)
- Offer insurance coverage for assessment and intervention. (Objectives 2a-2d)
- Provide up-to-date information on home-related hazards, diagnosis and treatment in clinical and other professional initial and continuing education (CE credits). (Objectives 2a-2d)
- Ensure that primary care providers (PCPs) assess risks, screen, and provide follow-up treatment (using NHLBI-asthma, NYS, CDC-lead poisoning and other relevant guidelines) for building-related exposures and illnesses, e.g., lead poisoning, asthma, allergies, and referrals to support services (e.g., Healthy Neighborhood Program). (Objectives 2a, 2b, 2c)
- Establish and disseminate best practices for environmental history taking, treatment and diagnosis. (Objectives 2a-2d)
- Participate in coalition and partnership-building (e.g., between health, housing, advocacy and medical sectors) to share information about low-cost, effective assessment and control strategies. (Objectives 2a-2d)
Employers, Businesses, and Unions
- Goal #1:
- Promote healthy lifestyles, sustainability and adaptation to climate change.
- Provide workplace/member health promotion programs. (Objectives 1b)
- Conduct employee/member training. (Objectives 1b)
- Offer free products and training, e.g., healthy food, bikes, classes. (Objective 1b, 1g)
- Provide targeted education on the impact of the built environment on health (e.g., clinicians, teachers, employers, property owners, local planning and zoning boards). (Objective 1a-1i)
- Offer school-, workplace and community-based physical education programs. (Objective 1b)
Media
- Goal #1:
- Promote healthy lifestyles, sustainability and adaptation to climate change.
- Publicize warning network, e.g., extreme weather. (Objective 1h)
- Provide public education. (Objective 1a-1i)
- Promote successes/Model programs. (Objective 1a-1i)
- Publicize risk factors and steps to improve home environment. (Objective 1h)
- Support a warning network with the meteorological community to incorporate CO warnings into their alerts before an impending weather disaster. (Objective 1h)
- Goal #2:
- Improve home environment.
- Publicize warning network, e.g., CO. (Objectives 2b)
- Promote successes/model programs. (Objectives 2a-2d)
- Publicize risk factors and steps to improve home environment. (Objectives 2a-2d)
Academia
- Goal #1:
- Promote healthy lifestyles, sustainability and adaptation to climate change.
- Offer professional training. (Objective 1a-1i)
- Provide continuing education. (Objective 1a-1i)
- Promote successes/Model programs. (Objective 1a-1i)
- Evaluate and publish effective interventions and programs. (Objective 1a-1i)
- Assist with tracking and surveillance, e.g., vulnerable populations during extreme weather events, community environmental amenities and health risks. (Objective 1h)
- Goal #2:
- Improve home environment.
- Offer professional training. (Objectives 2a-2d)
- Provide continuing education. (Objectives 2a-2d)
- Conduct evaluation and dissemination about effective interventions and programs. (Objectives 2a-2d)
- Support a warning network with the meteorological community to incorporate CO warnings into their alerts before an impending weather disaster. (Objective 2b)
Community-Based Organizations
- Goal #1:
- Promote healthy lifestyles, sustainability and adaptation to climate change.
- Provide staff/client education. (Objective 1a-1i)
- Offer 'Green' and healthy living programming. (Objective 1a-1i)
- Advocate for resources, programs and facilities. (Objective 1a-1i)
- Offer public education about the impact of the built environment and climate change on health, with intensive strategies for vulnerable populations, e.g., poor, infirmed, elderly, children. (Objective 1a-1i)
- Goal #2:
- Improve home environment.
- Train staff and clients to recognize health and environmental issues and make referrals. (Objectives 2a-2d)
- Develop targeted educational programs and materials about exposures, health risks and effective control strategies for hazards in homes, schools and other indoor environments. (Objectives 2a-2d)
- Incorporate 'Healthy Homes' education and inspections into other (non-health) 'opportunity points', for example, building inspections, firefighters annual fall fund drive, i.e., installation and inspection of CO alarms. (Objectives 2a-2d)
Other Governmental Agencies
- Goal #1:
- Promote healthy lifestyles, sustainability and adaptation to climate change
- Support climate change, complete streets, waterfront revitalization programs. (Objective 1a, 1b, 1e, 1f, 1g)
- Offer school, workplace and community-based physical education programs. (Objective 1b)
- Construct and maintain safe sidewalks, bike lanes, recreational facilities, parks and other amenities, especially in low-income communities. (Objective 1e, 1f, 1g, 1i)
- Increase public lands designated for public recreation, particularly in low-income communities. (Objective 1e)
- Provide on-going inspection, maintenance and upgrade of surface transit. (Objective 1b, 1f)
- Issue penalties for promoting carbon, unsustainable building. (Objective 1a)
- Offer subsidies and other incentives to increase availability of healthy food in low-income communities. (Objective 1c)
- Goal #2:
- Improve home environment.
- Provide insurance coverage including Medicaid and Medicare reimbursement for home assessments and interventions. (Objectives 2a-2d)
- Incorporate 'Healthy Homes' education and inspections into other non-health opportunity points, e.g., building inspections, firefighters' annual fall fund drives, such as, installation and inspection of CO alarms. (Objectives 2a-2d)
- Provide home and building modifications, e.g., weatherization, CO alarms, smoke detectors, safety. (Objectives 2a-2d)
- Conduct ongoing building inspection and maintenance, e.g., to address water infiltration, mold, peeling paint and vermin. (Objectives 2a-2d)
- Support clean energy sources in homes, schools and other buildings, e.g., low-sulfur heating oil. (Objectives 2a-2d)
- Comply with and enforce existing property maintenance, building, fire and related codes, e.g., boilers, lead paint. (Objectives 2a-2d)
- Participate in coalition and partnership building, e.g., between health, housing, advocacy and medical sectors, to share information about low-cost, effective assessment and control strategies. (Objectives 2a-2d)
- Offer incentives for compliance with and enforcement of existing housing and building code, especially in high-risk housing. (Objectives 2a-2d)
Governmental (G) and Non-Governmental (NG) Public Health
- Goal #1:
- Promote healthy lifestyles, sustainability and adaptation to climate change.
- Provide surveillance analysis and tracking of risks and health outcomes. (G) (NG) (Objective 1b, 1c, 1d)
- Make emergency services available. (G) (NG) (Objective 1h)
- Provide public education about the impact of the built environment and climate change on health, with intensive strategies for vulnerable populations, e.g., poor, infirmed, elderly, and children. (G) (NG) (Objective 1a, 1b, 1e, 1f, 1g, 1i)
- Provide emergency services for vulnerable populations during extreme weather incidents. (G) (NG) (Objective 1h)
- Provide tracking and surveillance (e.g. vulnerable populations during extreme weather events; community environmental amenities and health risks). (G) (NG) (Objective 1h)
- Incorporate 'smart growth' into SEQR process. (G) (Objective 1a, 1b, 1e, 1f, 1g, 1i)
- Offer incentives for Brownfield Opportunity Areas. (G) (Objective 1a, 1b, 1e, 1f, 1g, 1i)
- Goal #2:
- Improve home environment.
- Provide surveillance, analysis and tracking of risks and health outcomes. (G) (NG) (Objectives 2a-2d)
- Ensure home assessments. (G) (NG) (Objectives 2a-2d)
- Support educational efforts aimed at primary care providers to assess risks, screen, and provide follow-up treatment (using NHLBI asthma, NYS, CDC-lead poisoning and other relevant guidelines) for building-related exposures and illnesses (e.g. lead poisoning, asthma, allergies). (G) (NG) (Objectives 2a-2d)
- Develop targeted educational programs and materials about exposures, health risks and effective control strategies for hazards in homes, schools and other indoor environments. (G) (NG) (Objectives 2a-2d)
- Enhance mechanisms for referrals to support services, for example, Healthy Neighborhood Program. (G) (NG) (Objectives 2a-2d)
- Offer up-to-date information on home-related hazards, diagnosis and treatment in clinical and other professional initial and continuing education (CE credits). (G) (NG) (Objectives 2a-2d)
- Incorporate 'Healthy Homes' education and inspections into other (non-health) 'opportunity points', e.g., building inspections, firefighters annual fall fund drives, i.e., installation and inspection of CO alarms. (G) (NG) (Objectives 2a-2d)
- Implement the Medicaid Redesign Team recommendations to provide home assessments, e.g., for children in at risk housing with asthma. (G) (Objectives 2a-2d)
- Provide a warning network with the meteorological community to incorporate CO warnings into their alerts before an impending weather disaster. (G) (NG) (Objective 2b)
- Conduct ongoing building inspection and maintenance, e.g., to address water infiltration, mold, peeling paint, vermin. (Objectives 2a-2d)
- Formalize communication, for example regarding referrals, inspections, remediation, and enforcement, between housing, building, fire, health and related agencies. (G) (NG) (Objectives 2a-2d)
- Participate in coalition and partnership building, e.g., between health, housing, advocacy and medical sectors, to share information about low-cost, effective assessment and control strategies. (G) (NG) (Objectives 2a-2d)
- Strengthen support for Healthy Neighborhood and other related programs to conduct home assessments, provide free or low cost safety measures, e.g., CO alarms, smoke detectors, and remediation, such as water infiltration. (G) (Objectives 2a-2d)
Policymakers and Elected Officials
- Goal #1:
- Promote healthy lifestyles, sustainability and adaptation to climate change.
- Strengthen and expand Smart Growth, Complete Streets and related initiatives. (Objective 1a, 1b, 1e, 1f, 1g, 1i)
- Subsidize smart growth projects. (Objective 1a, 1b, 1e, 1f, 1g, 1i)
- Offer targeted education on the impact of the built environment on health, for example, clinicians, teachers, employers, property owners, local planning and zoning boards. (Objective 1a-1i)
- Comply with and enforce existing laws and ordinances, e.g., NYS Smart Growth Infrastructure Act or NYS Complete Streets. (Objective 1a)
- Incorporate 'smart growth' into SEQR process. (Objective 1a, 1b, 1e, 1f, 1g, 1i)
- Offer incentives for sustainable and climate smart planning, zoning and development, incl. transportation. (Objective 1a, 1b, 1e, 1f, 1g)
- Develop progressive codes and incentives for 'green buildings', such as, solar and other on-site renewable power, green roofs to maximize energy efficiency and resilience to climate change. (Objective 1a)
- Issue penalties for promoting carbon, unsustainable building. (Objective 1a)
- Offer subsidies and other incentives to increase availability of healthy food in low-income communities. (Objective 1c)
- Offer subsidies and other incentives to increase access to parks in low-income communities. (Objective 1e, 1f, 1g)
- Increase public lands designated for public recreation, particularly in low-income communities. (Objective 1e, 1f, 1g)
- Goal #2:
- Improve home environment.
- Strengthen and expand housing standards. (Objectives 2c, 2d)
- Subsidize home repairs in low-income housing. (Objectives 2c)
- Impose restrictions on high particulate and sulfur burning fuels. (Objectives 2a, 2b)
- Provide incentives for compliance with and enforcement of existing housing and building code, especially in high-risk housing. (Objectives 2a-2d)
Communities
- Goal #1:
- Promote healthy lifestyles, sustainability and adaptation to climate change.
- Adopt Smart Growth, Complete Streets, Waterfront Revitalization, and related programs. (Objective 1a, 1b, 1e, 1f, 1g, 1i)
- Provide targeted education on the impact of the built environment on health (e.g. clinicians, teachers, employers, property owners, local planning and zoning boards). (Objective 1a-1i)
- Offer school-, workplace and community-based physical education programs. (Objective 1b)
- Construct and maintain safe sidewalks, bike lanes, recreational facilities, parks and other amenities, especially in low income communities. (Objective 1e, 1f, 1g)
- Increase public lands designated for public recreation, particularly in low income communities. (Objective 1e, 1f, 1g)
- Goal #2:
- Improve home environment.
- Provide home and building modifications, e.g., weatherization, CO alarms, smoke detectors, safety. (Objectives 2a-2d)
- Ensure clean energy sources in homes, schools and other buildings, e.g., low sulfur heating oil. Objectives 2a, 2b)
Philanthropy
- Goal #1:
- Promote healthy lifestyles, sustainability and adaptation to climate change.
- Make this a funding priority. (Objective 1a-1i)
- Fund demonstration programs. (Objective 1a-1i)
- Goal #2:
- Improve home environment.
- Make this a funding priority. (Objectives 2a-2d)
- Fund demonstration programs. (Objectives 2a-2d)
- Increase funding for Healthy Neighborhood and other related programs to conduct home assessments, provide free or low cost safety measures, e.g., CO alarms, smoke detectors) and remediation (e.g., water infiltration. (Objectives 2a-2d)
c The Prevention Agenda 2013-2017 has been extended to 2018 to align its timeline with other state and federal health care reform initiatives.
d This objective and its target are consistent with a similar one in the NYS DOT Strategic Highway Safety Plan, although the NYS DOT goal year for achieving the objective is 2014.
