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MARCH/APRIL 2011 :: 72(2)
Public Health and Environmental Health

The policy forum of this issue addresses the connection between public health and environmental health, drawing on papers and presentations from the 2010 North Carolina Environmental Health Summit. The forum is complemented by original research on barriers to municipal walking and bicycling projects, quality of asthma care, and use of public records for evaluating the health effects of treated sewage sludge, as well as by a review of the National Children's Study, which is presently underway at 2 sites in the state. Also in the issue, the North Carolina Department of Health and Human Services and the North Carolina Institute of Medicine review efforts associated with implementation of the Affordable Care Act.


Barriers to Municipal Planning for Pedestrians and Bicyclists in North Carolina

Kelly R. Evenson, Semra A. Aytur, Sara B. Satinsky, Daniel A. Rodríguez

N C Med J. 2011;72(2):89-97.PDF | TABLE OF CONTENTS

Background The Guide to Community Preventive Services recommends implementing community- and street-scale urban design, as well as land use policies and practices, to promote walking and bicycling. To better understand barriers to municipal walking and bicycling projects and policies, we surveyed municipal staff in North Carolina.

Methods We surveyed all 121 municipalities with at least 5,000 persons, and 62% responded. We also surveyed 216 of 420 municipalities with less than 5,000 persons, and 50% responded. The municipal staff member most knowledgeable about walking and bicycling planning was asked to complete the survey. Responses were weighted to account for the sampling design, to reflect prevalence estimates for all North Carolina municipalities.

Results Common barriers to walking and bicycling projects and policies were selected from a 14-item list. For walking, barriers included lack of funding (93% of responding municipalities), other infrastructure priorities (79%), automobile infrastructure priorities (66%), and staffing challenges (65%). For bicycling, barriers included lack of funding (94% of responding municipalities), other infrastructure priorities (79%), automobile infrastructure priorities (73%), issues were not high priorities for the municipality (68%), staffing challenges (68%), and insufficient support from residents (63%). Barriers generally were more prevalent among rural municipalities than among urban municipalities (9 of 14 barriers for walking and 5 of 14 for bicycling; P < .10).

Limitations The study relied on 1 respondent to report for a municipality. Additionally, job titles of respondents varied with municipality size.

Conclusions Health professionals and multidisciplinary partners can assist in overcoming the common local- and state-level barriers to walking and bicycle projects and policies that are reported by North Carolina municipalities.

Walking and bicycling for recreation or transportation contribute to numerous health benefits [1-5]. For example, a meta-analysis of walking found that approximately 8 metabolic equivalent-hours/week (approximately 30 minutes/day for 5 days/week) of walking was associated with a 19% reduction in the risk of coronary heart disease [2]. In another meta-analysis, walking and bicycling for commuting were associated with an 11% reduction in the risk of cardiovascular disease [5]. Other benefits include reductions in the risk of asthma, obesity, diabetes, depression, and some cancers; increases in quality of life; lower carbon emissions and reduced traffic congestion; lower fuel bills and health care costs; and opportunities to reduce health disparities. In addition, areas with facilities for walking and bicycling have higher property values.

Despite the benefits of walking and bicycling, adults and youth in North Carolina often do not reach recommended physical activity levels. In 2009, 17% of North Carolina adults reported any walking or bicycling for transportation, such as to or from work or shopping, during the past week, and 26% reported no leisure activities or exercises during the past month [6], a prevalence similar to the 2009 national average of 24% [7]. By use of a national data source, North Carolina ranked poorly (43rd among states) for the percentage of adults who walked or bicycled for transportation, compared with the rest of the nation [8]. Moreover, for 2005-2007, North Carolina ranked 43rd for walker safety and 47th for bicyclist safety [8].

The lack of physical activity also extends to North Carolina youth. In 2009, 40% of North Carolina middle school students and 54% of North Carolina high school students did not report at least 60 minutes of physical activity for at least 5 of the previous 7 days [9, 10]. Furthermore, in 2009, among North Carolina middle school students, only 19% reported walking or bicycling to school at least 1 day per week [9]. The burden of physical inactivity and its associated effects on obesity and other health-related conditions [10] generate enormous costs for youth and adults. Billions are spent annually in North Carolina on medical costs, workers’ compensation claims, and lost productivity related to these conditions [11], and this is projected to increase with rising obesity [7].

In working to improve physical activity levels, researchers and practitioners increasingly have relied on the ecologic framework [12, 13], which describes how intrapersonal, interpersonal, institutional or organizational, policy, and community or environmental characteristics can influence physical activity levels. Traditionally, physical activity interventions have focused on the intrapersonal and interpersonal domains; however, more recently, practitioners have focused on the policy and environmental domains and on interventions that span all levels of the framework. When promoting physical activity to their patients, health care professionals can consider broad policy and environmental contexts in which physical activity occurs. For example, physicians encouraged physical activity in specific locations by writing patients prescriptions to walk that included recommendations of places to go, which involved careful consideration of the environment [14]. In another example pertaining to the environmental context, Estabrooks and colleagues [15] designed an intervention that recruited patients through physician offices and connected them to physical activity resources near their homes and workplaces.

Because physical environments and policies are likely to influence physical activity levels, we surveyed North Carolina municipalities to determine barriers to pedestrian and bicycling projects and policies. We also explored whether these barriers differed between urban areas and rural areas, to inform context-appropriate strategies for individuals working with communities. We surveyed municipalities, rather than counties, since roads outside of municipalities are owned and maintained by the North Carolina Department of Transportation [16].

Sample. We classified the 541 North Carolina municipalities by their July 2006 population, estimated from 2000 US Census data, and surveyed all 121 municipalities with at least 5,000 persons. From the 420 municipalities with less than 5,000 persons, we drew a random sample of 50%. During 2008, we also collected all North Carolina pedestrian and bicycle plans, as described elsewhere [17, 18]. Smaller municipalities with a pedestrian or bicycle plan were also included in the survey, for a total of 216 municipalities of the possible 420 municipalities with a population of less than 5,000.

Survey. For each municipality, the survey targeted the municipal staff member most knowledgeable about walking and bicycling issues. To our knowledge, no comprehensive list of planners or other contact persons exists for all municipalities in North Carolina. Therefore, we used multiple strategies, including the use of planning-association lists, Web site searches, and telephone calls to the municipality, to find the appropriate people to invite to complete the survey. The survey was available by mail and on a Web site in spring 2009. We made several attempts to contact nonresponders.

To assess barriers to walking and bicycling in the community, we asked respondents 2 questions. The first focused on walking: “What barriers do you face in terms of implementing projects, policies, or programs to support walking in your locality?” The question on bicycling was similarly worded. Both had 14 different items for response. The response options for each item included “strongly disagree,” “disagree,” “agree,” and “strongly agree,” which were collapsed during analysis into “agree” and “disagree.” We also reviewed open-ended responses to the “other” category.

Statistical analysis. Survey responses were weighted to account for the sampling design and to reflect statewide prevalence estimates for all municipalities. The prevalence is reported using weighting only; as in most cases, the unweighted prevalence was quite similar to the weighted prevalence. We compared survey respondents to nonrespondents, using the Wald χ2 test, with US Census data on the municipalities.

To explore differences between rural areas and urban areas, we stratified the results by population size (ie, <5,000 persons vs ≥5,000 persons), extending from the process we used to weight the data; the categories are hereafter referred to as “rural” and “urban.” When we explored the validity of this definition, we found that 381 (91%) of 420 municipalities with a population of less than 5,000 were classified as rural (ie, they fell outside of the boundary of an urbanized area) on the basis of the 2000 US Census definition [19]. SAS, version 9.2 (SAS Institute), was used for all analyses.

Among municipalities with a population of at least 5,000 persons, 75 (62%) of 121 responded to the survey. Among municipalities sampled with a population of less than 5,000 persons, 108 (50%) of 216 responded to the survey. Respondents and nonrespondents were not different by region of North Carolina, urban area, percentage of residents who bicycle to work, household income, or income below the poverty level (Table 1). However, respondents were more likely to represent municipalities with a population of at least 5,000 persons and a lower proportion of residents who walked to work, compared with nonrespondents.

Among all respondents, 141 (77%) completed the survey by use of the Web site, and 42 (23%) completed it by use of a paper copy returned via mail. Respondents had been in their current position for a median of 62 months (interquartile range, 31-104 months).

Barriers to implementing walking and bicycling projects and policies are reported in Tables 2 and 3, respectively. Frequently reported barriers to walking projects and policies included lack of funding (93%), other infrastructure priorities (79%), automobile infrastructure priorities (66%), and staffing challenges (65%). Frequently reported barriers to bicycling projects and policies included lack of funding (94%), other infrastructure priorities (79%), automobile infrastructure priorities (73%), issues were not high priorities for the municipality (68%), staffing challenges (68%), and insufficient support from residents (63%). Answers provided in the open-ended response field included other barriers to these projects, such as the challenge of obtaining right-of-way, a need to retrofit roads to accommodate walkers and bicyclists, and inadequate driver education. Policy barriers included language in planning tools or documents, such as ordinances, which limited activities.

For 3 of 14 items, the prevalence of the bicycling barrier was at least 10% higher than that of the walking barrier. Barriers generally were more prevalent among rural municipalities than among urban municipalities (9 of 14 for walking and 5 of 14 for bicycling; P < .10). The only exception was the report of lack of funding for bicycle projects, which was higher among urban municipalities, compared with rural municipalities (97% vs 92%).

There are multiple statewide efforts to increase physical activity by creating supportive policies and environments. These include the North Carolina plan to address overweight and obesity in communities [20]; the Eat Smart, Move More NC blueprint for changing environments and policies, to increase physical activity [21]; the North Carolina Institute of Medicine objectives for 2020 [22]; and the North Carolina walking and bicycling long-range transportation plan [23]. Examples of relevant North Carolina health-related projects and collaboratives relevant to these goals are summarized in Table 4. In support of these statewide efforts, the present study documented barriers to implementing walking and bicycling projects and policies among North Carolina municipalities. We found a high prevalence of many barriers overall and a greater frequency of barriers for bicycling than for walking, as well as a greater frequency for rural areas than for urban areas. The discussion highlights opportunities for health professionals, with regards to these issues.

From the survey list, the most commonly selected barrier for walking and bicycling projects was a lack of funding (93% for walking and 94% for bicycling). In North Carolina, the Transportation Improvement Program (TIP) provides funding for these projects [24]. The TIP is a financially constrained 2-year plan of investments managed by metropolitan planning organizations (MPOs), rural planning organizations (RPOs) and the North Carolina Department of Transportation. In 2008, North Carolina had 17 MPOs (available at:, and 20 RPOs (available at: MPOs are federally designated and funded regional institutions that conduct transportation planning in all metropolitan areas of the United States. RPOs are transportation planning organizations in North Carolina that provide a forum for rural transportation issues and policies and work in coordination with the state government and the MPOs, though they are not federally mandated. Walking and bicycling projects typically are funded by the “transportation enhancements” funding category, for which law requires that 10% of federal funds under the Surface Transportation Program must be set aside. On the basis of 2004-2008 data, 1.2% of federal transportation dollars were spent on walking and bicycling projects in North Carolina [8].

Secondary sources of money for walking and bicycling projects include a municipality’s budget (eg, funds generated through local bonds and general revenue sources). Another funding option is through the North Carolina Department of Transportation, which administers the portion of the state gas tax that is returned to localities (referred to as State Street Aid or Powell Bill funding). The fund was established to assist municipalities in constructing and maintaining roadways within their jurisdictions, and, since 1994, it has included the planning, construction, and maintenance of sidewalks and bikeways. Last, private sources and external grants may provide funding for walking and bicycling projects. From our previous analysis of North Carolina pedestrian plans, we found that urban and rural municipalities identified similar funding sources for walking projects [25].

Designing roads to accommodate walkers and bicyclists and, where appropriate, building separate facilities for these users promises to be an effective strategy to increase physical activity among North Carolina residents. In 2007, 60% of North Carolina adults reported that they would be likely to increase their physical activity if their communities had more accessible sidewalks or trails for walking or bicycling [26]. Despite this, approximately two-thirds of the survey respondents selected staffing as a challenge to addressing walking and bicycling issues, and at a prevalence much higher in rural areas than in urban areas. Walking and bicycling issues may be one of many items for which a single staff person in a smaller municipality is responsible. Competing demands for a staff person’s attention create challenges to prioritizing walking and bicycling issues. There is opportunity for health professionals with overlapping interests to provide support.

Approximately two-thirds to three-fourths of respondents agreed that automobile and other infrastructure priorities take precedence over walking and bicycling issues in their municipalities. Additionally, one-half to two-thirds of respondents reported a lack of support for these issues locally, regionally, and at the state level. Bicycling issues garnered less support than walking issues, especially at the local level. Reported lack of support was much higher among rural municipalities than among urban municipalities.

Health professionals are well-positioned to communicate the relationships between environmental attributes, walking and bicycling, and chronic disease with town officials, local policymakers, and community-based organizations, whether in the role of medical experts or as residents. Specifically, they could become members of local commissions on planning, parks and recreation, bicycling, walking, or health. Health professionals could speak at public forums or join standing committees and provide feedback as plans or policies are proposed or amended. They could bring health to the forefront by identifying the problems of obesity and the lack of physical activity and by championing positive changes [27]. Health professionals could also assist local advocacy groups to become more involved in the municipal or county system, to affect infrastructure priorities and support. They could also consider regional or statewide involvement by working with regional or state departments or advocacy groups, such as those specified in Table 4, to address issues on walking and bicycling.

When asked whether development pressure makes it difficult to address walking and bicycling issues, 34% of respondents answered affirmatively for walking, and 47% answered affirmatively for bicycling. Development pressure in the form of policies that promote sprawl can complicate a local jurisdiction’s efforts to address walking and bicycling issues [28]. In Table 5, we describe examples of tools local communities may use to encourage walking and bicycling. They include a mix of strategies, guidelines, and programs that alternately help raise capital or address future land development.

Respondents reported that 26% and 31% of policies or regulations in local plans do not support walking and bicycling, respectively. For both walking and bicycling, the prevalence was much higher in rural municipalities than in urban municipalities. This may reflect conventional land use patterns and development policies in rural areas, which, since the mid-1900s, have emphasized low-density, auto-oriented growth and have not yet been updated with policies to support active living [39].

Some North Carolina communities integrate pedestrian and bicycle planning into local plans, such as transportation, land use, greenway, or park plans. Stand-alone pedestrian and bicycle plans are other avenues local governments can use to help create environments that support walking and biking. Such plans explain a community’s vision and goals for future activity; address relevant policies, programs, and facilities; and identify changes to laws and regulations that could enable residents to integrate walking and bicycling into daily routines. These plans also may set goals and benchmarks toward a more pedestrian- and bicycle-friendly community. In North Carolina, pedestrian and bicycle plans are less prevalent in rural areas than in urban areas and are less prevalent in places with smaller populations than in places with larger populations [25]. A majority of communities in North Carolina have neither type of plan [17]. In 2004, to encourage local entities to develop stand-alone pedestrian or bicycle plans, the North Carolina Department of Transportation’s Division of Bicycle and Pedestrian Transportation and Transportation Planning Branch initiated a competitive grant program to encourage municipalities to develop pedestrian and bicycle plans [40]. The funding has continued yearly, helping municipalities develop or update pedestrian or bicycle plans.

Many North Carolina pedestrian and bicycle plans integrate health into their goals [34]. The degree to which the goals are met remains unknown. However, communities with plans that address walking and bicycling may have, over time, more infrastructure for walking and bicycling in the community that can, in turn, contribute to more physical activity and lower obesity rates. For example, in North Carolina, municipalities with local pedestrian plans had higher percentages of workers walking or bicycling to work than did areas without such plans [25]. Others have found that having a local pedestrian or bicycle plan increases the likelihood that walking and bicycling projects will be included in the TIP, which guides most state construction or reconstruction projects [41].

Health professionals and researchers alike can convey the possible health impacts of plans and policies, help institutionalize the role of health in ongoing planning, and ensure that health considerations are addressed in development decisions [27, 41, 42]. Additionally, with innovative approaches to the integration of primary care and preventive medicine included in the Affordable Care Act [43], primary care professionals could propose policy and environmental changes that promote better patient outcomes. Kingdon’s framework on policy change [44], and examples of its implementation [45], lend support to this approach. Additionally, hospitals and health care facilities in several states are leading efforts to develop more supportive environments and policies for healthy lifestyles in their catchment areas. Regardless of the forum or role, a helpful initial step for health professionals may be to gain familiarity with relevant municipal, county, and state plans and policies, as well as their implementation processes.

Several respondents mentioned in the open-ended questions that state policies and practices could better support walking or bicycling in projects. Here, too, there is a role for health professionals. Those who communicate with state-level officials—be it on a committee, as part of a working group, or in some other way—have opportunities to convey many important health benefits associated with removing these barriers.

Our findings are subject to several limitations. First, respondent occupations varied across municipalities and included, for example, planners, planning directors, public works directors, and town managers. This reflects the diversity of job functions and positions across municipalities. In an effort to maintain consistency, the survey was targeted to the staff person most appropriate to talk about municipal pedestrian and bicycle planning. Second, some prevalence estimates had wide confidence intervals, as indicated by higher standard errors. The survey was weighted to represent all municipalities in the state of North Carolina. Nevertheless, these prevalence estimates should be interpreted in consideration of the precision of the estimates. Third, these data are subject to the potential of self-reporting bias. Fourth, we found some differences in municipalities that responded to the survey, compared with municipalities that did not respond to the survey (Table 1). The strengths of the study included a statewide survey with estimates reflective of North Carolina municipalities on barriers to walking and bicycling projects and policies not previously explored in this way in the United States.

The present study offers a unique perspective of staff with the most knowledge about walking and bicycling, from a representative sample of North Carolina municipalities. The findings can help identify strategies for multidisciplinary partners, to address common barriers to walking and bicycling projects and policies reported by North Carolina municipalities. Health professionals, in particular, are well-positioned to take action by engaging with town officials, policymakers at all levels of governance, and community-based organizations, to support strategies that promote walking and bicycling in North Carolina.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the Robert Wood Johnson Foundation or the Centers for Disease Control and Prevention.

We thank Ginny Lee and Fang Wen for help with survey data collection and analysis.

Financial support. Robert Wood Johnson Foundation Active Living Research Program (grant 68511) and North Carolina Physical Activity Policy Research Center (Centers for Disease Control and Prevention cooperative agreement U48-DP000), through the University of North Carolina Center for Health Promotion and Disease Prevention.

Potential conflicts of interest. All authors have no relevant conflicts of interest.

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Kelly R. Evenson, PhD, MS research professor, Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina–Chapel Hill, Chapel Hill, North Carolina.

Semra A. Aytur, PhD, MPH assistant professor, Department of Health Management and Policy, University of New Hampshire, Durham, New Hampshire.

Sara B. Satinsky, MCRP, MPH research associate, Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina–Chapel Hill, Chapel Hill, North Carolina.

Daniel A. Rodríguez, PhD, MST associate professor, Department of City and Regional Planning, and adjunct professor, Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina–Chapel Hill, Chapel Hill, North Carolina.

Address correspondence to Dr. Kelly R. Evenson, Bank of America Ctr, 137 East Franklin St, Ste 306, University of North Carolina–Chapel Hill, Chapel Hill, North Carolina 27514 (