Mass Transit and Health Outcomes

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Mass Transit and Health Outcomes by Mind Map: Mass Transit and Health Outcomes

1. WHO's document on transit policy and health


2. Citing articles of: Active transportation and physical activity: opportunities for collaboration on transportation and public health research

2.1. SCOPUS results:

2.2. Obesity relationships with community design, physical activity, and time spent in cars Frank, Lawrence D. et al. American Journal of Preventive Medicine , Volume 27 , Issue 2 , 87 - 96

2.2.1. More time in a car = more obesity Obesity relationships with community design, physical activity, and time spent in cars

2.2.2. Each km walked decreased LR of Obesity by 4%

2.2.3. Each quartile of land use more mixed leads to 12% decrease in obesity


3. Search Strategy

3.1. Inclusion / Exclusion

3.1.1. Exclude: papers w/o clinical outcomes

3.1.2. Include: Papers written in English

3.1.3. Interventions: policy affecting..., use of..., presence of..., light rail, bus systems, walkability, cycling infrastructure, subways, mass transit, public transit, urban design

3.2. Sources: OVID / Medline / Pubmed, GreyLit, Google Scholar

3.3. Scopus: to find relevant citing articles

4. What I've learned

4.1. I might care about access to parks more than I care about good public transit.

4.2. I still don't really care, personally, about the access argument.

4.3. I still have lots of specifics to learn, like "mass transit" vs. "public transit" and all the ways the federal and state governments measure the indirect "healthfulness" of a community; like walkability and such.

4.3.1. Community-scale environmental design

4.3.2. Streetl-scale environmental design

4.4. I would probably like a job as an admin at the Indiana State Deparment of Health

4.4.1. The Indiana State Health Commissioner is a UMBC Grad!

4.4.2. The Chief Medical Consultant seems to get to do cool stuff and sit on cool boards.

4.4.3. Jenn Walthall is the Deputy State Health Commissioner

4.4.4. ISDH's Org Cart

4.5. I just kept loving what a I read, even when it wandered outside my initial search criteria of "health outcomes."

5. Major Federal Transportation Policies affecting Health Outcomes


6. New Ideas

6.1. Can we show decreased MVA trauma with increased Public Transit?


6.1.2. There's a state trauma databse for Indiana that might be helpful.

6.2. College towns in IN have greatest ridership per capita (assumption is due to college students not having cars / money). Can IndyGo target IUPUI / UIndy / Marion better? Would this raise up a generation of young people who see public transit as a valid option?

6.3. How about a blog post about "what will it take?": describing what sort of obesity and chronic disease morbidity we'll have to suffer if we wait to make changes as long as we took for slaughterhouse and sanitation changes to be made in our recent past.

6.4. Are there any sci-fi examples of futuristic / eutopian societies with active transport or health as the center of their urban design?

6.5. What about an infographic that represented physical structures in terms of how much of it we could build for each chronic condition it is worth. Like how many miles of road is an MRI worth? Or how many heart attacks does a rail line prevent?

7. Major arguments for Public Transit

7.1. Will decrease asthma exacerbations

7.1.1. Indiana's Asthma Burden Report 2011 Lots of data on age, race, gender, prevalence, and state-wide goals. Shows that the poor and poorly educated have a higher burden of asthma. Shows that urban counties have a higher burden of asthma than non-urban counties.

7.1.2. Nino Künzli, Rob McConnell, David Bates, Tracy Bastain, Andrea Hricko, Fred Lurmann, Ed Avol, Frank Gilliland, and John Peters. Breathless in Los Angeles: The Exhausting Search for Clean Air. American Journal of Public Health: September 2003, Vol. 93, No. 9, pp. 1494-1499. doi: 10.2105/AJPH.93.9.1494 Discuss air pollution in SoCal Talk about increased school abscence, economic burden, and decreased lung function in areas of higher air pollution. Lower lung function growth associated w/ PM10, PM2.5, and NO2--pollutants from vehicles

7.1.3. Laura Perez, F.L., John Wilson, Manuel Pastor, Sylvia J. Brandt, Nino Künzli, and Rob McConnell, Near-Roadway Pollution and Childhood Asthma: Implications for Developing “Win–Win” Compact Urban Development and Clean Vehicle Strategies. Environ Health Perspect, 2012. 120: p. 1619-1626 Measured NO2 around major roadways of LA county Estimated that 8% of asthma exacerbations were due, in-part, to road-way air pollution issues

7.1.4. Perez, Laura, et. all. Chronic burden of nearroadway traffic pollution in 10 European cities European Respiratory Journal, 2013. 42(3): p. 594-605 2-15% of asthma exacerbations due to near-roadway pollution Study performed in 10 European cities

7.1.5. MAPC, Public Health: Youth Asthma Hospitalization. 2012, Metropolitain Area Planning Commission: Boston, Massachussetts Goals include: decrease vehicle idling, retrofit diesel engines, meet more strict NO2 level requirements, implement a light-/medium-duty vehicle inspection process, make public health data available to the public McConnell R, Berhane K, Yao L, Jerrett M, Lurmann F, Gilliland F, Künzli N, Gauderman J, Avol E, Thomas D, Peters J. 2006. Traffic, susceptibility, and childhood asthma. Environmental Health Perspectives. 114(5):766-772 Exposure to ozone increases dx of asthma Proximity of 50-100m of a major roadway increases risk of asthma Gauderman WJ, Gilliland GF, Vora H, Avol E, Stram D, McConnell R, et al. (2002). Association between air pollution and lung function growth in southern California children: results from a second cohort. Am J Respir Crit Care Med. 1;166(1):76-84. Exposure to ozone and other pollutants reduces lung function growth in children with asthma Jerrett M, Shankardass K, Berhane K, Gauderman WJ, Künzli N, Avol E, et al. (2008) Traffic-related air pollution and asthma onset in children: a prospective cohort study with individual exposure measurement. Environ Health Perspect. 116(10):1433-8. McConnell 2006. Proximity to traffic increases risk of asthma Massachusetts Department of Public Health, Bureau of Environmental Health. (February 2008), Air Pollution and Pediatric Asthma in the Merrimack Valley Final Report, Retrieved April 1, 2009, from environmental/tracking/asthma_merrimack_valley_report.pdf Children w/ asthma are more likely to live near a large volume of traffic. Certain populations suffer the pollution consequences of roadways more than others

7.1.6. Transportation and Air Quality in Southern California Larges sources of air pollution are heavy-duty diesel trucks > off-road equipment > ships > light-duty trucks > light-duty passenger cars > heavy-duty gas trucks > trains This is predicted to be come: ships > off-road equipment > heavy-duty diesel trucks > aircraft > trains ... Consequences of poor air quality for the region 8800 premature deaths 7700 hospitalizations 210000 asthma / pulm symptoms 1.4M work days lost 4.7M school absencs

7.1.7. Centers for Disease Control and Prevention, Respiratory Health & Air Pollution. 2009, CDC: Atlanta, Georgia During the Olympics in Atlanta GA in 1996, traffic decreased and so did asthma exacerbations.

7.1.8. CDC Has lots of stuff on air quality

7.2. Will decrease heart attacks and strokes

7.2.1. Similar materials to the asthma argumen--mostly about air quality

7.3. Will increase access to care

7.3.1. Randall, Marjorie J. (2012). Gap Analysis: Transition of Health Care From Department of Defense to Department of Veterans Affairs. Military Medicine, 177(1), 11-16 Shows that veterans don't get care immediately following discharge and one of the main reasons is transportation to the VA system

7.3.2. McCarthy, John F., Blow, Frederic C., Valenstein, Marcia, Fischer, Ellen P., Owen, Richard R., Barry, Kristen L., Ignacio, Rosalinda V. (2007). Veterans Affairs Health System and Mental Health Treatment Retention among Patients with Serious Mental Illness: Evaluating Accessibility and Availability Barriers. Health Services Research, 42(3P1), 1042-1060 The farther away from the VA the pt w/ schizophrenia or bipolar lives, the more likely to have a 12mo care gap.

7.3.3. McCarthy, John F., & Blow, Frederic C. (2004). Older patients with serious mental illness: sensitivity to distance barriers for outpatient care. Medical Care, 42(11), 1073-1080 Showed older patients at VA w/ schizophrenia or bipolar were more likely to be limited by distance barriers for care

7.3.4. Fortney, John C., Booth, Brenda M., Blow, Frederic C., Bunn, Janice Y., & Cook, Cynthia A. Loveland. (1995). The Effects of Travel Barriers and Age on the Utilization of Alcoholism Treatment Aftercare. American Journal of Drug & Alcohol Abuse, 21(3), 391-406 Veterans discharged w/ outpt aftercare plans are less likely to return for care when 1) elderly, 2) rural residence, etc.

7.3.5. Burgess, James F., & DeFiore, Donna Avery. (1994). The effect of distance to VA facilities on the choice and level of utilization of VA outpatient services. Social Science & Medicine, 39(1), 95-104 Distance keeps veterans from coming in for care, especially the elderly.

7.3.6. LaVela, Sherri L., Smith, Bridget, Weaver, Frances M., & Miskevics, Scott A. (2004). Geographical proximity and health care utilization in veterans with SCI&D in the USA. Social Science & Medicine, 59(11), 2387-2399 Veterans w/ spinal cord injuries were less likely than other disease systems to utilize care (kidney, urinary, circulatory, respiratory). Contributing factors for non-use of facilities were: female gender, increased distance from facility, non-white race, and increased age.

7.3.7. Piette, J. D., & Moos, R. H. (1996). The influence of distance on ambulatory care use, death, and readmission following a myocardial infarction. Health Services Research, 31(5), 573-591 Pt's w/ MI are less likely to seek follow-up care if they live farther than 20 miles. Those who received follow-up care were 79% as likely to die w/in the following year.

7.4. Weight / activity

7.4.1. Will decrease obesity

7.4.2. Will lower BMI

7.4.3. Will increase physical activity

7.4.4. The Effect of Light Rail Transit on Body Mass Index and Physical Activity. MacDonald, John M. et al. American Journal of Preventive Medicine , Volume 39 , Issue 2 , 105 - 112 Light rail decreases BMI

7.4.5. Frank, L.D., Andresen, Martin A., & Schmid, Thomas L., Obesity Relationships with Community Design, Physical Activity, and Time Spent in Cars. American Journal of Preventive Medicine, 2004. 27(2): p. 87-96. Increased walkability increases time in physical activity

7.4.6. Lilah M. Besser, Andrew L. Dannenberg, Walking to Public Transit: Steps to Help Meet Physical Activity Recommendations, American Journal of Preventive Medicine, Volume 29, Issue 4, November 2005, Pages 273-280, ISSN 0749-3797, Use of transit can increase meeting SG's goal of >= 30min walking each day

7.4.7. Lachapelle, Ugo; Frank, Lawrence. “Transit and Health: Mode of Transport, Employer-Sponsored Public Transit Pass Programs, and Physical Activity”. J of Public Helath Policy 2009, 30, S73-S94 Use of transit can increase meeting SG's goal of >= 30min walking each day

7.4.8. Ryan D. Edwards, Public transit, obesity, and medical costs: Assessing the magnitudes, Preventive Medicine, Volume 46, Issue 1, January 2008, Pages 14-21, ISSN 0091-7435, Transit use increases walking, decreases obesity, and could save $5500/person in health costs

7.4.9. Mass Transit workers have poor medical outcomes NO ACCESS: Ragland J of Occupational Health Psychology

7.5. Safety from Trauma / Accidents

7.5.1. Reid Ewing, Richard A. Schieber, and Charles V. Zegeer. Urban Sprawl as a Risk Factor in Motor Vehicle Occupant and Pedestrian Fatalities. American Journal of Public Health: September 2003, Vol. 93, No. 9, pp. 1541-1545. doi: 10.2105/AJPH.93.9.1541


7.5.3. As "sprawl index" decreases, so do pedestrian and motor occupant injuries

7.6. Justice and Equality

7.6.1. Lee V, Mikkelsen L, Srikantharajah J, Cohen L. Strategiesfor Enhancing the Built Environment to Support Healthy Eating and Active Living. Oakland, CA: Prevention Institute; 2008. Available at: Accessed October 10, 2008. Low income neighborhoods have lower access to safe places to walk, bike, or play. Poor neighborhoods have less access to healthy and affordable foods.

8. Advocacy groups

8.1. ICAT

8.1.1. Mission statement, hx, etc.

8.1.2. Advocacy toolkit

8.1.3. Benefits of transit

8.1.4. FAQ

8.2. Health By Design

9. Indiana Citizens' Alliance for Transit

9.1. Have a great fact-page on Disability and Transit

9.1.1. Talks primarily about access to healthcare appointments being important


9.2. Have a fact-sheet on Public Transit and Health of the Aging Population in Central Indiana

9.2.1. Summary: makes the argument that elderly population is growing and needs access to medical care and community resources but that our system doesn't compare to other cities of the same size.


9.2.3. Mass transit good for connecting elderly to work, volunteer opportunities, social and medical services, and family / friends / worship communities.

9.2.4. 15% of Indiana's population is >65yo as of 2015

9.2.5. Only 50% of 80yo are licensed; >90% of 65yo are.

9.2.6. Does not have solid data truly representing difficulty of getting to appointments

9.3. Have a fact sheet on Millenials, Technology, Health, and Transit

9.3.1. Summary: Makes the argument that Millenials want tech and money savings more than cars, will choose their mode of transit as appropriate for each trip, and are obese and that obesity can be made better with mass transit.


9.3.3. Millenials = born 1980-2000

9.3.4. Millenials choose the best mode for each trip.

9.3.5. MVA are still leading cause of death in ages 15-29--the very persons who admit to texting while driving.

9.3.6. Suggests (but has not data to prove) that mass transit can increase safety for millenials while allowing them to maintain their technology-driven functional state.

9.3.7. Millenials are the most underemployed, educational debt-burdened generation; they are looking for money saving transit options for each trip. (No data to back up first clause.)

9.3.8. Americans 16-34yo drove 23% LESS in 2009 than in 2001.

9.3.9. Americans 21-34yo purchased 38% of all new cars in 1985 but only 27% in 2010.

9.3.10. Public transit reduces obesity (no references provided) Persons using public transit get 3x the physical activity per day of those who don't.

9.3.11. 27% of young adults cannot meet physical requirements to join the military

9.4. Have a fact sheet on Public Transit and Children's Health in Indiana

9.4.1. Summary: makes the argument that lots of Hoosier children have asthma and are obese--both of which could be ameliorated by introducing public transit.

9.4.2. Makes the argument that Asthma is made worse by lots of cars Asthma has higher prevalence in children living in higher traffic density Asthma exacerbations increase during peak travel times. Asthma is 3rd most common reason for hospitalization in Indiana. 1:13 (total of 136k) Hoosier children have asthma 14% of asthma diagnoses are likely due to traffice congestion.

9.4.3. Makes the argument that obesity is bad and could be better with Public Transit 30% of Hoosier children are overweight or obese. Public transit can increase physical activity Frank, L.D., Andresen, Martin A., & Schmid, Thomas L., Obesity Relationships with Community Design, Physical Activity, and Time Spent in Cars. American Journal of Preventive Medicine, 2004. 27(2): p. 87-96. Each 1k walked decreases likelihood of obesity by 5% Each 1h in car increases likelihood of obesity by 6% Manson, J.E.a.B., S. S. , Obesity in the United State. American Medical Association, 2003. 289(2): p. 229-230. Obesity is risk factor for death, diabetes, cardiovascular disease, osteoarthritis, and cancers.


9.5. Have a fact sheet on Public Transit and Veterans

9.5.1. Summary: There are 500k veterans in Indiana and many of them don't get the care they need due to inability to access the care, primarily shown to be the case when >30mi away.

9.5.2. 500k veterans in Indiana; 360k have served during war.

9.5.3. Makes the argument that distance from facility and transportation to the facility are barriers to care. >20mi from facility increase 1y mortality by 25% in post-MI patients >30mi from facility, # of visits decreases w/ age when it should increase w/ age. Difficulty getting to facility cited as reason for >3mo gap in end-of-service to beginning-of-care.


9.6. Have a Myths and Facts Sheet

9.6.1. Summary: Has 10 or so myths and facts, very little about health outcomes


9.6.3. Argues that those that don't ride transit still benefit 60% of ozone in IN is from cars Large urban areas of IN fail American Lung Associations air quality standards 0.18 of every USD goes to owning a car; this can be reduced if public transit is developed

10. Built Environment as Health Impactor

10.1. CDC's "Healthy Places"

10.1.1. Has a Summary Document of what CDC has done Summary: Is starting to measure how built environments measure up across states, is trying to provide resources to help schools and community planners and public health officials build more healthy environments.

10.2. Richard J. Jackson. The Impact of the Built Environment on Health: An Emerging Field. American Journal of Public Health: September 2003, Vol. 93, No. 9, pp. 1382-1384. doi: 10.2105/AJPH.93.9.1382

10.2.1. Summary: The intro to an entire journal edition focused on built environment and health. An excellent overview on the many factors that are a part of the built environment's impact on health.


10.2.3. Other articles in same issue Risa Lavizzo-Mourey and J. Michael McGinnis. Making the Case for Active Living Communities. American Journal of Public Health: September 2003, Vol. 93, No. 9, pp. 1386-1388. doi: 10.2105/AJPH.93.9.1386 We are engineering active living out of our lives. Policy and design changes can increase activity. Japanese elderly w/ sidewalks, trees, and parks live longer than those without. Wheeling Walks is a program that increased the community's walking by 14%. Wendy Collins Perdue, Lesley A. Stone, and Lawrence O. Gostin. The Built Environment and Its Relationship to the Public’s Health: The Legal Framework. American Journal of Public Health: September 2003, Vol. 93, No. 9, pp. 1390-1394. doi: 10.2105/AJPH.93.9.1390 Built environment was most obviously important when infectious disease was the prominent cause of mortality (think of the water pump, slaughterhouses, etc.) It is important to understand the legal framework behind building environmental changes through policy. Lots to read here and lots o historical references. Marice Ashe, David Jernigan, Randolph Kline, and Rhonda Galaz. Land Use Planning and the Control of Alcohol, Tobacco, Firearms, and Fast Food Restaurants. American Journal of Public Health: September 2003, Vol. 93, No. 9, pp. 1404-1408. doi: 10.2105/AJPH.93.9.1404 Discusses using zoning laws to reduce prevalence of ATF stores in communities. Matt Egan, Mark Petticrew, David Ogilvie, and Val Hamilton. New Roads and Human Health: A Systematic Review. American Journal of Public Health: September 2003, Vol. 93, No. 9, pp. 1463-1471. doi: 10.2105/AJPH.93.9.1463 Building new roads increases "disturbance" and community "severance"

10.3. State Indicator on Physical Activity, 2010; by the CDC


10.3.2. Describes which states have "transortation and travel policies" that encourage non-motorized travel

10.3.3. Indiana does not qualify as a state with a transportation and travel policy.

10.3.4. Has some other measures of community features that encourage fitfulness, for example: density of parks and access to fitness centers

10.3.5. The "National Action Guide" counterpart offers "action items" for areas where a state might struggle.

10.4. CDC's Duide to Increasing Physical Activity in the Community


10.4.2. Defines an action item to increase street-scale changes to that encourage walking and cycling

10.4.3. Defines an action item to increase community-scale urban design changes to encourage physical activity 12 studies were cited for a total of "161% increase" in activities like walking and cycling

10.5. Health By Design has an excellent fact sheet


10.5.2. Talks about built environment's affect on health.

10.6. Health by Design's benefits of transit


10.7. NO ACCESS: Coen, Social Science and Medicine

10.7.1. Parks near areas of poor health outcomes have similar qualities (poor physical activity features, near multi-lane roads, near industrial areas)

11. Bell, J. and L. Cohen, The Transportation Prescription: Bold new ideas for healty, equitable transportation reform in America, S. Malekafzali, Editor. 2012, Prevention Institute Policy Link, Convergence Partnership: Washington, D.C

11.1. file:///C:/Users/Peter/Downloads/The%20Transportation%20Prescription.pdf

12. Haas, S.A., The Long-term Effects of Poor Childhood Health: An Assessment and Application of Retrospective Reports. Demography, 2007. 44(1): p. 113-135


13. APHA, At the Intersection of Public Health and Transportation: Promoting Health Transportation Policy. 2012, American Public Health Association: Washington, D.C


14. The Access Argument

14.1. Wallace, Mull. Access to Healthcare and NEMT


14.1.2. People can't get to their appointments, especially, poor, women, ill-educated, and elderly

14.1.3. It may be cost effective to provide transport to decrease overall medical management costs

15. Indiana-specific Arguments

15.1. CDC's Numbers on Obesity


15.1.2. 30-35% of Hoosiers are overweight or obese

15.2. Indiana's Transportation Report


15.3. Burden of Asthma in Indiana, 2010 report


15.3.2. 3rd leading cause of hospitalization in Hoosiers <17yo = 9000 each year; equivalent to $122 million

15.3.3. 9% of adults and 9% of Hoosiers have asthma

15.3.4. 31000 ED visits for asthma; increased 9.8% from 2008; equivalent to $46 million

15.3.5. 68 deaths from asthma in 2007

15.3.6. Indiana is above the national guidelines for asthma care goals 22.9 deaths per million when IN is 41.9 at baseline 18.1 hospitalizations per 10k when IN is 27.8 at abaseline

15.3.7. Rate of ED visits is increasing steadily from 2004-2009

15.3.8. Rate of asthma deaths is decreasing steadily from 1999-2009

15.3.9. Blacks visit ED more often and are hospitalized more often despite no statistically significant higher prevalence of disease.

15.3.10. The poor (<$15k) and the ill-educated have the highest prevalence of asthma

15.3.11. Has a section on indoor air quality but not outdoor air quality

16. Resources

16.1. CDC's Policy Database for Health-related policies


16.1.2. Ability to search health policies; can limit by state or status of the policy

16.2. Active Living by Design


16.2.2. Work to foster community and professional projects, including research and program grants