Abstract
BackgroundThe health impacts of community design have been studied extensively over the past two decades. In particular, public transportation use is associated with more walking between transit stops and shops, work, home and other destinations. Change in transit access has been linked with physical activity and obesity but seldom to health outcomes and associated costs, especially within a causal framework. Health related fiscal impacts of transit investment should be a key consideration in major transit investment decisions.MethodsThe Rails & Health study is a natural experiment evaluating changes in clinical measures, health care utilization and health care costs among Kaiser Permanente Northwest (KPNW) members following the opening of a new light rail transit (LRT) line in Portland, Oregon. The study is prospectively following 3036 adults exposed to the new LRT line and a similar cohort of 4386 adults who do not live close to the new line. Individual-level outcomes and covariates are extracted from the electronic medical record at KPNW, including member demographics and comorbidities, blood pressure, body mass index, lipids, glycosylated hemoglobin, and health care utilization and costs. In addition, participants are surveyed about additional demographics, travel patterns, physical activity (PA), and perceived neighborhood walkability. In a subsample of the study population, we are collecting direct measures of travel-related behavior—physical activity (accelerometry), global positioning system (GPS) tracking, and travel diaries—to document mechanisms responsible for observed changes in health outcomes and cost. Comprehensive measures of the built environment at baseline and after rail construction are also collected. Statistical analyses will (1) examine the effects of opening a new LRT line on chronic disease indicators, health care utilization, and health care costs and (2) evaluate the degree to which observed effects of the LRT line on health measures and costs are mediated by changes in total and transportation-associated PA.DiscussionThe results of the Rails & Health study will provide urban planners, transportation engineers, health practitioners, developers, and decision makers with critical information needed to document how transit investments impact population health and related costs.
Highlights
The health impacts of community design have been studied extensively over the past two decades
[39] studies that examine the impact of these interventions have rarely captured objective measures of physical activity (PA) or assessed the relationship between built environment and health-related biomarkers such as body mass index (BMI), blood pressure, or glycemic control. [40,41,42] Available studies do not capture the behavioral and personal factors within a possible “causal pathway” that may mediate the relationship between the built environment and health outcomes
Recent cross-sectional evidence makes clear connections between built environment, activity patterns, and health outcomes; increasing levels of transit access and walkability are associated with increased physical activity and reduced levels of chronic disease
Summary
The health impacts of community design have been studied extensively over the past two decades. Detailed, longitudinal data are needed, first to fully establish the relationship between improvements in community design—including public transportation infrastructure—and objectively measured clinical health outcomes; second, to determine how behavioral factors, changes in physical activity, influence and mediate this relationship; and to understand the impact environmental interventions such as transit investments have on healthcare utilization and costs. This information will allow policymakers and other decision makers to best align limited infrastructure investment resources with their potential for improved population health and cost savings. We present strategies used to establish consistent, participant-specific neighborhood environmental measures related to community walkability, access to destinations and services, and social contexts
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