Health Promoting Community Design

Rarely do we see a true paradigm shift. This is one of those times. For the past 3 decades, health promotion scientists and professionals have concentrated their efforts on developing more effective methods to motivate people to attempt lifestyle improvements and on helping people use the most efficacious behavior change techniques to make these changes. What has been the impact of these efforts? Intensive clinical programs have succeeded in reversing heart disease-something medical science has never achieved. Hundreds and perhaps thousands of employer health promotion programs have produced health improvements and medical cost savings. Millions of people have quit smoking. Legions of baby boomers have maintained fitness levels close to what they enjoyed as adolescents. We should be proud of these successes and continue to refine these methods. 

Despite those successes, we need to look objectively at the impact of our programs on a population-wide basis. A larger percentage of American teenagers smoke today than in the 1970s, especially among girls. The portion of the population who are sedentary has not improved significantly despite the striking growth in fitness centers and amateur athletes. The rate of obesity has increased to the point that more Americans are expected to die from obesity than from smoking by the end of the decade. What did we do wrong? From one perspective, we did nothing wrong. We helped people who were already living healthy lifestyles continue those lifestyles. We also helped those who were ready to change make those changes more successfully. If we had not helped these groups, the health risks of the nation would no doubt be far worse than they are. Our failure came in not reaching the people who were not ready to make changes. We now understand that roughly 20% of people who have a health risk factor are ready to make a health change and the remaining 80% are probably not. How do we reach those people? We reach them by building communities that promote health; and this special issue addresses this concept. This is, of course, not an ENTIRELY new idea. When we started the Journal in 1986, we defined health promotion programs as having three levels: awareness, behavior change, and supportive environments. We envisioned these supportive environments to have cultural norms modeling good health practices, employee ownership to maintain them, policies and incentives encouraging and rewarding them, and ongoing programs and physical environments to support them. Many workplace programs incorporate all three levels, but most community programs have focused on improving awareness and enhancing behavior change. 

This is where the paradigm shift occurs. By building communities that promote health, we have a greater chance of reaching those who are not yet motivated to make health changes on their own. A central element in this strategy is the concept of engineering routine physical activity back into people's lives. An important contributor to that strategy is the Active Living by Design program of the Robert Wood Johnson Foundation, www.ActiveLivingByDesign.org, also the sponsor of this special issue. As the articles in this issue illustrate, we have engineered physical activity out of many parts of our lives. The majority of kids are driven to school rather than encouraged to walk or ride a bike. Adults drive cars to work and even on short errands, rather than walk or take public transportation. Engineering innovations seem to be dominated by labor-saving devices such as the Segway, TV and garage door clickers, suitcases with wheels, etc. 

There is also a paradigm shift from the perspective of who is involved in planning and implementing programs. For example, a recent meeting of the Active Living Network hosted by the Robert Wood Johnson Foundation involved transportation engineers, city planners, environmental horticulturists, park and recreation managers, bicycle advocates, commercial home builders, and others not normally seen at health promotion meetings. Fortunately, these people fully embraced the concept of active living. City planners endorsed the idea of having ''health impact'' studies included in all new development projects. Commercial home builders reported that active-living communities sell faster and at a higher profit margin than most other housing options. Bicycle advocates see great advantages in having the credibility of the public health community on their side in policy discussions. 

What environmental changes might be made to engineer activity back into our lives? If children had safe routes to school and schools were located close to home, they could walk or bike to school. If cities had efficient public transportation systems, residents could walk to and from the bus or subway and leave more space on the roads for bicycle lanes. If mixed zoning statutes allowed homes, stores, and offices to be in the same area, people could walk to work and do errands. If federal transportation funds required that pedestrians and bicyclists be accommodated in all highway projects using federal funds, more than adequate funding would be available. If buildings were designed to feature stairs instead of hide them, people would use elevators less and stairs more. If urban centers were revitalized to make them safe and attractive for pedestrian traffic, more people would walk. These are just a few of the changes we can make to create health promoting community designs, and most of them should be cost neutral. However, we need to reallocate existing resources to implement them. 

What impact would these changes have on physical activity, obesity, and health? The Centers for Disease Control and Prevention estimates that a difference of 100 calories of exercise per person per day, the equivalent of 20 minutes of walking, could eliminate the obesity epidemic we are now experiencing. The science and practice of health promoting community design is just emerging, and this special issue is one small part of that beginning. The concept needs to be refined, the study methodology validated, and the interventions implemented, tested, and improved. As a follow-up to this special issue, we have created a regular editorial section on health promoting community design and will continue to publish original research, literature reviews, and editorials on this topic. The editor and associate editors of this special issue are Richard Killingsworth, JoAnne Earp, and Robin Moore. They describe the special issue on the following pages. 

Michael P. O'Donnell, PhD, MBA, MPH
Editor in Chief, American Journal of Health Promotion