









































October 2019 Volume  4 Issue 1

A CASE STUDY ON INCORPORATING HEALTH AND EQUITY 
INTO URBAN PLANS, TRANSPORTATION, AND LAND USE 

POLICIES

Kelly Haworth, MPH; Elizabeth Young Winne, MPH, MURP

Abstract: 

In 2017, the Built Environment Program at the Larimer County Department of Health and Environment 
(Colorado, USA) collaborated with a partner municipal agency to create a health and equity index to be 
a component of a revitalized sidewalk prioritization model. The Health Equity Index uses indicators that 
are linked to the determinants of health to spatially understand factors that contribute to an individual 
or household’s likelihood of being more vulnerable. The data to create the Health Equity Index is publicly 
sourced at block group level from the United States Census American Community Survey 5-year estimates 
and at census tract level from the Center for Disease Control and Prevention’s 500 Cities dataset. The score 
is one of three factors used to determine sidewalk improvement priorities in the City.  The new model 
mapped prioritization and created broader geographic distribution than what was previously used. The 
creation of the Health Equity Index was a valuable partnership that led to multiple outcomes outside of 
the sidewalk prioritization process. First, its creation has established a foundation for partnership between 
two sectors across different government agencies. Second, the Health and Equity Index has also been used 
as an assessment tool for the adopted City Plan, the guiding comprehensive plan for the municipal agency. 
Through this process, we have learned that elements of Health Impact Assessment can be a powerful tool for 
understanding the health impacts of a policy or process on community, as well as for building and developing 
trusted cross-sector relationships.

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Introduction

The United States (U.S.) spends nearly $3.0 trillion 
in health care annually, 90% of which is to treat 
chronic and mental health conditions (OASH, 2016; 
CDC, 2019). However, the exorbitant expenses are 
not leading to better health outcomes. Compared 
to similar wealthy countries, Americans are dying 
younger and faring worse in measurable health 
indicators like obesity, diabetes, and injury (OASH, 
2016; CDC, 2019). In the U.S., obesity affects almost 
30% of adults and 20% of children, nearly one-third 
of all deaths can be attributed to heart disease or 
stroke, and approximately 30 million people have 
diabetes (CDC, 2019). As health professionals see 
the expenses, morbidity, and mortality climb, the 
viable programmatic solutions to address chronic 
diseases have become more complicated. According 
to the Office of the Assistant Secretary for Health 
(OASH) at the U.S. Department of Health and Human 
Services, “scholars estimate that behavioral patterns, 
environmental exposure, and social circumstances 
account for as much as 60% of premature deaths. 
These factors shape the context of how people make 
choices every day - and reflect the social and physical 
environments where these choices are made” (OASH, 
2016, p. 7). Furthermore, the Robert Wood Johnson 
Foundation states, “…positive changes in health 
behaviors require action on the part of the individual, 
but also require ‘that the environments in which 
people live, work and play support healthier choices’ 
” (Robert Wood Johnson, 2014, p. 6). This research 
demonstrates the need for interventions that take a 
system and environmental approach to addressing 
chronic diseases.  

In 2003, the American Journal of Public Health 
released a special issue on “Built Environment and 
Health,” which led other professional journals to do 
the same over the next few years; a sign that design 
professionals are engaged in the topic, research, and 
practice of including health into land use (Jackson et 
al., 2013). As a result of the research instigated by 
this special issue, there has been a growing body of 

strategies that public health practitioners and urban 
planning professionals are able to leverage to address 
built environment in their communities. For example, 
the Community Preventive Services Task Force 
through the CDC has recommended a combined built 
environment approach to increasing physical activity 
in the community (CDC, 2019b). This combined 
approach includes connecting every-day destinations 
to activity friendly routes to create a strategy that 
leverages both land use and transportation policies. 
Health in All Policies (HiAP) is another example of 
an approach that can be utilized to consider the 
health ramifications in all policies and all sectors 
including transportation, land use, agriculture, and 
housing (Robert Wood Johnson, 2014). Health Impact 
Assessments (HIA) are an example of a tool that can 
be used to implement an HiAP strategy; where HIA’s 
use a standardized process to understand the effects 
a development, policy, or plan can have on the health 
of a local community before it is implemented (CDC, 
2016). Public health practitioners are able to leverage 
Public Health 3.0, a national call to action crafted by 
the Department of Health and Human Services which 
emphasizes designing public health interventions to 
address the upstream determinants of health, or “...
the macro factors that comprise social-structural 
influences on health and health systems, government 
policies, and the social, physical, economic and 
environmental factors that determine health” 
(Bharmal et al., 2015, p. 1). All these examples are 
evidence that the public health field has a growing 
body of tools, resources, and models to address 
chronic diseases through a built environment lens. 

This article will discuss, from a public health 
practitioner’s perspective, how a local public health 
agency has begun to incorporate principles of HIA’s 
to address chronic disease by working closely with 
a local municipal organization to incorporate health 
factors into their sidewalk prioritization process. 
We review the local context, partnership, methods, 
and results of how a prioritization of sidewalk 
development shifted after including health as a key 
factor for decision making. 



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Context

In 2016 the Larimer County Department of Health and 
Environment (LCDHE), a local public health agency, 
launched a new Built Environment Program (BEP) that 
works to promote physical activity and address health 
inequities by promoting healthy community goals 
in urban plans and subsequent policy documents. 
LCDHE does not have the authority to implement land 
use and transportation policies, so in order to achieve 
desired program goals, BEP staff must collaborate 
closely with municipal staff who implement the 
transportation and land use policies. As a result, 
BEP uses a two pronged approach: working directly 
with professional partners who implement land 
use and transportation policies to support them in 
finding ways to include health into plans and policies, 
and working with community members, non-profit 
agencies, and advocacy organizations to develop 
community-driven projects and support community 
engagement efforts. 

Implementation of the BEP’s two-pronged approach 
is simple: the BEP seeks projects from partners and 
offers technical assistance to create and increase 
organizational capacity to incorporate health into 
plans and policies (see Figure 1).  Although not 
formalized through a policy mandate or resolution, 
the BEP follows a HiAP approach. In practice, this 
requires a diverse range of partners, representing 
sectors including non-profit, community-based 
groups, data analysts, planning, transportation, public 
works, and engineering. With this strategy described 
above, a partnership was formed with a Municipal 
Engineering Department in the City of Fort Collins and 
resulted in the creation of the Health Equity Index 
(HEI) which was used as a portion of the municipal 
agency’s sidewalk prioritization model. The HEI 
described in this paper followed the same process as 
conducting a HIA and was used as a tool to implement 
our HiAP strategy. 

Figure 1: Technical Assistance graphic



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Sidewalk Prioritization 

Prior to the inclusion of the HEI into the sidewalk 
prioritization model, the partner municipal agency 
used a process that was largely based on pedestrian 
demand, and as a result the Downtown and the area 
around the University were the highest scoring areas 
to target infrastructure funding and changes (Duggan, 
2014). To address this, Municipal Engineering staff 

worked with BEP to develop a new model that would 
incorporate indicators that would identify health 
inequities and ultimately redistribute funding to areas 
of the municipal boundary as referenced in Figure 2 
(City of Fort Collins, 2017). Below, we will discuss the 
methods for creation of the HEI portion of the overall 
sidewalk prioritization model.

Figure 2: Updated sidewalk prioritization model



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Health Equity Index

The intent of the HEI is to identify where vulnerable 
communities may be concentrated within the 
municipal boundary so prioritization of sidewalks can 
be targeted to assist those who may be more likely to 
need access to higher quality sidewalk infrastructure. 
The index is part of an overall location model and 
represents just one factor for final decision making. 

The HEI methods that are listed below provide more 
details of the assessment phase for an HIA. Including 
the HEI as part of a prioritization process required 
following the standard HIA process (screening, 
scoping, assessment/recommendation, reporting, 
evaluation). A summary of these steps is included in 
Table 1 and is expanded upon below. 

Table 1: Summary of HIA Process

Screening The screening process was conducted in partnership 
with the municipal agency. Through conversations 
it was identified that there was an opportunity for a 
process to include health and equity as criteria for a 
decision to prioritize future sidewalk development. 
Stakeholders involved in screening were staff 
from BEP and the municipal agency’s Engineering 
Department. 

Scoping Stakeholders identified relevant community health 
outcomes that were likely impacted by sidewalks 
through literature reviews and best practices. Equity 
indicators were included as a consideration of which 
populations were more likely to be impacted by 
sidewalk availability.

Assessment/ Recommendation The HEI described in the methods section below 
provides more details of the assessment phase of the 
HIA. Recommendations were to include the HEI as 
a portion of the sidewalk model to prioritize future 
sidewalk development in vulnerable communities. 

Report The municipal agency incorporated the HEI into the 
City Plan, the City’s Comprehensive Plan.

Evaluation No formal evaluation has yet been conducted.



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Methods

Screening and Scoping 
A brief literature review of sidewalk prioritization 
models used by cities was conducted. After reviewing 
and discussing with the municipal agency, the 
indicators and methods for the HEI were adapted 
from the Seattle Department of Transportation’s 
Pedestrian Master Plan (Seattle Department of 
Transportation, 2017). 

Assessment
The HEI is made up of two scores: a health score and 
an equity score.  The Equity Score is 70% of the total 
score and the Health Score is 30%. The two scores are 
combined and standardized to a 100-point scale (See 
Figure 3). A score of 100 indicates the most health 
and equity vulnerabilities and implies a geographic 
area with greater need for sidewalk quality and 
availability. 

Figure 3: Health Equity Index Graphic



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The Equity Score 

The Equity score uses Block Group level 2011-2015 
American Community Survey 5-year estimates for 
age (under 18 and over 65 years old), households 
at or below Federal Poverty Level, Hispanic/Latino, 
race (non-white), households without a vehicle, 
and disability status. The population count for each 
indicator was compiled and standardized by the total 
population of the block group. Block groups were 
then ranked from highest to lowest by decile and 
each block group received an equity score between 
one and ten; ten being the highest possible rank, 
indicating the most vulnerable. It is important to note, 
disability status is only reported at census tract-level, 
so an assumption was made that the population of 
people with disabilities was evenly spread throughout 
block groups based on population, and a proportion 
was created at the block group level.

The Health Score 

The Health score uses 3 indicators: rate of obesity 
in adults, rate of no leisure time physical activity in 
adults, and rate of poor mental health for more than 
14 days in adults. These indicators were identified 
by staff creating the HEI and the new prioritization 
model as the most relevant indicators to measure 
overall health that could be attributed to absence 
or presence of sidewalk. Additionally, this data was 
used as it was readily available through the CDC’s 500 
Cities Project, which uses the Behavioral Risk Factor 
Surveillance System’s (BRFSS) data. The percent of 
each health indicator was combined, and Census 
Tracts were sorted according to overall percent and 
were assigned a score of one through five; five being 
the highest, indicating poor health. Block groups 
within the same census tract were assigned the same 
health score.

The two scores were combined and standardized 
on a 100-point scale, which created a final Health 
Equity Score. The score was visualized geospatially, as 
referenced in Figure 4.



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Figure 4: Health Equity Index for the City of Fort Collins



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Recommendation

The municipal agency ultimately decided to use 
a weighted scale to incorporate three different 
priorities into the sidewalk prioritization process, 
shown in Figure 2. The three different priorities 
included are: Demand (weighted at 35%), Health 
Equity Index (weighted at 20%), and Safety (weighted 
at 45%).  The weighted health score is the final health 
and equity score that was calculated by BEP. 

Discussion

The original demand model that was used for 
sidewalk prioritization concentrated infrastructure 
investments near the central Downtown and the 
area surrounding Colorado State University, a local 
university, shown in Figure 5 (Robert Mosbey, 
personal communication, March, 2019). The areas of 
dark red indicate areas of the city with the highest 
demand for sidewalk infrastructure. 

Figure 5: GIS map of Previous City of Fort Col-
lins Pedestrian Priority Rating

Figure 6: GIS map of  Updated Sidewalk Priorities 
and safety



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After modifying the model to include safety 
and health, the priority sidewalks became more 
geographically dispersed throughout the municipal 
boundary, as shown in Figure 6 (City Fort Collins, 
2017).  At this point in time, no formal analysis on the 
comparative models has been done to determine a 
percentage of change. However, visually, users can 
note that with the updated model, the Downtown 
is still the major focus area but some of the priority 
ratings have shifted. For example, there are hotspots 
in the southern end of the city that are no longer 
identified as medium-high priority using the updated 
model. Additionally, there are more identified areas 
in the north and west of the city that heightened their 
priority ranking by becoming a medium or medium-
high priority. 

Limitations

There are several identified limitations of the 
HEI. First, there are two potential issues with 
the accessible data utilized for the HEI to be 
acknowledged: first, there are self-report concerns 
in BRFSS data that cannot be accounted for; second, 
HEI uses estimated and modelled data from the 
American Community Survey 5-year estimates and 
from the Centers for Disease Control and Prevention’s 
500 Cities data. In knowing that this is estimated and 
modelled information, we acknowledge there may 
be a diluted effect when this information is weighted 
again and again in the HEI and in the sidewalk 
prioritization model. The HEI is an attempt to spatially 
understand factors that contribute to an individual 
or household’s likelihood of being vulnerable, and 
therefore, it is just an example of one tool to be 
considered in a decision-making process.  

Second, disability status is not reported at a block 
group-level. The American Community Survey 
estimates do not report disability status at a 
block group level only at the census tract-level.  
This information was estimated by assuming the 
population of people with a disability are spread 
evenly throughout the block groups in a census tract. 

Each block group received a proportionate number 
of people reporting a disability based on the total 
population size of that block group. 

Third, the 500 Cities data only reports on 14 cities 
in Colorado and only 500 cities in the United Sates. 
Users outside of those 14 cities (or 500 Cities, 
nationally) may consider talking with the state 
health department about accessing community level 
estimates or any other available health data. 

Fourth, the 500 Cities data compiles information 
at the census tract-level; additionally, some of the 
indicators do not exist at the Census tract-level. The 
information that does not exist was estimated by 
finding the block groups with the same equity score 
as the census tract that did not have corresponding 
health data and an average of the health scores using 
the block groups with the same equity score is used 
as an estimated health score. 

Fifth, American Community Survey estimates and the 
500 Cities data is updated regularly and therefore, the 
model becomes outdated annually. Ideally, HEI would 
have the ability to pull data and update automatically. 

Last, the indicators were not weighted individually 
and are weighted as a combined number. Therefore, 
some individuals and households (depending on the 
indicator) are counted multiple times and the percent 
of total for a block group may be over 100%.

Implications and Lessons Learned 

Although there was a shift in sidewalk distribution 
due to the inclusion of the HEI into the sidewalk 
prioritization model, we also saw two large 
unintended outcomes that are worth discussing: 1) 
The relationship built between two sectors and 2) 
The inclusion of the HEI in the municipal agency’s City 
Plan, the comprehensive urban planning document 
(City Fort Collins, 2019). In the paragraphs below we 
will discuss the implications of these two outcomes. 



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An important outcome was the development of a 
relationship between a local health department 
and a municipal organization. The creation of the 
HEI was dependent on two different sectors coming 
together to utilize the skills and expertise of the 
other which required a thoughtful approach to 
understanding organization context and skills as well 
as dedicated staff time to develop the partnership. 
For example, to better understand the skills and 
expertise from the BEP the Municipal Engineering 
staff worked with BEP to become knowledgeable on 
best practices for inclusion of health and equity, the 
determinants of health, and the relationship between 
health and the built environment. Conversely, BEP 
staff worked with Municipal Engineering staff to 
understand the previous sidewalk location model, 
how sidewalk funding was allocated, the policies 
associated with sidewalk prioritization, decision 
making process, and timing of sidewalk development. 
In these two examples listed above the education 
and capacity building was delivered during one-
on-one conversations. Ultimately, taking the time 
to understand and value each sectors contribution 
to changing a process was essential in the creation 
and utilization of the HEI. The staff time that was 
dedicated to this process is important to note as 
building relationships in order to follow the HIA 
process required significant time and may be unique 
to the LCDHE BEP. BEP staff capacity is currently 
supported through state level competitive grants 
that allow staff to provide technical assistance to 
conduct assessments and co-create tools with partner 
agencies. 

The second unintended implication was the inclusion 
of the HEI into the municipal agency’s City Plan, which 
is both the Comprehensive and Transportation Plan 
for the City of Fort Collins (City of Fort Collins, 2019). 
The BEP was able to leverage the work already done 
in partnership with the City Engineer and provide the 
HEI to the Planning staff at the City of Fort Collins for 
consideration of including the HEI in the City Plan. 
The HEI was then included in the “Trends and Forces” 
chapter which outlined existing conditions in the 
City of Fort Collins and is central to the Health Equity 
“spread” presented in the introductory chapter of the 
adopted City Plan. As the City Plan is a foundational 
urban planning document, it is likely the HEI will 
lead to the inclusion of health into future decision-
making regarding distribution of capital improvement 
projects and land use policies that will have an 
impact on Health Equity within Fort Collins. However, 
as comprehensive plans are 20-30 year guiding 
documents, this plan has yet to create any tangible 
benefits for vulnerable communities in the city. 

Conclusion

Local Public Health Agencies have numerous 
tools, resources, and models to address upstream 
Determinants of Health, especially through a built 
environment lens. Elements of HIA can be a powerful 
tool for not only understanding the health impacts 
of a policy or process on community, but also 
for building and developing trusted cross-sector 
relationships. 



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A Case Study on Incorportating Health and Equity into Urban Plans, Transportation, and Land Use Policies Haworth; Young Winne

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CORRESPONDING AUTHOR
Kelly Haworth, MPH
Larimer County Department of  Health and Environment
1525 Blue Spruce Drive
Fort Collins, CO 80524
970-498-6774
khaworth@larimer.org

CHIA Staff:

Editor-in-Chief  
Cynthia Stone, DrPH, RN, Professor, Richard M. Fairbanks School of  Public Health, Indiana University-Purdue 
University Indianapolis

Journal Manager 
Angela Evertsen, BA, Richard M. Fairbanks School of  Public Health, Indiana University-Purdue University 
Indianapolis

Chronicles of  Health Impact Assessment Vol. 4 Issue 1 (2019) DOI: 10.18060/23354
© 2019 Author(s): Haworth, K.; Young Winne, E.
       This work is licensed under a Creative Commons Attribution 4.0 International License

ACKNOWLEDGEMENTS
The authors would like to acknowledge Annemarie Heinrich, MPH, MURP for her work in creating the original Health Equity 
Index model, as well as Robert Mosbey at the City of  Fort Collins for implementation of  the sidewalk prioritization model. 
Phonejwaimberg@temple.edu


