









































November 2018 Volume  3 Issue 2

Susan Sutherland, R.S., MPH

Abstract: 

Background: One of the goals of the Health Impact Assessment (HIA), was to assess potential health implications 
in providing opportunities for active transportation to the Simon/Tanger Outlet Mall in Berkshire Township, 
Delaware County, Ohio by community connectivity. 

Methods: This case study was conducted by using the Health Impact Assessment model and incorporated 
community input through survey methodologies, assessment protocols, best practices, and  peer-reviewed 
literature.

Results: Many of the risk factors for chronic diseases can be traced on how communities have been built. Several 
pathways have been identified in the research linking built environments with travel patterns, physical activity 
levels, body mass index, and associated health outcomes. Residential density, land use mix, and neighborhood 
connectivity have all been consistently associated with multiple outcomes related to good health. By making 
neighborhoods more walkable, we not only can create converging health benefits, but environmental benefits 
and more equal access to jobs and opportunities. Emerging research on the presence of sidewalks, cycling 
infrastructure, street design, and building placement and site design have been linked to various health and 
health-related travel behavior outcomes (Frank 2008). 

Discussion: Continuing modifications to the built environment provide opportunities, over time, to institute 
policies and practices that support the provision of more activity-conducive environments, which improve the 
community’s health.  

1

THE SIMON/TANGER OUTLET MALL HEALTH IMPACT 
ASSESSMENT: RESULTING IN ACTIVE TRANSPORTATION 

THROUGH COMMUNITY CONNECTIVITY



Simon/Tanger Outlet Mall Health Impact Assessment Sutherland

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Introduction

The purpose of the Health Impact Assessment (HIA) was 
to assess the potential health impacts to community 
health of the development of the Simon/Tanger 
Outlet Mall in Berkshire Township, Delaware County, 
Ohio. Convened and facilitated by Delaware General 
Health District, and the Berkshire Township Residents’ 
Advisory Group, the HIA process was supported by the 
HIA Steering Committee representing 17 organizations 
whose expertise assisted in providing input on 
best practices for community planning and design, 
economic and neighborhood development, open 
space, green space, active transportation including 
bicycle, and walking path infrastructure.

The Simon Property Group and Tanger Outlets will 
develop a 350,000-square-foot outlet center with 

90 retail businesses on approximately 50 acres in 
Berkshire Township, Delaware County, Ohio. Plans also 
include additional future commercial and office uses 
on the remaining land.  

The analysis of this HIA included the impact that the 
Simon/Tanger Outlet Mall project could have on the 
potential of creating opportunities for connectivity 
of the surrounding neighborhoods, schools, walking/
biking trails and to existing or planned parks, 
restaurants, office buildings and other planned 
development. 

Methods

Undertaking a HIA followed the step-by-step model 
process as detailed below (see Table 1).

Table 1. The HIA Step process and methodology

HIA Step Methodology

Screening The Health Commissioner and the author attended a Berkshire Township Residents’ 
Advisory Group meeting, and discussed how an HIA might help decision-makers further 
evaluate and prioritize the residents’ concerns about the Simon/Tanger Outlet Mall 
project and its potential impact on community health and make recommendations to 
mitigate or minimize negative health impacts.  

The HIA project team determined that an HIA would provide an opportunity 
to examine the potential health impacts of the proposed Premium Outlet Mall 
development and alternatives to help further refine and improve infrastructures and to 
help the township possibly prioritize funding for projects that provide health as well as 
environmental and economic benefits.

Scoping The scoping phase of this HIA was used to gain an understanding of what issues were 
most important to the community concerning the development of the Premium Outlet 
Mall. The scoping process was finalized during a meeting where 25 stakeholders 
and 7 Berkshire Township residents met with the Director of Development for the 
Simon/Tanger Outlet Mall. The purpose of the meeting was to give the community an 
opportunity to voice their concerns and to make recommendations to improve the 
infrastructure that supports active transportation, decreases traffic congestion, and 
other improvements to the built environment. The scope of this HIA was determined 
by the entire group based on the discussions held at the meeting.



Simon/Tanger Outlet Mall Health Impact Assessment Sutherland

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Assessment The assessment process was to understand the impact of the development of Simon/
Tanger Outlet Mall on community health. Data was collected that included the amount 
of minutes per day of physical activity engaged by adults in Delaware County, and adult 
and child chronic disease rates in Delaware County. This information was obtained 
from the Delaware County Adult Risk Behavior Factor Surveillance Survey and the 
Youth Risk Behavior Factor Surveillance Survey. Many literature sources on the built 
environment and physical activity were reviewed. All sources supported the fact that 
the built environment impacts community health. In addition, the assessment included 
a pedestrian and bike infrastructure index scoring. The assessment portion also 
included prediction models that described the economic benefits of health outcomes 
by increasing walkability and bikeability through a study conducted by Boarnet, 
Greenwald and McMillan in 2008.

Recommendations The Trans Associates Engineering Consultants, Inc. recent Traffic Impact Study prepared  
for Simon Property Group and Tanger Factory Outlet Centers, Inc., based conclusions 
and recommendations to improve roadway design and allow for increased safety for 
motorists, bicyclists, and pedestrians. The recommendations would also increase 
opportunities for physical activity that will prevent or reduce chronic diseases should 
the residents choose active transportation options.

Reporting The findings and recommendations of this HIA were presented and discussed with the 
community stakeholders, Simon Properties’ developer, the District Advisory Council 
of Delaware County, and the Berkshire Township Residents Advisory Group. An article 
about the HIA appeared in the Delaware Gazette and the Urban Studies Journal.

Monitoring/
Evaluation

The following evaluations were completed:
• A survey of the stakeholders was conducted to determine how useful the HIA 

information was in their decision-making.
• The number of future land-related projects that consider the HIAs in their decision-

making process was collected. 
• A evaluation of the number of recommendations considered and how it 

influenced physical activity, the baseline community health status, and community 
connectivity. 

  
Monitoring was intended to track the impacts of the HIA on the decision-making 
process and decision, the implementation of the decision, and impacts of the decision 
on health determinants.  



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Results

With the potential creation of a park, trails, green space 
and providing connectivity surrounding the outlet mall, 
the number of days residents could engage in physical 
activity could increase. Increasing connectivity for 
pedestrians and bicyclists makes walking and bicycling 
more attractive choices, enabling people to increase 
their trips by these active modes. This should increase 
the health benefits associated with greater levels of 
physical activity and reduce the costs and negative 
impacts associated with motor vehicle travel. It is 
also expected that there is improved mental health 
indicators with improved access to other regional 
destinations and associated activities. 

Health Impact Assessments make evidence-based 
recommendations to promote positive health 
outcomes and minimize negative consequences. One 
of the scopes of this HIA is community connectivity. 
Since the scope is very broad, these recommendations 
not only included the area being developed for 
the Simon/Tanger Outlet Mall, but also included 
anticipated future development within the surrounding 
area, and recommendations are multi-jurisdictional. 
The recommendations, strategies, and evidence are 
divided into these categories:

• Policy Adoption 
• Promotion of Active Transportation
• Increased Connectivity
• Enhanced Walkability/Bikeability

POLICY ADOPTION
To achieve walkable communities, pedestrian 
considerations and provisions and policies should 
be fully integrated into ongoing planning activities 
(comprehensive planning, zoning regulations, site plan 
ordinances and review, street design standards). The 
planning process should increase sustainable mobility. 
Safe and convenient bicycling and walking will be the 

cornerstone of this mobility. Effective pedestrian-
oriented land-use and transportation systems planning 
will have a significant impact on pedestrian travel, it 
is recommended that the revised comprehensive plan 
include options for residents to walk or bike to many 
of their destinations (connectivity); and, provisions for 
children to walk or bike to their schools and to nearby 
parks. 

The plan should encourage the adoption of street 
design standards that give priority to safe, easy access 
for pedestrians in residential and commercial areas, as 
well as in areas near schools, parks, dining, shopping, 
and other public places. Such things as vehicle speed, 
number of lanes, overall roadway width, location and 
width of sidewalks, and intersection crosswalks should 
be designed for safety to encourage walking. 

Additional plan and policy recommendations include: 
1). A Bike-Transit Integration Study; 2). Improved 
countywide bike-friendly policies along with marketing 
and engineering efforts; 3). Adoption of a Complete 
Streets Policy.

PROMOTE ACTIVE TRANSPORTATION
1.Accommodate all roadway users with 

comprehensive street design measures such as 
“complete streets,” including sidewalks, bicycle 
lanes, and share-the-road signs that provide safe 
and convenient travel for all users of the roadway. 
All new roads entering the outlet mall should have 
sidewalks installed on both sides of the road and 
wide enough to accommodate people walking in 
groups or pushing strollers and individuals with 
disabilities. A ‘furnishing zone” should be added 
to each sidewalk to provide a buffer between 
pedestrian and street traffic, which would include 
pedestrian scale street lighting. 

2. Provide streetscape amenities such as benches, 
landscaping, lighting, and public art. Amenities 
are placed to not block or narrow sidewalks 



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particularly for the visually impaired, older adults, 
people pushing strollers, and individuals with 
disabilities. 

3. Encourage wayfinding with signs, maps, and 
landscape. Cues to direct pedestrians and 
bicyclists to the most direct routes to the outlet 
mall. 

4. Provide bicycle parking at workplaces and transit 
stops. Designate bicycle-specific crossings and 
signals to organize the movement of pedestrian, 
cyclists, and motorists at the busy intersection 
into the entry of the mall.  Offer a buffer between 
bicyclists and cars to increase safety.

5. Ensure that site design, parking, and fences do 
not preclude safe and comfortable pedestrian 
connections to future development.

6. Support physical activity among people with 
disabilities and special needs such as elderly and 
handicapped by making all new roads and paths 
universally accessible. 

7. Provide safe and convenient bicycle and 
pedestrian connections such as a trial or 
easement to dedicated green space and potential 
public parks and recreation areas.

INCREASE CONNECTIVITY
Connectivity of walking and bicycle infrastructure is 
associated with both increased walking and increased 
transportation walking (Berrigan, Pickle, & Dill, 2010).   
Connectivity refers to, in this context, as the number 
of blocks and intersections, as well as the presence 
of walking/biking infrastructure linking different 
destinations, mostly because they assist in providing 
more direct routes for accessing locations. Increasing 
the connectivity of the street network is an important 
component of this HIA. 

1. Connect existing neighborhoods and greenways 
by installing sidewalks, bike lanes, and provide 
connection paths to existing trails. The Ohio to Erie 

trail has been partially completed in Galena and 
will eventually connect to Sunbury. This is a great 
opportunity to connect this new development 
with eastern Delaware County. 

2. New development and redevelopment should 
provide pedestrian and bicycle connectivity 
through walkways, bike lanes, and multi-use paths 
between individual development sites to provide 
alternative means of transportation in this area to 
major destinations such as transit stops, schools, 
parks, food, and other shopping centers. 

3. Recommend policies that maximizing the 
density of neighborhoods requiring new 
developments be mixed-use and high density 
with good connectivity by incorporating active 
transportation infrastructure in neighborhoods. 
These kinds of changes to the built environment 
will make the areas more conducive to active 
transportation, which will have positive health 
benefits through increased physical activity, 
decreased air pollution, and reduced car collision 
fatalities for drivers, pedestrians, and bicyclists. 

4. Ensure that new parks are easily accessible by 
foot, bike, or public transit from neighborhoods 
that are currently underserved by parks. Create 
greenways/pedestrian and bicycle friendly 
routes and increase transit service, especially 
on weekends and holidays, from underserved 
neighborhoods to the site.

5. A needs assessment of existing neighborhoods in 
Berkshire Township should be conducted prior to 
updating the Berkshire Township Comprehensive 
Plan to determine park needs, walkability issues, 
and other connectivity needs of the residents.

ENHANCE WALKABILITY/BIKEABILITY
The placement and proximity of destinations is one 
of the most important factors in determining how 
much people walk for transportation. The presence 
and convenience of utilitarian destinations has been 
associated with walking for transportation, especially 



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destinations such as grocery stores, restaurants, post 
offices, and banks. A national survey of more than 
12,000 adults found that the most common purpose 
of walking trips (38%) was for personal errands, such 
as going to the grocery store. Another important 
factor is the density of housing, which can increase the 
number of people who can live within a short distance 
(generally ¼ to ½ mile) of commercial, retail, school, 
work, or transit-stop destinations. Higher density at the 
parcel level has been associated with odds of walking 
frequently for transportation.

1. Follow development and redevelopment practices 
that support walking, biking and transit use.

2. Consider changing minimum parking requirements. 
Consider alternative parking provision strategies. 

3. Allow zoning/re-zoning that facilitates mixed-use 
development. 

4. Incentivize mixed-use development in Berkshire 
Township. 

5. Provide interconnected streets, pedestrian 
sidewalks and other pedestrian facilities to 
increase walking. 

6. Linkage to a variety of land use/regional 
connectivity. Provide pedestrian and cyclists 
infrastructure to access shopping, transit, schools, 
parks, offices and other communities in this region 
of the county.

7. Coordinate between jurisdictions. Close 
coordination with adjacent jurisdictions to meet 
future pedestrian and cyclists’ connectivity 
infrastructure. 

8. Accessible and appropriately located transit. 
Provide transit facility close to commercial area 
to encourage transit usage, and include shelter, 
benches, and bike racks. 

9. Pedestrian-supportive land-use patterns. Use a 
grid street layout with short blocks in commercial 
area to enhance pedestrian mobility. 

Discussion

Neighborhood design can also significantly impact 
physical activity and health, especially through 
features such as land use mix, walkability, bicycling 
infrastructure, parks, and open space. 

The most consistent characteristics positively 
associated with physical activity were population 
density, land use mix, and distance to nonresidential 
destinations. Conversely, a study on the association 
between time spent in cars, physical activity and obesity 
found that each additional hour spent in a car per day 
was associated with a 6% increase in the likelihood of 
obesity.  Street design facilitates or hinders walking 
and cycling.  Other environmental features influencing 
mode of transport choice include the availability of 
cycle and pedestrian lanes, preferably separated from 
other road users and other measures to calm motorized 
traffic (Lee & Moudon, 2006).

Land use practices that isolate employment locations, 
shopping and services and housing locations can 
encourage car use, particularly where public transport 
options are not available or attractive alternatives 
(Heath et al., 2006). Where urban development is 
unplanned or uncontrolled and spreads out into areas 
adjoining the edge of a city – commonly known as 
urban sprawl – car dependency is likely to be increased 
(Heath et al., 2006). Evidence suggests that people 
living in sprawling communities drive three to four 
times more than those who live in efficient, well-
planned areas. Compared to those living in compact 
areas, people living in sprawling areas walk less for 
exercise, have higher weight levels and are more likely 
to have high blood pressure (Dannenberg et al., 2003).  

Walking or biking for utilitarian trips is an opportunity 
to incorporate routine physical activity into daily living.  
There are multiple environmental barriers that both 
children and adults face to achieving recommended 



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levels of physical activity including: limited discretionary 
time, barriers to accessing parks and recreational areas, 
reductions in school physical education programs, and 
sidewalks, streets, or outdoor spaces that are not or 
are not perceived as safe to use.   Encouraging and 
facilitating active transportation – walking or cycling as 
a form of travel for utilitarian trips – is a key strategy for 
increasing daily physical activity.  Built environmental 
factors that are associated with active transportation 
via walking and cycling include increased resident and 
employment density, greater diversity of land use mix 
(e.g., residential land use near retail land uses), shorter 
distances destinations, and street design factors (e.g., 
grid street networks, the presence of sidewalks) 
(Sustainable Communities Index, 2018).

Evidence that physical activity has multiple health 
benefits is unequivocal.  A comprehensive literature 
review documents the particularly strong evidence for a 
causal relationship between activity level and enhanced 
cardiorespiratory and muscular fitness, cardiovascular 
and metabolic health biomarkers, bone health, body 
mass and composition in children and youth.  In adults 
and older adults, strong evidence demonstrates that, 
compared to less active counterparts, more active men 
and women have lower rates of all-cause mortality, 
coronary heart disease, high blood pressure, stroke, 
type 2 diabetes, metabolic syndrome, colon cancer, 
breast cancer, and depression.  For older adults, 
strong evidence indicates that being physically active 
is associated with higher levels of functional health, 
a lower risk of falling, and better cognitive function.  
A study conducted in Atlanta, Georgia encourages 
walking and was associated with a 12% reduction in 
the likelihood of obesity (City of New York, 2014). 

This research reported reasonably consistent findings 
specifically for the health benefits of walking – showing 
a consistently lower risk of all-cause mortality for those 
who walk two or more hours per week.  A 2011 report 
issued by an international group of experts using 

data from Copenhagen documents similar all-cause 
mortality benefits from regular cycling for commuting 
controlling for socio-demographic and leisure time 
physical activity (World Health Organization, 2011)  

In 1996, commissioned as a response to the rising 
levels of obesity in the U.S., the U.S. Department of 
Health and Human Services Surgeon General’s report 
on physical activity and obesity was the first to bring 
to the forefront the positive health outcomes of 
physical activity. Based on this and a number of other 
comprehensive reviews of the literature, engaging in 
physical activity affects a variety of health outcomes 
including: All causes of mortality; Cardiovascular 
disease; Diabetes mellitus; Cancer (colon and breast); 
Hypertension; Bone and joint diseases (Osteoporosis 
and osteoarthritis); Mental health (Department of 
Health and Human Services, 1996). 

The U.S. Surgeon General issued a report confirming 
what is generally known: Americans aren’t getting 
enough exercise (U.S. Department of Health and Human 
Services, 1996).  The American Heart Association has 
listed physical inactivity as the fourth major risk factor 
associated with chronic disease (Haskell et al., 2007). 
Of great concern to public health officials in all parts 
of the United States, the trend of physical inactivity is 
getting worse: a 2009 summary by the Robert Wood 
Johnson Active Living Research program revealed that 
fewer than 50% of children and adolescents and fewer 
than 10% of adults in the U.S. achieve public health 
recommendations of 30 to 60 minutes per day of 
moderate- to vigorous-intensity physical activity on 5 
or more days of the week (Designing For Active Living, 
2017). 

Physical activity is associated with all-cause mortality 
in an inverse dose-response fashion; increasing levels 
of physical activity being associated with decreasing 
levels of mortality. In addition, studies have found that 
physical activity has reduced caused-specific mortality, 



Simon/Tanger Outlet Mall Health Impact Assessment Sutherland

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including deaths from cardiovascular disease. In 
addition, physical activity is associated with lowered 
risk of colon cancer and breast cancer in women 
(American Society of Clinical Oncology, 2016). 

Reviews of physical activity interventions suggest 
that people may be more willing and able to adopt 
moderate physical activities. Once such activities are 
set in motion they are more inclined to maintain them 
over time, as compared with other types of vigorous 
physical activity (HIA Guide, 2014). 

Physical activities that are incorporated into daily life or 
have an inherent meaning, or lifestyle activities, rather 
than structured exercise regimens, are good strategies 
for increasing physical activity.  Even relatively small 
changes in physical activity can translate into potentially 
large changes in weight trends at the population level 
(University of California, Los Angeles Health Impact 
Assessment – Clearinghouse Learning & Information 
Center, n.d.). 

According to the Centers for Disease Control and 
Prevention, a total of 30 minutes of moderate to 
vigorous physical activity, which can be achieved via 
brisk walking or cycling on most days of the week, 
reduces the risk of cardiovascular diseases, diabetes 
and hypertension, and helps to control blood lipids 
and body weight.  These benefits are conferred even 
if the activities are done in short ten- to fifteen-
minute episodes. Thus, CDC’s physical activity 
recommendations for adults call for at least 30 minutes 
of moderate to vigorous activity per day for health 
benefits.

An article in the Springer Journal describes the link 
between physical activity and health outcomes.  
An economic study, it revealed that urban design 
could be significantly associated with some forms of 
physical activity and with some health outcomes. After 
controlling for demographic and behavioral covariates, 

the county sprawl index had small but significant 
associations with minutes walked. Those living in 
sprawling counties were likely to walk less, weigh more, 
and have greater presence of hypertension than those 
living in compact counties. Although the magnitude of 
the effects observed in this study was small, they do 
provide added support for the hypothesis that urban 
design affects health and health-related behaviors 
(Frank et al., 2005). 

Another report from the peer-reviewed literature, 
Linking Objectively Measured Physical Activity with 
Objectively Urban Form, claims that there are now 
sufficient studies documenting associations between 
the built environment and physical activity and to 
consider land-use decisions as a critical public health 
issue (Humboldt, 2008). The built environment may be 
contributing to the obesity epidemic, because obesity 
is more prevalent in areas where land use makes it 
difficult to walk to destinations and where there are 
relatively few recreational resources (Frank et al., 
2005).  

Sufficient evidence was found in the literature that 
street-scale design and the land use policies to support 
physical activity in small-scale geographic areas are 
effective in increasing physical activity such as bicycle 
and pedestrian infrastructure (Heath et al., 2006).   

In conclusion, according to the Centers for Disease 
Control and Prevention, environments that support 
walking, biking and transit trips as an alternative to 
driving have multiple potential positive health impacts.   
Quality, safe pedestrian and bicycle environments 
support a decreased risk of motor vehicle collisions and 
an increase in physical activity and social cohesion with 
benefits including the prevention of obesity, diabetes, 
and heart disease as well as stress reduction and 
mental health improvements that promote individual 
and community health. Environments that encourage 
walking and biking while discouraging driving can 



Simon/Tanger Outlet Mall Health Impact Assessment Sutherland

9

further reduce traffic-related noise and air pollution 
– associated with cardiovascular and respiratory 
diseases, premature death, and lung function changes, 
especially in children and people with lung diseases 

such as asthma (Centers for Disease Control and 
Prevention, n.d.).



Simon/Tanger Outlet Mall Health Impact Assessment Sutherland

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References

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Berrigan, D., Pickle, L.W., & Dill, J. (2010). Associations between street connectivity and active transportation. 
International Journal of Health Geographics, 9(1), 20.

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City of New York. (2014). Promoting physical activity and health in design active design g. Retrieved from 
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Dannenberg, A. L., Jackson, R. J., Frumkin, H., Schieber, R. A., Pratt, M., Kochtitzky, C., & Tilson, H. H. (2003). 
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Frank, L. (2008). The built environment and health: A review. City of Calgary. Alberta.

Frank, L., Schmid, T., Sallis, J., Chapman, J., & Saelens, B. (2005). Linking objectively measured physical activity 
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Haskell, W. L., Lee, I. M., Pate, R. R., Powell, K. E., Blair, S. N., Franklin, B. A., …Bauman, A. (2007). Physical 
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CORRESPONDING AUTHOR
Susan Sutherland, R.S., MPH
Delaware General Health District
1 W. Winter Street
Delaware, OH. 46015
ssutherland@delawarehealth.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. 3 Issue 2 (2018) DOI: 10.18060/22709
© 2018 Author(s): Sutherland, S.
       This work is licensed under a Creative Commons Attribution 4.0 International License

Sustainable Communities Index. (2018). For a more sustainable future. Available from:  https://www.
sustainable.org/index.php

U.S. Department of Health and Human Services.  (1996). Physical activity and health: A report of the Surgeon 
General. Retrieved from https://www.cdc.gov/nccdphp/sgr/pdf/sgrfull.pdf 

University of California, Los Angeles Health Impact Assessment - Clearinghouse Learning & Information Center. 
(n.d.). Physical Activity. Retrieved from http://www.hiaguide.org/sectors-and-causal-pathways/pathways/
physical-activity 


