









































September 2023 Volume 8 Issue 1

Maxim Gakh, JD, MPH; Courtney Coughenour, PhD; Emily Strickler, MPH;
Megan R. McDonough, MS, RD; Priyambda Kumra; Jennifer R. Pharr, PhD;

Timothy Bungum, DrPH; Nicole Bungum, MS, CHES; Mindy Meacham

ENHANCING HEALTH THROUGH BUILT ENVIRONMENT 
IMPROVEMENT: A SOUTHERN NEVADA HEALTH IMPACT 

ASSESSMENT CASE STUDY 

Abstract
Background: Health Impact Assessment (HIA) is a public health tool to evaluate 
how choices made outside the health sector can affect health. HIAs are utilized in 
transportation, housing, planning, and other fields. Since the built environment can 
impact community health outcomes, including physical activity rates, injuries, and 
overweight and obesity, an interdisciplinary team composed of public health, planning, 
transportation, and land use professionals conducted an HIA in Las Vegas, Nevada. 

Methods: The HIA consisted of (1) screening, (2) scoping, (3) assessment, (4) 
recommendations, (5) reporting, and (6) monitoring and evaluation. It examined 
proposed physical improvements to a 0.66 mile stretch of a major arterial roadway 
in the City of Las Vegas where nearby residents experience many health inequities. 
Collection and analysis of land use and survey data, analysis of secondary data, and 
literature reviews were completed to predict potential health effects produced by built 
environment changes. Stakeholder feedback informed each HIA step. 

Results: The HIA generated recommendations to improve physical activity, reduce 
pedestrian and bicyclist injury rates, and decrease obesity and overweight prevalence, 
by presenting “good,” “better,” and “best” physical infrastructure improvements. The 
process and resulting recommendations enhanced collaboration among health and non-
health sectors.

Conclusions: Data and analysis revealed that the proposed changes could improve 
walkability and bikeability and reduce pedestrian and bicyclist injury. By encouraging 
active transportation through bicycling and walking, the plan could, over time, 
contribute to reduced overweight and obesity. The HIA facilitated inter-sector cross 
collaboration and the integration of health into future decision-making. 



Enhancing Health through Built Environment Improvement

2

Introduction
Connections between land use and health 
are well documented. One prominent area 
of research is the use of urban planning 
and infrastructure changes to increase 
rates of active transportation within 
neighborhoods. Enhancing neighborhood 
walkability and bikeability can increase 
rates of physical activity through 
exercise (physical activity for physical 
fitness) and active transport (physical 
activity for transportation) (Grasser et 
al., 2013; Prins et al., 2016; Sallis et al., 
2016). The relationship between regular 
physical activity and human health is 
likewise well documented (Centers for 
Disease Control and Prevention [CDC], 
2022b). Benefits of physical activity 
include improved cognition and thinking, 
weight management, reduced chronic 
disease risk, strengthened muscles and 
bones, and improved quality of life (CDC, 
2020b).  Unfortunately, only about half of 
U.S. adults engage in the recommended 
amounts of aerobic physical activity 
(CDC, 2020a). And about $117 billion 
are spent annually on healthcare costs 
associated with physical inactivity (CDC, 
2020b). 

Prioritizing physical activity in a 
community can have economic, safety, 
and workforce benefits (CDC, 2022a). 
Walkable communities can enhance 
safety for all users (CDC, 2020b; 
Reynolds et al., 2009). Some of the most 
common measures of neighborhood 
walkability include net residential density, 
street connectivity, land use mix, and the 
proportion of retail land-area to retail-
building-floor area (also known as Retail 
Floor Area Ratio) (Adams et al., 2015; 
Frank et al., 2010; Grasser et al., 2013; 
Sallis et al., 2016; Wei et al., 2016). In 
addition, availability of sidewalks, overall 
aesthetics, and users’ perceptions of 

these features, including safety, are also 
related to walking and rates of physical 
activity (Barnett et al., 2017). Similarly, 
bikeable communities are associated 
with increased rates of bicycling (Winters 
et al., 2016), and certain types of 
infrastructure improve safety (Reynolds 
et al., 2009; DiGioia et al., 2017; Pucher & 
Buehler, 2016).

It must be acknowledged that active 
transport may increase crash risk in 
terms of absolute numbers, as “[t]he 
more a person travels, the more they 
are exposed to the potential risk of a 
traffic-related injury or death” (Merlin 
et al., 2020). Bicyclists and pedestrians 
are vulnerable road users and make up a 
disproportionate share of crashes (The 
League of American Bicyclists, 2018). 
There were 6,516 pedestrian fatalities 
and 938 bicyclist fatalities in the U.S. 
in 2020 (National Center for Statistics 
and Analysis [NCSA], 2022). Pedestrian 
fatalities from motor vehicle crashes 
increased by 46% between 2011 and 
2020 while bicyclist fatalities increased 
by 38% in the same period (National 
Highway Traffic Safety Administration, 
n.d.). Improving pedestrian and bicyclist 
infrastructure can substantially reduce 
these fatalities (Schneider et al., 
2017; United States Department of 
Transportation, 2014).

Although land use and health are linked, 
integrating health into planning and 
design decisions remains a challenge 
(Nieuwenhuijsen et al., 2020). Health 
Impact Assessment (HIA) is a tool that 
can help identify and inform health 
implications of choices, plans, and 
projects that traditionally do not consider 
health (National Research Council [NRC], 
2011; CDC, 2016; The Pew Charitable 
Trusts, n.d.). Regular use of HIAs could 



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lead to more consistent integration of 
health into decisions made by other 
sectors and better prioritization of 
health equity (Morley et al., 2016). Land 
use decisions are especially conducive 
to HIAs because HIAs can enhance 
collaboration between the health and 
planning sectors, improve land use 
plans, and catalyze more systematic 
assessments of health in land use choices 
(Wernham, 2011).  

An HIA on proposed built environment 
improvements along a 0.66 mile stretch of 
a major arterial roadway was conducted 
in the City of Las Vegas. Residents near 
the stretch exhibited various health 
disparities. The primary aim of the HIA 
was to advance the integration of health 
and equity into regional land use decisions 
through analysis and collaboration. This 
paper provides an adapted report of the 
HIA and its findings in the context of HIA 
and Health in All Policies work. 

Methods
This HIA consisted of all six steps: (1) 
screening, (2) scoping, (3) assessment, 
(4) recommendations, (5) reporting, and 
(6) monitoring and evaluation, along with 
stakeholder engagement throughout 
(NRC, 2011; The Pew Charitable Trusts, 
2014). A Research Team (RT) consisting 
of University of Nevada, Las Vegas School 
of Public Health faculty and students 
partnered with a Working Group (WG) 
representing the Southern Nevada 
Health District (SNHD); City of Las Vegas 
– Department of Public Works (CLV 
DPW); Nevada Minority Health & Equity 
Coalition; the Regional Transportation 
Commission of Southern Nevada (RTC); 
and the Nevada Institute for Children’s 
Research & Policy to complete the HIA. 
The HIA was supported by a Racial and 
Ethnic Approaches to Community Health 

Grant from the CDC, which was awarded 
to the SNHD.

In screening meetings, the RT and WG 
identified land improvement projects 
that were in the planning stage that 
could benefit from the use of HIA. 
Screening discussions of the RT and 
WG also generated selection criteria 
for a proposed project. The project 
had to (1) be within a Las Vegas ZIP 
Code with residents who experience 
health disparities, (2) be in the 
appropriate phase of planning so that 
recommendations could be considered, 
(3) contain built environment features 
studied in literature, (4) potentially 
impact the health determinants and 
outcomes of interest (5) potentially 
impact connectivity to schools, parks, 
and transit, (6) highlight existing 
processes at CLV DPW into which health 
considerations could be integrated, (7) 
be executable with available time and 
resources, and (8) serve as a case study 
to build a project scoping tool (PST) to 
bring health concerns into future land use 
decisions. 

The RT and WG chose the Charleston 
Medical District Improvement Plan 
because it met all of these selection 
criteria. This project was a 0.66 mile 
stretch of a major East-West arterial road 
in the Medical District within the City of 
Las Vegas. This area is home to numerous 
medical facilities, including a major 
public hospital, a dental school, medical 
school facilities, and a mix of commercial, 
retail, and other land uses. It also has a 
relatively high prevalence of pedestrian 
activity. The proposed improvement 
plan at the time included adding bicycle 
lanes, enhanced crosswalks, pedestrian 
activated beacons, signage, trees, and 
landscaping; narrowing vehicular travel 



Enhancing Health through Built Environment Improvement

4

lanes; reducing speed limits; and acquiring rights of way to improve and widen existing 
sidewalks. 

The HIA examined demographic and health-related data from adjacent Census Tracts. 
The residents of these adjacent Tracts are at higher risk for negative health outcomes 
compared to many other parts of Southern Nevada (Healthy Southern Nevada, 2022). 

The activities associated with each of the six HIA steps are summarized in Table 1.



Gakh; Coughenour; Strickler; McDonough; Kumra; Pharr; Bungum; Bungum; Meacham 

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Screening The RT and WG met to determine selection criteria and choose an appropriate 
project from numerous improvement plans that were in planning stages.

Scoping The RT and WG selected HIA goals and objectives and key health concerns to 
examine. The HIA aimed to reveal the baseline conditions of the area and then 
determine potential impacts if certain recommendations were implemented. 
Five key focus areas identified were: 1) health equity, 2) walkability, 3) bikeability, 
4) pedestrian and bicyclist injury, and 5) overweight and obesity. The RT and 
WG crafted research questions to guide assessment of direct, intermediate, and 
downstream health outcomes in these focus areas. See Figure 1 for the pathway 
diagram linking the proposed decisions to health outcomes.

Assessment The assessment was a three-step process:
1. Examine baseline conditions of the Census Tracts immediately adjacent to the 

project corridor based on the key focus areas.
a. Health equity & obesity/overweight: Secondary data from the American 

Community Survey (ACS) and the City Health Dashboard were used to 
examine socio-demographic, economic, and health factors, including 
median household income, adult physical inactivity, obesity, and health 
insurance status (United States Census Bureau [USCB], n.d.; City 
Health Dashboard, 2019).

b. Walkability & Walking: Walkability was assessed through primary data 
on five segments of the project corridor using the 54-item Microscale 
Audit of Pedestrian Streetscapes (MAPS), Abbreviated Version (Cain et 
al., 2017). Walking rates were assessed using secondary data from the 
CLV DPW, RTC, and the ACS commuting database (USCB, 2017).

c. Bikeability & Bicycling: Bikeability was assessed by evaluating bicycle 
infrastructure using the Bicycle Level of Traffic Stress secondary data 
metric (Alta Planning and Design, 2017) and through primary data using 
the Active Neighborhood Checklist (Active Neighborhood Checklist, 
2011). Bicycling rates were assessed using secondary data: the ACS 
commuting database (USCB, 2017) and RTC information on the number 
of bicycles brought onto buses that traverse the project corridor.

d. Pedestrian & Bicyclist Injury: Injury rates were determined utilizing 
secondary motor vehicle crash data from the Nevada Department of 
Transportation.

2. Conduct an intercept survey of pedestrians in the area during varying times 
of the day over three weeks in June and July 2019. Primary data obtained 
included demographics, reasons users were in the area, primary modes 
of transportation, perceptions of safety and available infrastructure, and 
preferences regarding pedestrian and bicycle infrastructure. 

Table 1. Summary of Health Impact Assessment Steps



Enhancing Health through Built Environment Improvement

6

3. Assess project impacts through a series of literature reviews. The RT searched 
Google Scholar for relevant systematic reviews and meta-analyses to examine 
how the proposed built environment features relate to physical activity and 
downstream health indicators like overweight, obesity, and injury. Sample 
search terms included walkability, pedestrian, sidewalk, bikeability, bicycle, 
bicycling, bike lane, speed, injury, traffic, health, built environment, obesity, 
overweight, and BMI.

Recommendations The RT used findings from the assessment, WG suggestions, and feedback 
from a stakeholder input session to develop recommendations to improve the 
project corridor. The stakeholder session was attended by the RT, WG, and 
representatives from organizations like the county school district, health-focused 
community organizations, academia, and the state public health department. 
It included discussion of the HIA’s screening, scoping, and assessment; how to 
encourage bicycling and walking in the area; community members’ involvement 
in land use decisions; and better connections between the land use and health 
sectors. Final recommendations were organized into “good,” “better,” and “best” 
categories to maximize health outcomes in each focus area but also enhance 
flexibility and feasibility for project partners.

Reporting A final report summarizing the HIA and key recommendations was made 
available to the WG. WG members were asked to share the final report with their 
partners and networks. The RT also presented the HIA’s findings to regional, 
health-focused community coalitions and to transportation-focused community 
partners in Spring 2019.

Monitoring & 
Evaluation

Monitoring: To support continued monitoring of the project area, the RT 
developed a system of tracking spreadsheets to outline applicable indicators and 
provide relevant data sources. These spreadsheets were provided to WG partners. 
They could be used periodically to monitor land use modifications and changes to 
priority health behaviors and outcomes. As HIA partners developed the PST, they 
also continued to track land use changes and health indicators in the area. 
Evaluation: The RT completed a process evaluation through an anonymous 
survey of the WG and a facilitated face-to-face discussion between the RT and 
WG. The survey and discussion evaluated the execution of each step of the HIA, 
the HIA’s potential to improve community and cross-sector collaboration, and the 
opportunities for stakeholders to engage in the HIA process. 

Table 1. Summary of Health Impact Assessment Steps (continued)



Gakh; Coughenour; Strickler; McDonough; Kumra; Pharr; Bungum; Bungum; Meacham 

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Figure 1. Charleston Medical District Pedestrian Improvement Plan Pathway Diagram 
Linking Proposed Decisions to Health Outcomes 

Results
Baseline Conditions

After analyzing available secondary data, 
the RT found that project area residents 
were more racially and ethnically diverse 
than the overall average for the City 
of Las Vegas. Some adjacent Census 
Tracts had lower high school graduation 
rates, higher rates of unemployment, 
poverty, and uninsured status, and lower 
median incomes (USCB, n.d.; City Health 
Dashboard, 2019). Some Census Tracts 
likewise had higher rates of obesity and 
chronic health conditions like diabetes 
and high blood pressure compared to 

City of Las Vegas and national averages 
(USCB, n.d.; City Health Dashboard, 
2019). Area residents also had higher 
rates of high-risk health behaviors, 
including smoking and physical inactivity 
(City Health Dashboard, 2019). Average 
life expectancy in all Census Tracts in 
the project area was well below that of 
city and national averages (City Health 
Dashboard, 2019). See Table 2 for 
demographic and health-related baseline 
characteristics for the project area’s 
adjacent Census Tracts.



Enhancing Health through Built Environment Improvement

8

Table 2. Demographic and Health-Related Baseline Information for Residents in 
Census Tracts Adjacent to Charleston Corridor, with Comparisons to the City of Las 
Vegas and the 500-City Average

Census Tract
 2.03 Value

(90% confidence 
interval)

Census Tract 
3.01 Value

(90% 
confidence 

interval)

Census Tract
2.04 Value

(90% 
confidence 

interval)

City of Las Vegas
Value

(90% confidence 
interval)

500-
City 

Average

Social and Economic Factors

Median Age (years)*
35.3

(30.7-39.9)
37.6

(32.1-43.1)
45.2

(43.6-46.8)
37.4

(37.1-37.7)
-

Education (Population 25 years and over)
High school 
graduate or higher*

76.1%
(70.3-81.9)

73.9%
(68.5-79.3)

84.9%
(75.4-94.4)

84%
(83.5-84.5)

- 

Bachelor’s degree or 
higher*

18.4%
(11.8-25)

5.4%
(2.5-8.3)

36.7%
(24.7-48.7)

23.2
(22.6-23.8)

- 

Race & Ethnicity

White*
52.2%

(40.7-63.7)
32.1%

(24.2-40.0)
69.7%

(56.4-83.0)
62.7% 

(62.1-63.3)
- 

Black or African 
American*

17.3%
(11.1-23.5)

46.4%
(39.9-52.9)

3.7%
(0.8-6.6)

12.2%
(11.8-12.6)

 -

American Indian, 
Alaskan Native*

0.5%
(0-1.1)

0.2%
(0-0.6)

0.2% 
(0-0.7)

0.7%
(0.6-0.8)

 -

Asian*
9.3%

(4.4-14.2)
2.6%

(1.0-4.2)
18.8%

(6.6-31.0)
6.7%

(6.4-7.0)
 -

Native Hawaiian, 
Other Pacific 
Islander*

0.6%
(0-1.5)

0.3%
(0-0.9)

0.7%
(0-2.0)

0.7%
(0.6-0.8)

 -

Some Other Race*
16.0%

(7.0-25.0)
16.0%

(9.5-22.5)
3.4%

(0-6.8)
12.3%

(11.7-12.9)
 -

Two or More Races*
4.2% 

(1.9-6.5)
2.4%

(0.4-4.4)
3.5%

(0.5-6.5)
4.8%

(4.5-5.1)
 -

Hispanic*
40.4%

(33.4-47.4)
39.9%

(33.5-46.3)
23.5%

(10.3-36.7)
32.7%

(32.2-33.2)
- 

Economic Factors

Children in Poverty
54.5% 

(37.8-71.3)
47.6% 

(32.5-62.6) 
12.5%

(0-32.7)
23.7% 21.4%

Households with 
Excessive Housing 
Cost

53%
(42.7-63.2)

43%
(34.1-52)

34.1%
(19.0-42.9)

37.4% 36.3%



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Economic Factors
Median Household 
Income*

$32,476
(24,069-40,883) 

$30,000
(23,586-36,414) 

$66,111
(57,137-75,085) 

$53,159
(52,282-54,036) 

- 

Unemployment
16.4%

(8.9-23.8)
13.4%

(6.8-20.0)
3.8%

(0.4-7.1)
8.8% 6.9%

Uninsured
27.8%

(20.4-35.3)
31.0% 

(24.9-37.1)
27.5%

(16.0-38.9)
18.1% 12.4%

Below 100% of the 
Federal Poverty 
Level*

40.9%
(30.5-51.3)

41.0%
(32.5-49.5)

11.2%
(0-23.2)

16.2%
(15.6-16.8) 

- 

Food Insecurity+ 26.7% 27.9% 7.3% -  -

No Vehicle Access+ 23.4% 31.4% 0.0%  - - 

Physical Environment
Average Daily 
Concentration of Air 
Particulate Matter 
(PM 2.5)

7.7/m3 7.7/m3 7.7/m3 6.9/m3 8.8/m3

Walkability Index 
(2019)

37.4 55 39.3 40.6 41.3

Limited Access to 
Healthy Foods

96.7%
(96.3-97.2)

36.5%
(35.0-37.9)

47.0%
(44.6-49.5)

57.2% 65.9%

Health Behaviors 
Current Adult 
Smoking

25.8%
(23.9-27.7)

29.5%
(27.9-31.1)

15.0%
(13.0-17.0)

20.5% 17.2%

Adult Physical 
Inactivity

37.3%
(35.5-39.1)

42.9%
(41.5-44.3)

25.9%
(23.8-28.0)

29.9% 26.2%

Health Outcomes 
Adults with High 
Blood Pressure

37.8%
(37.1-38.5)

45.8%
(45.1-46.5)

37.8%
(36.7-38.9)

31.8% 29.6%

Adults with Diabetes
15.0%

(14.4-15.6)
19.9%

(19.2-20.6)
12.2%

(11.4-13.0)
11.2% 10.0%

Average Life 
Expectancy at Birth 
in 2015 (years)

71.2 
(68.7-73.7)

69.3
(66.8-71.8)

65.1
(59.4-70.8)

77.4 79.1

Adult Obesity
33.5%

(32.7-34.3)
41.0%

(40.3-41.7)
24.0%

(23.1-24.9)
28.2% 29.7%



Enhancing Health through Built Environment Improvement

10

Definitions:
• Children in Poverty – Children living in households ≤100% of the Federal Poverty Level
• Housing Cost, Excessive – Households where ≥30% of household income is spent on housing costs
• Unemployment – Population aged ≥16 years that is unemployed but seeking work
• Uninsured – Current lack of health insurance among people aged 0-64 years
• Air Pollution-Particulate Matter – Average daily concentration of fine particulate matter (PM2.5) per 

cubic meter
• Walkability – Neighborhood amenities accessible by walking as calculated by Walk Score®
• Limited Access to Healthy Foods – Population living more than ½ mile from the nearest 

supermarket, supercenter, or large grocery store
• Adult Physical Inactivity – No leisure-time physical activity in past month among adults aged ≥18 

years
• Food Insecurity – Estimated percentage of population that experienced food insecurity at some 

point during the year
• No Vehicle Access – Estimated percentage of households without a vehicle

The five segments assessed for 
walkability using the MAPS Abbreviated 
Audit (primary data collection) (Cain 
et al., 2017) earned scores between 19-
32, indicating the area was “somewhat 
walkable.” The main project area received 
the highest walkability score of all the 
segments assessed, likely because it 
had a high land use mix, including many 
retail and healthcare destinations. The 
audit revealed that the area needed 
improvement in the perception of safety 
and sidewalk width to accommodate 
multiple pedestrians and/or mobility 
device users.

Data on the rate of walking to work in the 
Census Tracts immediately surrounding 
the project was not available. However, a 
recent equity analysis indicated that the 
area just north of the project falls into 
parts of the Las Vegas Valley experiencing 
the highest inequity. The area just south 
falls into parts experiencing the second 
highest inequity. Inequity was measured, 
in part, based on (1) household 
percentages with no car for daily use, 
(2) household income below 200% of 
the federal poverty level, (3) non-white 

population, and (4) under 18 and over 
64 years population (RTC, 2017). These 
characteristics are associated with higher 
rates of walking to work (McKenzie, 
2014). Pedestrian counts obtained by 
CLV DPW at two intersections within the 
project area during peak times (7am-8am 
and 5pm-6pm) on multiple dates between 
2002 and 2015 indicated a relatively high 
presence of pedestrians in this area. This 
walking data was compared with national 
and regional walking data. Nationally, 
2.7% of all work trips are made by walking 
(USCB, 2017). In Las Vegas overall, 1.8% 
of residents report walking to work, which 
is slightly higher than the entirety of 
Clark County (1.7%) (RTC, 2017). 

The bikeability assessment conducted 
by the RT found no physical separations 
or painted markings for designated 
bike paths or bike lanes and no signage 
to alert drivers to share the roadway. 
According to secondary data, bicycling 
in the area would be uncomfortable for 
most, meaning only avid bicyclists, often 
termed the “strong and fearless,” would 
voluntarily cycle along this stretch (Geller 
2009; Alta Planning and Design, 2017). 



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Bike lanes crossed the segment only 
once through an intersecting street and 
the nearest bike routes were over a mile 
away. 

Bicycling rates for the project-adjacent 
Census Tracts were not available. 
However, because of the project’s 
proximity to parts of the Las Vegas 
Valley with high inequity (RTC, 2017), 
demographic factors indicated that 
nearby residents would be more likely to 
bicycle to work than others in the region. 
RTC secondary data (2017) indicated 
that between January 2015 and February 
2019, about 3,514 bicycles were loaded 
onto the public bus route running East-
West along Charleston Boulevard in and 
beyond the project area. This bicycling 
data was also considered in light of other 
secondary national and local biking data. 
Only 0.6% of all work trips are made 
by bicycle nationally (USCB, 2020) and 
in Las Vegas, about 0.5% of residents 
bicycle to work, which is slightly higher 
than the 0.4% in Clark County (RTC, 
2017).

Nevada Department of Transportation 
(NDOT) secondary crash data indicated 
that 3.7% of motor vehicle crashes 
between 2015 and 2017 along this 
segment involved a pedestrian (NDOT, 
n.d.), which is well above the national 
average of 1.1% (Campbell et al., 2016). 
Of the 11 pedestrian crashes in the 
corridor, seven involved vehicles turning 
right, suggesting increased hazards to 
pedestrians in the project area (NDOT, 
n.d.). There were three bicycle crashes 
along this segment between 2015 and 
2017 (NDOT, n.d.). All three crashes 
were classified as “injuries” or “injuries 
reported by the person” and two of them 
involved a driver turning right at an 
intersection (NDOT, n.d.).

Community Input

An intercept survey involved primary 
data collection and was completed by 
81 participants. It was developed by the 
RT with WG guidance and implemented 
by RT partners. Surveyors approached 
individuals who were outside and were 
walking, biking, standing, or otherwise in 
the project area. People were approached 
to participate at various points in time 
(7:30 am – 8 pm) and on multiple days 
of the week (Mondays-Fridays) over a 
three-week period in June and July 2019. 
Individuals who expressed interest in 
participating received research study 
information and a survey. Surveyors 
collected completed information. If 
participants requested help, surveyors 
assisted by orally reading questions 
and/or recording answers. This survey 
was deemed exempt by the University 
of Nevada, Las Vegas Institutional 
Review Board. The RT then examined the 
collected data.

The highest proportion of participants 
resided in surrounding ZIP Codes (89101, 
89102, and 89106), which are some of 
the ZIP Codes experiencing the greatest 
health inequities in the region (“Health 
Equity Index,” 2022). Most participants 
self-identified as white (43%), followed 
by African American (24%), and Hispanic 
or Latino (22%). Over half reported 
using automobiles as their primary 
mode of transportation (53%), followed 
by public transportation (36%), and 
walking (8%). About a quarter reported 
that they walk in the area most days of 
the week and over 40% reported they 
walk less than once per month. At the 
time of the intercept survey, participants 
were walking to get to work (27%), 
seek healthcare services (26%), and 
connect to public transportation (18%). 



Enhancing Health through Built Environment Improvement

12

Only about 9% of survey participants 
said they were walking there that day 
because they lived in the area, which is 
adjacent to Census Tracts experiencing 
health inequities. This may potentially 
limit the conclusions that can be drawn 
from the survey about nearby residents. 
However, proposed project changes 
would impact all area users, including 
residents. In addition, other survey 
participants may also be members of 
communities experiencing inequities. 
For example, about 26% of respondents 
said they were in the area for medical 
reasons. Some of them may have been 
in the project area to visit the county’s 
public hospital. This hospital sees 10% 
uninsured, 18% Medicare, 48% Medicaid, 
and 5% government insured patients 
and provides almost $41 million of 
uncompensated care annually (American 

Hospital Association, 2023).  

About 74% of participants in the intercept 
survey believed that cars traveled too 
fast in the area to feel safe walking or 
bicycling. Only 22% reported that existing 
bicycling infrastructure was sufficient 
for safety. Participants identified the top 
three area safety concerns as: (1) vehicle 
speeds (59%), (2) distracted driving 
(58%), and (3) potential for crime (48%). 
When shown detailed pictures of bicycle 
and sidewalk infrastructure and asked 
which they would most likely use to walk 
and bicycle, participants most commonly 
chose bicycle lanes raised higher than 
street level and lower than sidewalk level 
(43%; n=74) and 10-foot-wide sidewalks, 
with 8 feet dedicated to the sidewalk and 
2 feet to a landscape buffer (43%; n=75). 
Table 3 presents detailed survey results. 

Main Form of Transit Used (n=73)
Automobile 53%

Public Transit 36%

Walking 8%

Wheelchair/scooter 1%

Other 1%

How Often You Walk in the Area (n=81)
Less than once per month 41%

1-3 times per week 21%

1-3 times per month 12%

Most days of the week 26%

Reasons for Walking in the Area Day of the Survey (n=79)
I go to school in this area 10%

I live in this area 9%

I work in this area 27%

I'm connecting to another bus route 18%

Other: 37%

Other/Medical 26%

Other/Errands 2%

Other/Roaming 3%

Table 3. Pedestrian Intercept Survey Results



Gakh; Coughenour; Strickler; McDonough; Kumra; Pharr; Bungum; Bungum; Meacham 

13

Road Design Options "I Feel"

Cars are too fast for:
Pedestrians

(n=79)
Bicyclists

 (n=79)

Strongly Agree 37% 44%

Agree 37% 29%

I Don't Know 5% 6%

Disagree 14% 11%

Strongly Disagree 8% 9%

I feel safe from traffic while:
Walking
(n=78)

Bicycling (n=80)

Strongly Agree 13% 3%

Agree 24% 11%

I Don't Know 9% 43%

Disagree 33% 20%

Strongly Disagree 21% 24%

I feel enough infrastructure exists for safety in:
Walking
(n=80)

Bicycling (n=78)

Strongly Agree 14% 10%

Agree 36% 12%

I Don't Know 3% 17%

Disagree 21% 23%

Strongly Disagree 26% 38%

Safety Concerns (n=81)
Speed of cars/trucks 59%

Motorists 58%

Distracted driving 58%

Potential for crime 48%

Too many cars/trucks 35%

Narrow sidewalks 33%

Conflicts or collision with cars/trucks 28%

Not enough lighting 25%

Not enough other people out walking 20%

Poles/light posts in the sidewalk 20%

Overgrown bushes/vegetations 14%

I have no safety concerns 6%

Other
“Other” written-in concerns: Crosswalks too far apart, 
older adult population usability, not enough shade/trees

11%



Enhancing Health through Built Environment Improvement

14

Project Impacts

Available data and literature supported 
the prediction that walkability and 
associated walking behaviors would 
likely increase under the plan, especially 
for populations experiencing inequities. 
Literature suggests that objectively 
measured built environment features, 
such as street connectivity, diversity 
of land uses, and population and 
employment density, are consistently 
associated with walking and 
neighborhood walkability. In addition, 
perceptions of the built environment 
(e.g., perceived sidewalk availability, 
safety, and aesthetics) correlated more 
strongly with physical activity than 
objective measures (Barnett et al., 2017).

Objective measures of walkability include 
land use mix and street connectivity 
(Khanal & Mateo-Babiano, 2016), 
gross population density (Grasser et 
al., 2013), Walk Score (Hall & Ram, 
2018; Walk Score, 2019), and design 
and diversity (Ewing & Cervero, 2010). 
The area contained existing features 
that support walkability (e.g., access 
to services and destinations, public 
transit, high land use mix, and jobs/
housing balance). The proposed changes, 
including improved 10-foot sidewalks, 
landscaping, crosswalks, and slower 
posted travel speed limits, could improve 
perceived walkability. Furthermore, 
because populations experiencing health 
inequities walk more – particularly as 
transit – walking among the population 
residing adjacent to the project area 
would be even more likely to increase. 

Available data and literature also 
supported the projection that the 
plan could enhance bikeability and 
increase bicycling rates. Bikeability and 

bicycling rates are closely related to: 
(1) availability of bicycle infrastructure, 
including separating bicyclists and 
motorists (Pucher & Buehler, 2008; 
Pucher et al., 2010), (2) higher density, 
more connectivity, and greater land 
use mix (Saelens et al., 2003), and (3) 
enforcement of traffic laws to reinforce 
policies that favor bicycle travel over 
motor vehicle travel (Pucher et al., 2010). 
The amount of infrastructure necessary 
to increase bicycling rates is not fully 
understood (Buehler et al., 2012); 
however, one model suggests that a one-
mile increase in bicycle lanes per 100,000 
people is linked to about a 0.07% 
increase in bicycle commuting (Nelson & 
Allen, 1997); another suggests that every 
additional urban mile of bicycle lanes 
per square mile generates a 1% bicycling 
increase (Dill & Carr, 2003). Since the 
original plan focused on separating 
vehicles and bicyclists, it could enhance 
the level of comfort for bicyclists. 
Increased bicycle infrastructure 
and connectivity would likely yield 
increased bicycle commuting.  Given the 
uncertainty about the exact connection 
between bicycle infrastructure and 
bicycling rates and the fact that the 
project would create less than 1 mile 
of new bicycle lanes, the RT expected 
changes to bicycling rates under the plan 
to be small. The RT also concluded that 
there would be an increased likelihood of 
bicycling in this area compared to other 
parts of Las Vegas and Clark County 
because of the high bicycle counts 
data, area demographics, and survey 
participants’ indications of insufficient 
bicycling infrastructure in the area. 
Over time, adding more infrastructure 
could increase bicycle commuting rates, 
particularly as connectivity grows. 

Given that changes in walkability 



Gakh; Coughenour; Strickler; McDonough; Kumra; Pharr; Bungum; Bungum; Meacham 

15

and bikeability predicted increases 
in both walking and bicycling, the RT 
likewise predicted reductions in the 
downstream health effects of injury 
and overweight. Several infrastructure 
changes show promise in the literature 
for reducing pedestrian and bicyclist 
injury. Interventions such as reduced 
motor-vehicle speeds (Cairn et al., 
2014), improved traffic or pedestrian 
signals, separation of pedestrians from 
traffic with fencing or refuge islands, and 
increased roadway lighting (Retting et 
al., 2003) are linked to pedestrian crash 
reductions. A meta-analysis by Bunn and 
colleagues (2003) found a pooled rate 
ratio of 0.89 for pedestrian injury with 
use of traffic-calming measures. 

Literature findings specifically for bicycle 
injury reduction were less clear. It is 
possible that increasing the numbers 
of bicyclists on the road could likewise 
increase the probability of bicycle versus 
motor-vehicle crashes; however, there is 
a nonlinear relationship between number 
of bicyclists on the road and injury rates 
(Kondo et al., 2018). This is likely due to 
the “safety in numbers” phenomenon, in 
which more bicyclists on the road actually 
seems to offer protection from motorists, 
perhaps because it makes motorists 
more aware of bicyclists in general 
(Kondo et al., 2018; Prati et al., 2018). 
Bicycle versus motor-vehicle crashes 
are more likely to occur at intersections 
or roundabouts, in areas of high vehicle 
speed, where there is insufficient lighting 
at night, in the presence of high traffic 
volumes, in the presence of obstacles 
(such as road signs), or where there are 
entrances/exits to the roadway, such 
as driveways, parking lots, or tunnel 
entrances (Kondo et al., 2018; Morrison 
et al., 2019; Prati et al., 2018; Reynolds 
et al., 2009). Dedicated bike lanes are a 

common intervention to reduce bicycle 
crashes, but evidence that bike lanes 
alone reduce bicyclist injury is lacking 
(Mulvaney et al., 2015). Morrison et 
al. (2019) suggest that this is because 
bicycle lanes decrease risk of crashes 
at different rates depending on the 
type of bicycle lane and other roadway 
infrastructure. Bicycle lanes appear to be 
most effective at reducing crashes where 
vehicle speeds are high, traffic lanes 
are narrow, and bus or tram routes are 
present (Morrison et al., 2019). The best 
protection of bicyclists has been found 
with paved, bike-only tracks with a high 
degree of separation from the roadway, 
adequate lighting, and low-angled grades 
(Reynolds et al., 2009). Reducing vehicle 
speed limits and providing dedicated 
bike paths separated from traffic are 
ubiquitous recommendations in the 
literature for reducing risk of bicycle 
crashes (Morrison et al., 2019; Prati et 
al., 2018; Reynolds et al., 2009).

Overall, the RT predicted that plan-
related changes would likely reduce 
pedestrian injuries, but impacts 
on bicyclist injury were difficult to 
determine. Bicycle crashes could increase 
under the plan with more bicyclists, but 
the addition of a bicycle lane and bicycle 
signage as well as decreased speed 
limits could also decrease bicycle injuries 
(and possibly crashes) compared to the 
existing infrastructure. Pedestrian and 
bicyclist injury projections would likely 
disproportionately apply to populations 
experiencing health inequities, including 
those residing adjacent to the project, 
because such populations tend to walk 
and cycle at higher rates, particularly for 
utilitarian purposes.

The RT also concluded that a healthier 
neighborhood built environment under 



Enhancing Health through Built Environment Improvement

16

the recommended plan could contribute 
to reductions in overweight and obesity. 
It would likely be in a limited way, 
however, because overweight and obesity 
are extremely complex; due to the size 
of the project and the fact that persons 
residing near the project area were 
already overburdened by obesity and 
overweight, reductions may be harder 
to realize. Research shows a strong link 
between walkability and obesity, as well 
as hypertension and Type 2 diabetes 
outcomes; it also strongly supports 
a relationship between measures of 
urban sprawl and obesity outcomes 
(Chandrabose et al., 2019). It appears 
that improved perception of walkability 
is most important (as opposed to 
objectively measured walkability) when 
it comes to improving health outcomes 
(Barnett et al., 2017; Chandrabose et al., 
2019). Despite the fact that walking only 
to proximate destinations may not be 
enough to reduce obesity (Chandrabose 
et al., 2019), it could be that even 
improving residents’ perceptions of 
walkability in the area could contribute to 
overall increases in walking and therefore 
improved health outcomes. The literature 
connecting bicycling and overweight and 
obesity outcomes was also promising, 
but inconclusive. One study conducted 
in a low-income community found that 
adults who bicycled were less likely to 
be overweight or obese than the general 
population (Noyes et al., 2014). Others 
found associations between bicycling to 
work and reduced obesity risk (Brown 
et al., 2013; Wojan & Hamrick, 2015). 
Suminski et al. (2014) found that bicycle-
promoting policies were associated with 
more bicycle infrastructure, a higher 
percentage of adults bicycling to work, 
and lower rates of overweight and 
obesity.

To summarize, the plan was expected 
to increase walkability through wider 
sidewalks, enhanced landscaping, 
improved crosswalks, and decreased 
motor vehicle speed limits. Such changes 
would build on the area’s existing 
features that favor walkability, including 
high residential and employment density, 
mixed land use, and public transit access. 
This, along with plans for enhanced 
bicycle infrastructure, could increase 
both walking and bicycling rates. Thus, 
the project could also contribute to 
reductions in overweight and obesity, 
while simultaneously reducing risk of 
injury.

Recommendations & Reporting

The RT combined assessment findings, 
WG suggestions, and feedback from a 
stakeholder input session to determine 
the focus of recommendations, namely 
separation of vehicles in time and 
space from pedestrians and bicyclists, 
reduction of speed limits, traffic calming, 
improved pedestrian and bicyclist 
infrastructure, enhanced connectivity, 
improved visibility, and enhanced 
aesthetics – categories identified in 
the literature as relevant to bikeability 
and walkability (Retting et al., 2003). 
Recommendations were presented as 
“good,” “better,” and “best” to provide 
best-case scenario ideas for health-
enhancing improvements, but also 
allow for flexibility given budgeting or 
other constraints. For example, to help 
separate vehicles from pedestrians, it 
was suggested that it would be “good” 
to retain the proposal to install and 
maintain 10-foot sidewalks; “better” to 
install and maintain 10-foot sidewalks 
plus add pedestrian islands at a 
proposed crosswalk and paint driveways 
to alert drivers to yield; and “best” to 



Gakh; Coughenour; Strickler; McDonough; Kumra; Pharr; Bungum; Bungum; Meacham 

17

Survey respondents strongly agreed that 
because of the HIA they had a better 
understanding of the HIA tool and were 
more likely to recognize the link between 
built environment and health. A majority 
reported thinking that the HIA would 
benefit the community. All respondents 
either “strongly agreed” or “agreed” that 
the HIA (1) met its aims and objectives, 
(2) was beneficial to them and their 
organizations, and (3) the process valued 
their input during feedback discussions. 
Most respondents also indicated that 
they were given adequate opportunity 
to provide HIA comments and that the 
benefits of the HIA outweighed the time 
associated with WG participation. Survey 
results were mixed about whether HIA 
recommendations would be considered 
during plan implementation. The RT and 
WG continued to refer to and discuss the 
HIA and to track changes to land use and 
health indicators as it worked on the PST 
to aid with future land use decisions. 

Discussion
This HIA focused on the Charleston 
Medical District Improvement Plan, which 
proposed modifications to the built 
environment. It relied on data on baseline 
conditions, pedestrian and bicyclist use 
and injury, built environment audits, an 
intercept survey, literature reviews, and 
stakeholder feedback. Using this analysis, 
it was determined that implementation 
of the plan could help improve walkability 
and bikeability, reduce crashes involving 
pedestrians and bicyclists, and increase 
physical activity through active transport 
– especially among residents living 
adjacent to the project area. This HIA 
produced evidence-informed alternatives 
to modify the plan to further improve 
health determinants and outcomes 
of interest. These recommendations 
were shared with project partners and 

install and maintain 10-foot sidewalks, 
add pedestrian islands at a proposed 
crosswalk, consolidate driveways, and 
add driveway pavement markings. To 
help add bicycle infrastructure, a “good” 
suggestion was to add ample bicycle 
parking; “better” to add ample bicycle 
parking near popular destinations and 
bicycle-specific traffic signals; and 
“best” to add ample bicycle parking near 
popular destinations, bicycle-specific 
traffic signals, and bicycle lockers closer 
to destinations. To reduce motor vehicle 
speeds, we suggested it would be “good” 
to retain the proposal to reduce posted 
speed limits to 35 miles per hour (MPH) 
and reduce lane width to 11 feet; “better” 
to reduce it to 30 MPH, reduce lanes to 
11 feet, and add radar signs; and “best” 
to reduce it to 20 MPH, reduce lanes to 11 
feet, add radar signs, and approve future 
buildings that promote more pedestrian- 
and bicyclist-oriented frontage. Further 
examples of recommendations will 
be included in a separate manuscript 
describing a project scoping tool (PST) 
generated from this analysis (manuscript 
in progress). These and other detailed 
recommendations were included in the 
final HIA report and shared with other 
partners (UNLV, 2019).  

Monitoring and Evaluation
 
During the in-person process evaluation 
discussion, WG members expressed 
that the HIA helped them understand 
the “how” behind connecting health 
implications to planning decisions. One 
weakness the group noted during the 
evaluation discussion was the ability 
to quantify health impacts more, e.g., 
a specific type of bike lane reducing 
crashes by a specific percent. The 
WG process evaluation survey (n=11) 
yielded generally positive feedback. 



Enhancing Health through Built Environment Improvement

18

stakeholders, and monitoring of plan 
implementation and health behaviors and 
outcomes continues. 

This HIA provides a practical example 
of how to connect land use and public 
health in the context of a specific project. 
Literature indicates that improving a 
community’s built environment is likely 
to encourage physical activity for that 
area’s population (Carlson et al., 2019; 
Cambra & Moura, 2020; Forsyth & Krizek, 
2010; Stappers et al., 2018; Wei et al., 
2016). The focus on physical activity and 
its connection to chronic disease is a 
major avenue for collaborations between 
the health and planning sectors (Frank 
et al., 2019). Literature also indicates 
that land use choices impact pedestrian 
and bicyclist crashes and injuries (Cairns 
et al., 2014; Prati et al., 2018). However, 
HIAs are often not used in transportation 
planning, which instead tends to focus on 
assessing monetary costs and associated 
project benefits (Nieuwenhuijsen et al., 
2020). 

While HIAs have promise to bridge 
this gap and enhance the planning 
process and its outcomes (Wernham, 
2011; Nieuwenhuijsen et al., 2020), 
land use HIAs can be highly contextual 
(Nieuwenhuijsen et al., 2020; Waheed et 
al., 2018). This HIA used existing data, 
literature, and feedback to generate 
actionable recommendations to promote 
walkability and bikeability, and thereby 
help address physical activity rates, 
injury, and obesity. Through this process, 
the HIA demonstrated how Southern 
Nevada could meld health and land 
use considerations and also fostered 
connections for future collaboration in 
this area. Many WG participants indicated 
that the process helped make practical 
connections between these sectors. The 

outcomes of this HIA were consistent 
with their potential, as articulated by 
Wernham (2011): enhanced collaboration 
and improved plans. The HIA outcomes 
were also consistent with findings that 
primary HIA benefits include building 
cross-sector relationships and raising 
awareness of health issues among 
decision-makers (Bourcier et al., 2015; 
Dannenberg et al., 2008; Sohn et al., 
2018). 

A remaining challenge for HIAs is how to 
integrate health concerns into decisions 
of other sectors systematically (Morly 
et al., 2016). This HIA focused on one 
short stretch of a roadway in a large 
urban area. However, one goal of this 
HIA at the outset was to build capacity 
and interest in integrating health 
concerns in transportation and land use 
decisions more broadly. There is growing 
interest in tools that can help shape how 
transportation projects are developed 
and prioritized and some indication that 
they may promote projects that support 
active transportation (Chirstofa et al., 
2020).This HIA served as an entry point 
for continued collaboration among 
the partners to create a PST for future 
built environment project decisions 
to assess existing baseline conditions 
and built environment infrastructure 
in a geographic area through a process 
that necessitates less time and fewer 
resources than an HIA. Dannenberg’s 
and colleagues’(2008) suggestion to 
incorporate recommendations as a 
formal step between the assessment 
and reporting steps is now integral to an 
HIA. The recommendations generated 
during this HIA are central to the PST. 
This HIA suggests that HIA-generated 
recommendations may be used beyond 
one specific HIA to inform subsequent 
projects and to integrate health 



Gakh; Coughenour; Strickler; McDonough; Kumra; Pharr; Bungum; Bungum; Meacham 

19

concerns into land use decisions more 
systematically. 

This HIA also encountered a challenge 
experienced in other HIAs: how to 
prioritize health equity (Morley et al., 
2016). Health equity was central to 
the structure of this HIA, since it was 
part of a larger project focused on 
improving health in geographic areas 
where residents were experiencing 
health inequities – areas that included 
disproportionate numbers of African 
American and Latinx residents. This 
resulted in a project that considered 
disparities in the HIA assessment, 
conducted an intercept survey, and 
fostered close collaboration with 
stakeholders who engaged with these 
communities in other contexts. In the 
typology of integrating health equity into 
transportation-related HIAs, this HIA 
focused on populations experiencing 
disparities, examined disparities, worked 
with stakeholders and incorporated 
stakeholder ideas, and aimed to build 
stakeholder capacity (Cole et al., 
2019). These efforts enriched the HIA 
process and outcomes. However, with 
additional resources, deeper community 
engagement in this HIA process may 
have enhanced the ability to integrate 
experiences and perspectives from the 
resident populations directly into the HIA 
process and perhaps also into the PST. 

Finally, this HIA process, including 
conversations of the WG, the process 
evaluation, and the stakeholder 
feedback event, revealed broader 
considerations adjacent to this plan 
and other built environment projects. 
Improving bikeability and walkability 
can be a slow and long-term process. 
This work requires initial investment 
and sustained efforts, which can make 

it difficult to catalyze these types of 
projects given competing interests for 
local infrastructure funding. Sustained 
collaborations across mutually beneficial 
projects may effectuate true change. 
In addition, walkability is especially 
influenced by land use mix. Questions 
of land use can involve stakeholders 
beyond governmental transportation and 
planning departments. This can pose 
additional challenges. 

Collaborative efforts, such as the 
PST, which aim to bolster existing 
processes with practical and contained 
health-focused-analysis, may help 
address some of the sustainability 
and equity concerns articulated in the 
literature and echoed through this 
HIA. As this HIA demonstrates, HIAs 
can spark partnerships (Chirstofa et 
al., 2020) and can be indispensable in 
establishing collaborations, articulating 
priorities, uncovering data, generating 
recommendations, and discovering 
existing decision-making processes that 
can serve as a foundation for sustained 
and equity-focused systems change 
work. Moving beyond any one HIA is 
also important to further systematic 
change and make progress in Health in All 
Policies efforts. 
 



Enhancing Health through Built Environment Improvement

20

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Gakh; Coughenour; Strickler; McDonough; Kumra; Pharr; Bungum; Bungum; Meacham 

25

CORRESPONDING AUTHOR
Maxim Gakh, JD, MPH
School of Public Health
University of Nevada, Las Vegas
Mail Stop #3063
4700 S. Maryland Pkwy., Suite 335
Las Vegas, NV 89119
maxim.gakh@unlv.edu

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, BS, Richard M. Fairbanks School of Public Health, Indiana University-Purdue 
University Indianapolis 

Acknowledgements
This project was supported by grant #NU58DP6578, funded by the Centers for Disease Control and 
Prevention and awarded to the Southern Nevada Health District. Its contents are solely the responsibility 
of the authors and do not necessarily represent the official views of the Centers for Disease Control and 
Prevention or the Department of Health and Human Services. We also want to acknowledge and thank our 
project partners, whose contributions to the project are discussed in this piece.

Chronicles of Health Impact Assessment Vol. 8 Issue 1 (2023) DOI: 10.18060/26864
© 2023 Author(s): Gakh, M.; Coughenour, C.; Strickler, E.; McDonough, M.;  Priyambda, K.; Pharr, J.; 
Bungum, T.; Bungum, N.; Meacham, M.
        
       This work is licensed under a Creative Commons Attribution 4.0 International License

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