Message from the Secretary, U.S. Department of Health and Human Services

Figure

Being physically active is one of the most important steps that Americans of all ages can take to improve their health. But only half of adults and about a quarter of high school students get the amount of physical activity recommended in national guidelines. Step It Up! The Surgeon General’s Call to Action to Promote Walking and Walkable Communities aims to get Americans walking and wheelchair rolling for the physical activity needed to help prevent and reduce their risk of chronic diseases and premature death. And it supports positive mental health and healthy aging as well.

From the time we take our first steps as children, walking becomes such an important part of our lives that we often take it for granted. As a way to enjoy nature, get the blood moving, or just get from one point to another, for many people, walking is an easy and free way to explore the world.

But for some, access to safe places to walk isn’t so simple. Without well-connected sidewalks and paths, or nearby destinations, our daily decision to walk or roll can be a bit tough. And that is especially true for people who need to use assistive devices or wheelchairs.

That is why this Call to Action is so important.

The Call to Action provides strategies that communities can use to support walking, which we hope will result in long-lasting changes to improve the health and health care of Americans today and of the generations that follow. The Call to Action adds to our work to educate, empower, and engage Americans to take control of their health, including initiatives like the National Prevention Strategy: America’s Plan for Better Health and Wellness, the National Physical Activity Plan, Healthy People 2020, and the Healthy Self campaign.

Like all parents, I am looking for easy, fun ways to keep my family healthy. Walking is an important option, and I believe all Americans want that choice. We need access to safe and convenient places to walk and wheelchair roll and a culture that supports activity where we live, learn, work, and play. As Secretary of Health and Human Services, I urge all areas of society—transportation, community design, education, business, nonprofits, parks and recreation, health care, public health, and the media—to help make our communities more walkable, so that walking is an easy choice for Americans to improve their health.

• Sylvia Mathews Burwell
  Secretary
  U.S. Department of Health and Human Services

Foreword from the Surgeon General, U.S. Department of Health and Human Services

Figure

There are many reasons to take a walk. We may walk to school, to work, or even to our places of worship. We may walk to help us think better and relieve stress. Often, we may take a stroll in order to spend quality time with the people and the pets we love most. And, throughout history, we’ve walked and marched in order to make our voices heard and our presence felt. As your Surgeon General, I celebrate all the many reasons for walking—and wheelchair rolling. Carving out just 22 minutes a day on average or 2 ½ hours a week for physical activity, like brisk walking, can do wonders for your overall health.

That is why I am proud to release Step It Up! The Surgeon General’s Call to Action to Promote Walking and Walkable Communities. This Call to Action reflects my deep commitment to several key principles for improving the health of our great nation.

First, the Call to Action focuses on promoting optimal health before disease occurs. As Americans, we lead the world in treating disease. As America’s Doctor, I believe we must also lead the world in preventing disease. Robust scientific evidence shows that physical activity is critical for both preventing and treating many of the chronic conditions we face today. Being physically active is one of the most important ways to improve health and well-being throughout our lives.

Second, the Call to Action is applicable to the health of people at all ages and stages of life. Walking is the most common activity of teens and adults. It requires no specialized skills or equipment and is a great first step (pun intended) for anyone who has been inactive. Taking a walk with family or friends can help our emotional well-being and connect us to our communities. And because active older adults are less likely to suffer from falls, walking is a great way to help us enjoy a good quality of life and live independently for years to come.

Third, the Call to Action recognizes that everyone should have access to spaces and places that make it safe and easy for us to walk or wheelchair roll—whether in urban, suburban, or rural settings. This means that the people who design our cities and neighborhoods should include well-maintained sidewalks, pedestrian-friendly streets, access to public transit, adequate lighting, and desirable destinations that are close to home. It also means that law enforcement and community leaders should work closely together to ensure that none of us has to walk in fear for our safety. Walkable communities are good for social connectedness, good for business, good for the environment, and, most importantly, good for our personal health.

My goal for this Call to Action is for each one of us to recognize and embrace our role in building the great American community, a place where being physically active is not only easier but also more engaging and fun. Find ways to make walking a part of your daily routine and invite friends, family, and colleagues to join you. Make your voice heard in decisions that affect how your city or town is planned. And support efforts to build more sidewalks, hiking trails, and public parks. Finally, I encourage you to partner with institutions and organizations that have already embraced this vision in your communities. You can learn more about some of these institutions and organizations on our website at www.surgeongeneral.gov.

Walking for better health may seem simplistic, but sometimes the most important things we can do are also the easiest and the most obvious. It’s time to step it up, America! The journey to better health begins with a single step.

• Vivek H. Murthy, M.D., M.B.A.
  Vice Admiral, U.S. Public Health Service
  Surgeon General
  U.S. Department of Health and Human Services

Promoting Walking and Walkable Communities: A Strategy to Improve Health

One out of every two U.S. adults is living with a chronic disease, such as heart disease, cancer, or diabetes.¹ These diseases contribute to disability and premature death.² In addition, the medical treatment of chronic diseases incurs substantial costs for individuals, families, and the nation.³

The good news is that many chronic diseases can be delayed, prevented, or managed through healthy behaviors. Along with eating a healthy diet⁴ and avoiding tobacco use,⁵ people can decrease their risk of chronic disease by being physically active.^6,7 Physical activity can help people with chronic diseases manage their conditions.^7,8 In addition, physical activity reduces the risk of premature death and supports positive mental health and healthy aging—making it one of the most important actions people can take to improve their overall health.⁶ To obtain substantial health benefits, the 2008 Physical Activity Guidelines for Americans recommends that adults get at least 150 minutes of moderate-intensity aerobic physical activity or 75 minutes of vigorous-intensity physical activity, or an equivalent combination, each week and that children and adolescents be active for at least 60 minutes every day.⁶

Despite the many benefits of physical activity, only one-half of all U.S. adults and about one-quarter of high school students meet the guideline for aerobic physical activity in the 2008 Physical Activity Guidelines for Americans.^9,10 Walking is an excellent way for most people to increase their physical activity. It is a powerful public health strategy for the following reasons:

• Walking is an easy way to start and maintain a physically active lifestyle.
• Walking is the most common form of physical activity for people across the country.
• Walking can serve many purposes. It can be a way to exercise, have fun, or get to school, work, or other nearby destinations.
• Making walking easier can help communities by improving safety, social cohesion, and local economies and reducing air pollution.

To promote walking, community strategies can be implemented where people live, learn, work, and play. Places for walking can be designed and enhanced to improve their walkability. Improving walkability means that communities are created or enhanced to make it safe and easy to walk and that pedestrian activity is encouraged for all people.¹¹ Improving the walkability of communities can benefit people of all abilities, including those who run, bike, skate, or use wheelchairs. This publication, Step It Up! The Surgeon General’s Call to Action to Promote Walking and Walkable Communities, is intended to increase walking across the United States by calling for improved access to safe and convenient places to walk and wheelchair roll, as well as for a culture that supports these activities for people of all ages and abilities.

This Call to Action presents five goals and supporting implementation strategies that are grounded in scientific and practice-based evidence. These goals call for action by multiple sectors of society, including transportation, land use, and community design; parks, recreation, and fitness; education (schools, colleges, and universities); business and industry; volunteer and nonprofit; health care; media; and public health. Families and individuals will also need to be involved to achieve these goals.

This Call to Action complements existing recommendations to help Americans become more physically active, such as those found in the National Prevention Strategy: America’s Plan for Better Health and Wellness¹² and the Solving the Problem of Childhood Obesity Within a Generation: White House Task Force on Childhood Obesity Report to the President,¹³ as well as the national health objectives for physical activity in Healthy People 2020.¹⁴ It also aligns with the goals of initiatives such as Let’s Move!,¹⁵ the Go4Life Campaign,¹⁶ the U.S. Department of Transportation’s Safer People, Safer Streets Initiative,¹⁷ the America’s Great Outdoors Initiative,¹⁸ and the Partnership for Sustainable Communities.¹⁹

In addition, this Call to Action builds on the National Physical Activity Plan,²⁰ which was developed by public and private partners to provide a comprehensive set of policies, programs, and initiatives that can help all people become more physically active and meet the 2008 Physical Activity Guidelines for Americans. It also reflects comments received in response to a request for information (78 FR 19491) published in the Federal Register on April 1, 2013. More than 750 comments were received from the public, state and local governments, nonprofit organizations, and professional organizations. All comments were carefully considered in the preparation of this Call to Action.

The first section of this publication introduces the Call to Action. The second section provides information about the prevalence and costs of chronic diseases in the United States and why being physically active is one of the most important steps people can take to decrease their risk of chronic diseases and improve their overall health. It also summarizes the 2008 Physical Activity Guidelines for Americans and current physical activity levels in the United States. The third section explains why walking is a relevant public health strategy for improving physical activity levels. The fourth section describes barriers to walking. The fifth section shares what communities can do to support walking. The sixth section examines the major gaps in surveillance, research, and evaluation related to walking and walkability. The final section identifies specific goals and strategies to promote walking and walkability in the United States and calls for nationwide action.

Figure

Physical Activity: An Essential Ingredient for Health

Being physically active is one of the most important steps that people of all ages and abilities can take to improve their health.⁶ We know that increasing people’s physical activity levels will significantly reduce their risk of chronic diseases and premature death and support positive mental health and healthy aging.^6,7 Increased physical activity can help children and adolescents; young, middle-aged, and older adults; women and men; people of different races and ethnicities; and people with disabilities and chronic health conditions.^6,7

This section provides a brief review of the prevalence and costs of chronic diseases in the United States and the well-established benefits of physical activity. This section also summarizes the 2008 Physical Activity Guidelines for Americans and documents the current levels of physical activity in the United States.

Physical Activity Guidelines for Americans

In 2008, the U.S. Department of Health and Human Services issued the first Physical Activity Guidelines for Americans.⁶ These guidelines outline the health benefits associated with physical activity and provide guidance for the amount of physical activity needed for substantial health benefits (see box, page 6). People who are inactive and those who do not yet meet the guidelines are strongly encouraged to work toward this goal. Those who are inactive and become more active may reap the most benefits.⁷ Adults with disabilities who are unable to meet the guidelines should avoid inactivity and try to get regular physical activity according to their abilities.⁶

Box

From the 2008 Physical Activity Guidelines for Americans.

Physical Activity in the United States

In 2013, about 3 out of every 10 U.S. adults reported being inactive during their leisure time (Figure 1), and only one-half reported levels of physical activity consistent with the guideline for aerobic physical activity (Figure 2).⁸⁰ Physical inactivity was more common among women; people who were older, black, or Hispanic; and people with lower levels of education (Figure 1). Conversely, adults who were male, younger, white, or Asian or who had higher levels of education were more likely to meet the aerobic component of the 2008 Physical Activity Guidelines for Americans (Figure 2). In addition, the percentage of older adults who were inactive increased with increasing age: 35% of those aged 65–74 years were inactive, 47% of those 75–84 years were inactive, and 64% of those 85 years or older were inactive. Conversely, the percentage of older adults who met the aerobic guideline decreased with increasing age: 42% of those aged 65–74 years, 31% of those aged 75–84 years, and 18% of those aged 85 years or older.

Figure 1

Percentage of U.S. Adults Aged 18 Years or Older Who Were Inactive During Their Leisure Time, 2013. Abbreviations: AI/AN, American Indian/Alaska Native; HS, high school; NH, non-Hispanic. Source: Centers for Disease Control and Prevention, National Center (more...)

Figure 2

Percentage of U.S. Adults Aged 18 Years or Older Who Met the Aerobic Physical Activity Guideline, 2013. Abbreviations: AI/AN, American Indian/Alaska Native; HS, high school; NH, non-Hispanic. Source: Centers for Disease Control and Prevention, National (more...)

In 2013, only 27% of high school students reported levels of physical activity that met the guideline for 60 minutes of physical activity a day (Figure 3).¹⁰ Male high school students and students in lower grade levels were more likely to meet the guideline; no differences were observed by race.^10,80

Figure 3

Percentage of U.S. High School Students Who Met the Aerobic Physical Activity Guideline, 2013. Abbreviations: AI/AN, American Indian/Alaska Native; NH, non-Hispanic; NH/PI, Native Hawaiian/Other Pacific Islander. Source: Centers for Disease Control and (more...)

Why Focus on Walking as a Public Health Strategy?

Strong evidence exists that physical activity has substantial health benefits.^6,7 People can get these benefits through brisk walking or by adding brisk walking to other physical activities.⁶ This section reviews the relevance and importance of walking as a public health strategy to increase physical activity levels in the United States.

Walking Is a Common Form of Physical Activity

Walking is common among people who are physically active. Among adults who reported any physical activity in 2011, 52% of men and 74% of women reported walking as one of the top two activities in which they participated.⁸⁴ Similarly, when high school students were asked about the physical activities they did during the past 12 months, they most frequently reported walking (81% of boys and 87% of girls).⁸⁵ Among school-aged youth (6–17 years), about 40% who live 1 mile or less from school reported that they usually walk to or from school on most days.⁸⁶

Figure

In 2010, more than 60% of adults reported walking 10 minutes or more in the past week for transportation or leisure.⁸⁷ Some groups were more likely to report walking than others (Figure 4).⁸⁷ Adults with more education, those who were white or Asian, and those who were younger were more likely than their counterparts to report any walking. No differences were observed between men and women.⁸⁷ Percentages of older adults who reported walking decreased with increasing age: 59% of those aged 65–74 years, 49% of those aged 75–84 years, and 41% of those aged 85 years or older.

Figure 4

Percentage of U.S. Adults Aged 18 Years or Older Who Reported Any Walking in the Past Week, 2010. Abbreviations: AI/AN, American Indian/Alaska Native; HS, high school; NH, non-Hispanic. Source: Centers for Disease Control and Prevention, National Center (more...)

Among people who walked, the average time spent walking was 13 minutes a day or about 90 minutes a week.⁸⁷ These average walking times, when walking is done at a brisk pace, provide slightly more than half of the time needed to meet the guideline of at least 150 minutes of aerobic physical activity each week. Not surprisingly, about 60% of people who walked met the guideline by walking alone or in combination with other forms of physical activity (e.g., running, biking), compared with 30% of those who did not walk.⁸⁷

Walking Is Multipurpose

People walk for many purposes, such as for transportation to get to school, work, a store, or the library or for leisure to have fun, socialize with friends or family, walk their dog, or improve their health. Because walking is multipurpose, it provides many opportunities for people to incorporate physical activity into their busy lives.

In 2010, about half of U.S. adults reported walking during their leisure time and less than one-third reported walking for transportation (Table).⁸⁸ Younger adults walked more than older adults for transportation, while walking for leisure was similar across the lifespan until it decreased among adults older than 65 years.⁸⁸ Whites and Asians were more likely than Hispanics and blacks to walk during leisure time; whites were less likely to walk for transportation than members of other racial and ethnic groups. Adults with more education were more likely to walk during leisure time and those with college degrees were also more likely to walk for transportation than those with less education.⁸⁸ Understanding these differences may help to increase the effectiveness and reach of interventions that encourage walking.

Table

Percentage of U.S. Adults Aged 18 Years or Older Who Reported Walking for Transportation or During Leisure Time, 2010.

Why Don’t People Walk More?

Many more people could meet the 2008 Physical Activity Guidelines for Americans⁶ by initiating walking or increasing the amount they walk. Although walking is a popular form of physical activity and can be easily done by most people, barriers to walking do exist. Understanding these barriers is essential to designing and implementing approaches that promote walking. This section reviews the most significant barriers to walking.

Figure

Disability, Chronic Conditions, and Aging

During 2009–2012, 11.6% of U.S. adults aged 18–64 years reported a disability, with estimates ranging from 1.7% for vision-related disabilities to 5.8% for mobility-related disabilities.¹⁴⁷ Adults with disabilities were more likely to be physically inactive than adults without a disability (47.1% versus 26.1%).¹⁴⁷ Some disabilities can make it difficult for people to walk without assistive devices.

Figure

Although many people with disabilities are able to be physically active, additional barriers exist that may limit their participation in some activities. These barriers include limited information about accessible facilities and programs, physical barriers in the environment, physical or emotional barriers to participating in fitness and recreational activities, and lack of training in accessibility and communication among fitness and recreation professionals.¹⁴⁸

Chronic conditions and age can also make it difficult for people to walk. For example, people with arthritis may find walking painful, and they may be uncertain about how to walk safely without worsening their arthritis.^56,149 For people with asthma, heart disease, and respiratory diseases, symptoms may be exacerbated when walking outdoors because of air pollution.^150,151 Older adults and those who are frail may be reluctant to walk because of concerns about falls and subsequent injury.

How to Increase Walking and Improve Walkability

Ultimately, individuals make the decision to walk. However, the decision to walk can be made easier by programs and policies that provide opportunities and encouragement for walking and by improvements to community walkability. Improving walkability means that communities are created or enhanced to make it safe and easy to walk and that pedestrian activity is encouraged for people of all ages and abilities.¹¹

Figure

Photo courtesy of www.pedbikeimages.org/Carl Sundstrom

This section focuses on community strategies as a way for our nation to support walking and walkability. Strategies at the community level generally have greater reach and result in longer lasting change than strategies focused on individual behavior.¹⁵² These strategies are based primarily on recommendations from the Community Preventive Services Task Force on approaches to increase physical activity in the community^153,154 and supplemented with other evidence from the scientific literature. This section discusses what communities can do to promote walking, the evidence for these strategies, and key roles that different sectors of society can play to support walking and walkability.

What Sectors Are Needed to Help Implement Community Approaches?

Many groups have a role to play to make the United States a nation with safe, easy, and desirable places to walk as part of our daily lives. By working together across sectors of society at local, state, and national levels, we can achieve this goal.^12,20 The 2010 National Physical Activity Plan provides overarching strategies, as well as strategies and tactics for various sectors of society, for increasing physical activity across the United States.²⁰ This plan includes recommendations for transportation, land use, and community design; parks, recreation, and fitness; education (schools, colleges, and universities); worksite (business, industry, and other employers); volunteer and nonprofit; health care; media; and public health sectors.²⁰ This section briefly describes the roles that each sector can play—and in some cases are already playing—to support walking and walkability.

Transportation, Land Use, and Community Design

The transportation, land use, and community design sector has a role in walking and walkability by managing federal, state, tribal, territorial, and local resources that support roadways, sidewalks, bikeways, public transit, community planning and zoning, and economic development.^170–172 This sector includes transportation engineers, transportation and community planners, architects, and other design professionals, as well as members of planning commissions and planning boards. Everyone in the United States uses roads, and most people use sidewalks and live in communities that have planned how their land will be used. Nearly everyone is affected by the decisions and plans of this sector.

Figure

Photo courtesy of the U.S. Environmental Protection Agency

Decisions and plans made by the transportation, land use, and community design sector can affect whether communities and streets are designed to support walking. A 2010 policy statement by the U.S. Department of Transportation (DOT) specifically stated that, “Every transportation agency, including DOT, has the responsibility to improve conditions and opportunities for walking and bicycling and to integrate walking and bicycling into their transportation systems.”¹⁷³ This sector can change the design of communities and streets through roadway design standards, zoning regulations, and building codes.¹⁵³ This sector can also improve the pedestrian experience through landscaping, street furniture, and building design.¹⁷⁴ It can further ensure that sidewalks and streets are safe and accessible to all pedestrians by including features—such as Americans with Disabilities Act (ADA) curb cuts that reduce barriers to walking or wheeling and audible traffic signals for people with vision impairments—in design plans.¹⁴⁷

Core principles of some of the approaches used by this sector, such as adoption of policies that promote Complete Streets^158,175,176 and smart growth designs,^177,178 help support the routine design and operation of streets and communities that are safe for all pedestrians, regardless of age, ability, or mode of transport. When linked together, interconnected facilities and design features create connected pedestrian networks that allow people of all ages and abilities to reach their destinations safely and conveniently. Key features found on Complete Streets include sidewalks, bike lanes, special bus lanes, comfortable and accessible transit stops, frequent crossing opportunities, median islands, accessible pedestrian signals, and curb extensions.¹⁷⁶ As of December 2014, a total of 30 states and the District of Columbia and 664 regional and local agencies had adopted Complete Streets policies.¹⁷⁹

The transportation, land use, and community design sector can ensure that efforts designed to promote walking also address safety issues and are accompanied by efforts to prevent injuries and fatalities. Urban design strategies that foster safe neighborhoods, streets, and outdoor spaces to encourage walking and biking and increase access to public transit can simultaneously be designed to reduce injuries and fatalities.⁹¹ This sector can help ensure that plans and policies designed to increase walking incorporate evidence-based strategies for safety, such as those outlined in a publication developed by the Center for Active Design called Active Design Supplement: Promoting Safety.⁹¹

Figure

This sector is also integral in the planning and implementation of public transit systems. Use of public transit is associated with increased levels of walking.^{129,138–145} For example, a national study reported that people who use public transit walk an additional 21 minutes a day walking to and from a transit stop or station.¹⁴⁴ Creating walkable communities around transit hubs can further encourage walking.^180,181

However, improvements to community infrastructures, such as improved green space, transportation systems, and walking paths, may result in unintended consequences or inequitable distribution of benefits. Improvements to infrastructure may increase property values and lead to gentrification, where low-income residents are unable to pay increased rents or property taxes and are displaced by people with higher incomes.^182,183 Members of the transportation, land use, and community design sector should consider potential unintended consequences and work to minimize and mitigate these negative effects when they develop and implement community design plans and policies.¹⁸⁴ This sector can also work to ensure an equitable distribution of the benefits of walkability. For example, neighborhoods with a combination of high walkability and low air pollution have been shown to be located predominately in higher-income neighborhoods.¹⁸⁵ In contrast, people living in low-income neighborhoods are disproportionally at risk of pedestrian death.¹⁸⁶ The transportation, land use, and community design sector can help address issues that contribute to these types of disparities.

Parks and Recreational and Fitness Facilities

Public parks offer people access to places to walk.^187,188 In 2013, nearly 274 million people visited national parks.¹⁸⁹ About 720 million annual visits are made to more than 7,000 state parks in the United States that offer more than 38,000 miles of trails.¹⁹⁰ In addition to national (and other federally owned recreational areas) and state parks, many cities and regions also have local parks. Nearly 40% of people in the United States live within one-half mile of a park boundary.¹⁹¹ Across the country, nearly 1,900 rail-trails (shared-use trails on converted rail lines or alongside rail lines) cover more than 21,000 miles.¹⁹²

Evidence shows that people who have more access to green environments, such as parks, tend to walk more than those with limited access.^193–196 Better access to parks, playgrounds, and recreational centers also may encourage active transportation, such as biking or walking to the location.¹⁹⁷ Emerging evidence suggests that when parks add more signs and conduct outreach activities, the physical activity of park users increases.¹⁹⁸

In 2012, more than 30,000 health clubs were being used by more than 50 million people.¹⁹⁹ Living or working close to an exercise facility is related to adoption and maintenance of supervised physical activity programs and overall physical activity.²⁰⁰ Health and fitness facilities offer group walking programs and access to places for walking. For example, they provide indoor opportunities to walk during inclement weather or for people who prefer indoor or treadmill walking. These facilities can also provide options, such as warm water pools, to make walking safer and more comfortable for people with mobility limitations or chronic conditions such as arthritis. To ensure broad access to these benefits, facilities should be designed, built, and maintained to be accessible to the entire population.

Schools

In the United States, more than 130,000 elementary, middle, and high schools reach about 55 million students and 7.3 million teachers and staff members.²⁰¹ Young people spend much of their time in school: 6–7 hours a day for about 180 days a year.²⁰²

Schools can provide opportunities for physical activity through physical education, recess, after-school activity programs (including sports and physical activity clubs), and physical activity breaks,^105,203 and walking can be incorporated into these opportunities. An Institute of Medicine report on physical activity and physical education in the school environment documented that physical education, recess, and after-school activity programs can increase physical activity among children and adolescents.¹⁰⁵ Evidence is also emerging that classroom activity breaks can increase physical activity among youth.^203–205

Schools can also encourage walking by promoting safe routes for students to walk to and from school through community-wide approaches. The Safe Routes to School program²⁰⁶ and other efforts where a group of students walk to school with one or more adults have contributed to increases in children walking to and from school.²⁰⁷ Walk-to-school programs have also helped to address the safety concerns of parents, a major challenge to children walking to school.²⁰⁸ Efforts can also be made to improve safety for those walking to school, such as building entrances and exits that do not flow directly into streets and setting up bus lanes that do not create safety hazards for children.

Opening school facilities, such as gyms, playgrounds, fields, and tracks, to the community during nonschool hours (often referred to as shared use or joint use)²⁰⁹ is a promising strategy to increase access to physical activity and recreational facilities²¹⁰ and increase physical activity levels.^211–213 Community members of all ages can use these facilities for many different physical activities, including walking, and opening these facilities to the community can also encourage walking from homes to these locations.

Colleges and Universities

In the United States, more than 7,000 colleges and universities²¹⁴ reach about 21 million students and employ nearly 4 million staff members.²⁰¹ Colleges and universities can promote a campus walking culture by creating pedestrian-friendly campuses, adopting and implementing policies that support walking, promoting walking clubs and group events, and providing classroom instruction.

Walkable campus strategies help students, faculty, and staff members adopt active living behaviors on campus.²¹⁵ Leaders of the campus community can work together on strategies to address environmental factors that influence active living and walkability challenges, such as long distances between buildings and bus stops, lack of sidewalks, and safety concerns associated with vehicle traffic. They can also work together to redesign the campus to ensure that common destinations, such as libraries and bookstores, are within walking distance of campus housing and lecture halls.

Colleges and universities can also educate and train future professionals to recognize their role in promoting walking and walkable communities for people of all ages. This training can be directed to students in health disciplines (such as health care and public health), as well as to students in other relevant fields (such as architecture, transportation, urban design, and business).

Worksites

Almost 150 million U.S. adults participate in the labor force.²¹⁶ Many adults spend a significant amount of the day at a workplace—an average of 7.6 hours on a workday in 2013.¹⁰³ Worksites can encourage physical activity and walking through a multilevel approach.²¹⁷

Worksites can offer employees physical access to opportunities and supports for physical activity, including walking. Providing access to on-site facilities (e.g., gyms, locker rooms, showers) or to employer-subsidized, off-site exercise facilities is associated with physical activity among employees.^218,219 The use of active workstations, such as treadmill desks or workstations that encourage short periods of activity, have been shown to reduce sedentary behavior^220,221 and increase walking during office hours.²²² However, access to walking opportunities by itself may not be sufficient to motivate employees to walk more; informational outreach to support these opportunities can help promote use.¹⁶¹

Worksites can also adopt policies that enhance physical activity opportunities. For example, one study found that permitting physical activity during paid work hours combined with education or free access to an on-site gym increased physical activity.²²³ A meta-analysis reported that offering worksite physical activity programs during company-paid time resulted in larger improvements in physical fitness than programs offered outside company-paid time.²²⁴ Paid activity breaks have also been associated with improved employee perceptions of productivity.²²⁵

Figure

Incorporating short periods of physical activity into the workday routine has shown modest but consistent benefits in increasing physical activity in the workplace.²²⁶ Several groups, such as the National Coalition for Promoting Physical Activity and the American Council on Exercise, have promoted policies that include brief activity breaks, flexible schedules, and walking meetings as potential strategies to increase participation in worksite physical activity.^227–229

Worksite health promotion programs can also promote physical activity and walking. These programs can conduct health risk appraisals for employees that include a physical activity assessment. When combined with feedback and education, these assessments can be effective in increasing physical activity among employees.^230,231 Studies have also shown that health promotion teams or committees that represent employees can help employers develop, implement, and sustain worksite efforts.^229,232,233 Worksite health promotion programs designed to promote walking can include individually-adapted health behavior change programs as one component.¹⁶¹

Worksite health promotion programs should include ways to support and sustain employee participation. Incentives and rewards, such as employee recognition and free water bottles, pedometers, and T-shirts, can be used to encourage employees’ interest and participation in physical activity programs.²²⁹ Social support programs can also be used at the worksite.¹⁶¹ For example, worksites can set up walking clubs or buddy systems for groups of employees to walk together during breaks or lunch.

Volunteer and Nonprofit Organizations

The United States has 2.3 million nonprofit organizations,²³⁴ including those that work to address the needs of underserved populations or people with special needs. The volunteer and nonprofit sector encompasses a vast diversity of organizations across the country that differ in size, mission, and reach. Volunteer and nonprofit groups can provide access to facilities, programs, and information to promote walking. For example, they can open their facilities and walking programs to the wider community for free or at low cost, or they can organize social support programs. Organizations with facilities can link with evidence-based programs that are tailored to particular groups, such as minority populations or people with mobility limitations (e.g., GirlTrek, Walk With Ease),^235,236 to offer free or low-cost walking programs.

Because of their reach and the trusted relationship that volunteer and nonprofit organizations have with their members, these organizations can serve as messengers to share information about the benefits of walking and walking programs and ways to improve walkability. For example, pedestrian safety groups can provide valuable information, expertise, and support for best practices that can help enhance access to safe locations for walking. Conservation and environmental groups can develop and share educational programs that teach people how to make the environment walkable and livable.

Health Care

Health care professionals include people working in medicine, nursing, chiropractic, social work, mental health, nutrition, occupational therapy, and physical therapy, as well as allied health personnel, such as community health workers. A large proportion of people have contact with a health care professional each year. In 2012, almost 80% of U.S. adults visited a health care professional sometime in the past 12 months,⁹ and 75% of all children had contact with a health professional at sometime in the past 6 months.²³⁷

Professional organizations and recommendations from the U.S. Preventive Services Task Force (USPSTF) indicate that health care professionals have a role to play in counseling their patients about physical activity. Walking is an especially good activity for health care professionals to promote because most of their patients can walk, and walking can be easily modified to a person’s abilities. Professional organizations, such as the American College of Preventive Medicine²³⁸ and the American Academy of Pediatrics,²³⁹ encourage counseling as part of routine care for patients.

Figure

The USPSTF recommends behavioral counseling for adults who are overweight or obese and who have additional cardiovascular disease risk factors,^240,241 as well as for anyone aged 6 years or older who screens positive for obesity.^242,243 Physical activity is an integral component of these moderate to highly intensive behavioral interventions. Although the USPSTF does not recommend that clinicians offer intensive behavioral counseling related to physical activity to all patients, it does recommend that clinicians selectively counsel patients on the basis of their professional judgment and patient preferences.^244–246

Health care professionals who want to counsel patients about physical activity have several challenges, including limited time; reimbursement issues; lack of practical tools; and insufficient knowledge, skills, and confidence that counseling is effective.^247–249 Additional training and education for health care professionals about the importance of physical activity and how to help patients formulate a physical activity plan may help overcome some challenges. Health care professionals can also access existing tools and guides to help them counsel their patients about physical activity.^239,250 In addition, they can review resources specifically designed to help them discuss physical activity with patients with chronic conditions or disabilities.^250–252 Finally, programs such as Exercise is Medicine recommend that health care professionals write prescriptions for physical activity and provide information on local resources and support systems.²⁵⁰ These efforts can include referring patients to certified exercise professionals to oversee their exercise program.²⁵⁰

Media

Media outlets include mass media (e.g., television, radio, outdoor advertising), small media (e.g., brochures, posters), and social media (e.g., Facebook, Twitter, Pinterest, blogs). Each month, 287 million people watch television and 204 million use a computer to access the Internet.²⁵³

The media can be effective in influencing attitudes and changing behaviors, including health behaviors.^254–257 However, evidence on the effectiveness of stand-alone mass media campaigns to increase physical activity is inconsistent.^161,258,259 According to the Community Preventive Services Task Force, insufficient evidence exists to determine the effectiveness of stand-alone mass media campaigns to increase physical activity at the population level.^161,258,259 However, media campaigns have been part of effective multicomponent interventions. Mass media education campaigns, combined with other intervention strategies, were effective in increasing physical activity among adolescents²⁶⁰ and walking among adults.^261,262

Public Health

Public health focuses on protecting the health of entire populations and population sectors in locations ranging from local neighborhoods to entire countries and regions of the world.²⁶³ Public health professionals often work in federal, state, or local governments.²⁶⁴ In their efforts to promote population health, they typically partner with other groups and organizations, such as departments of transportation, health care professionals, academic institutions, public safety agencies, local planning agencies, human service and charity organizations, education and youth development organizations, recreational and arts organizations, economic and philanthropic organizations, and environmental agencies and organizations.^265,266

Public health professionals conduct research and evaluate programs to determine what works to promote and sustain physical activity, including walking. They can summarize findings about what community approaches work to increase walking and walkability. These findings and related recommendations can be used by other sectors of society to plan and implement interventions.

In addition to identifying evidence-based strategies, public health professionals can help other sectors design and implement interventions.²⁶⁵ They can convene partners across multiple sectors to learn from each other and to develop strategic action plans that efficiently use each partner’s expertise and resources. Public health professionals at federal, tribal, state, and local levels can share best practices and tools and provide technical assistance, training, and funding.

Public health professionals also collect data about walking and walkability to measure and monitor changes over time. They can assess and monitor pedestrian behaviors and environmental features that influence pedestrian safety. These data are important in the planning and evaluation of programs to support safe walking and promote walkability.

Figure

Gaps in Surveillance, Research, and Evaluation

Existing research provides an evidence base about what works to increase walking in the United States. However, additional surveillance, research, and evaluation work is needed to maximize the success of community approaches and address disparities in walking and walkability. Lack of economic analyses is a gap across both research and evaluation. This section identifies major gaps in what is currently known.

Surveillance

Public health surveillance is the ongoing, systematic collection and use of health data to plan, implement, and evaluate public health practice.²⁶⁷ It provides data to monitor health behaviors and environmental and policy supports over time. These data can also be used to support decisions about how to allocate resources and to evaluate the effect of various programs and interventions.

Walking

Walking among adults is assessed through self-report in several surveillance systems, such as the Behavioral Risk Factor Surveillance System,⁸⁴ the National Health Interview Survey (NHIS),⁸⁷ and the National Household Travel Survey.⁸⁶ However, these systems collect data in different ways, which can make comparisons difficult. For example, the NHIS Cancer Control Supplement collects information on the number of minutes that people walk,⁸⁷ whereas the National Household Travel Survey collects information on the number of trips made by walking.²⁶⁸ Systems also vary in the type of walking assessed—whether for leisure^84,87 or for transportation.²⁶⁸

Walking data at the community level are available for selected geographic areas that are part of larger state systems and have a sufficient number of survey respondents to produce stable estimates.²⁶⁹ Improvements to existing surveillance systems are needed to establish standard and valid measures of walking that can be used across systems at national, state, regional, and local levels.

Surveillance systems that assess walking among children and adolescents mainly collect data on walking for transportation. For school-aged youth, walking for transportation is systematically monitored at national and state levels and in selected localities with populations of more than 1 million people.^86,270,271 The National Youth Physical Activity and Nutrition Survey assessed walking in a national sample of high school students in 2010,⁸⁵ but this survey has not been repeated.

The number of people who walk on public streets can be monitored through counts of pedestrians.^111,272,273 Traditionally, these numbers have been collected manually. However, continuous monitoring programs are more likely to use electronic methods, such as infrared counters and video or laser counting technology.²⁷² A continuously emerging field is the development of methods that can supplement data from these devices with information from wireless devices and cell phone networks. Although pedestrian counts may help researchers conduct surveillance of a local transportation corridor or a sample of corridors, no standard method exists to collect these counts.¹¹¹ Methods that use pedestrian counts as part of national surveillance will also require further research on the best ways to compile and analyze these data.

Walkability

A walkable community is one where it is safe and easy to walk and where pedestrian activity is encouraged.¹¹ Conducting surveillance of walkability in the United States can be challenging. No single measure exists to measure walkability because it is defined by many local features. These features, however, can be measured and monitored. Examples of local neighborhood features include attractive scenery, convenient places to walk to (such as shops and restaurants), and safety features (such as street lighting).^127,134,274 Other examples of features that can be monitored, particularly for wheelchair rolling, include the condition of routes, such as sidewalks, in terms of surface condition, slope, and other barriers.²⁷⁵

No national surveillance system routinely and comprehensively monitors local neighborhood features of a walkable community. Some indicators of walkability are compiled in current databases and available at the Census Block Group level. A Census Block Group is a cluster of blocks, which is the smallest geographical entity for which census data are tabulated.^276,277 Environmental features of a walkable community—such as residential and employment density, land use diversity, access to destinations, and distance to transit—are available at the Census Block Group level in a database available from the U.S. Environmental Protection Agency.²⁷⁸ A database available from the U.S. Department of Housing and Urban Development contains a calculated feature of walkability—neighborhood block density—and combines it with data on housing and transportation affordability at the Census Block Group level.^279,280

Questionnaires and on-the-ground audits are the main tools used to directly assess features of community walkability. However, questions about walkability have not been included as routine core components of any national surveillance system. Some features of walkable communities have been assessed on topic-specific surveys or survey supplements.^117,281 For example, the 2012 National Survey of Bicyclist and Pedestrian Attitudes and Behavior assessed the presence of sidewalks and perceptions of safety.¹¹⁷ The 2015 NHIS Cancer

Figure

Photo courtesy of www.pedbikeimages.org/Dan Burden

Control Supplement is assessing the presence of places to walk (e.g., paths, sidewalks), the presence of places to walk to (e.g., shops, public transit, houses of worship), and perceptions about neighborhood safety.²⁸¹ In addition, several validated self-report questionnaires²⁸² can assess the perceived characteristics of the environment associated with physical activity. However, the length of most of these questionnaires precludes them from being considered for existing surveillance systems, where survey time is often limited. Although questionnaires with 7 or 9 items exist,^281,283 shorter questionnaires are needed to increase the feasibility of routinely assessing key features of the environment as part of core questions in surveillance systems.

On-the-ground audits of environmental supports can be used to examine the presence (or absence) of features that support walking, such as the presence and quality of parks, recreational facilities, and sidewalks.²⁸² Although several on-the-ground audit instruments exist, consistent evidence on which aspects of the environment should be examined is lacking. These types of audits are also difficult to conduct on a wide scale and therefore may be limited as surveillance tools. Narrowing their focus may improve their feasibility for surveillance use.

As audit tools are piloted in states and cities, additional information can be collected on their feasibility as surveillance tools. For example, in 2014, a multimodal collaboration led by the Federal Highway Administration, the Federal Transit Administration, the National Highway Traffic Administration, the Federal Railroad Administration, and the Federal Motor Carrier Association was initiated to conduct at least one walk/bike road safety assessment in every state.²⁸⁴ Findings from this project can provide further information in this area. In addition, future research should examine the use of technological approaches that provide images of neighborhood walkability features. For example, techniques such as imagery-based geographic mapping may help reduce the time and cost of conducting on-the-ground audits of walkability.^285–289

To connect behavior to walkability and other measures of the built environment, location data from diverse sources (e.g., health studies, surveillance systems) need to be geographically coded (or “geocoded”). Currently, national surveys—such as the National Health and Nutrition Examination Survey, the NHIS, and the National Household Travel Survey—collect residential address data, and these data have been geocoded for analyses in restricted data centers. However, residential address data do not adequately capture where most physical activity takes place.^290,291 To better characterize environmental influences on walking and physical activity, continued data integration is needed. More data are needed to identify the places where people are active—known as “activity spaces”—and the extent to which these activity spaces influence walking.^290,291 Surveillance data can support the research needed to determine the interrelationships between activity spaces, physical activity levels, and pedestrian safety (e.g., traffic exposure, rates of collisions involving pedestrians).

Surveillance of supports for walking and walkability are especially needed at worksites and schools, where adults and children spend much of their time. No national surveillance system currently monitors walking or physical activity supports in the workplace, although worksite physical activity is a national health objective.¹⁴ The most recent estimates available are from the 2004 National Worksite Health Promotion Survey, which estimated that only 19.6% of worksites offered a physical activity program.²⁹² For schools, some data on walking supports, such as state guidance on policies related to shared use and walking to and from school, are collected.¹⁰⁶ However, more specific information about these policies and how they are implemented is needed.

The Call to Action

This section presents five goals, with related strategies to support walking and walkability in the United States. Implementation of these strategies will not only make it easier and safer for people to walk, but many of these strategies will also make it easier and safer for people of all ages and abilities to use a wheelchair, ride a bike, and be active in other ways. To achieve these goals, we will need to work together across many sectors of society, including transportation, land use, and community design; parks, recreation, and fitness; education; business and industry; volunteer and nonprofit; health care; media; and public health.²⁰ Collaborative work is needed to amplify and extend existing efforts, as well as to undertake new initiatives to support these goals. Families and individuals will also need to be involved to make the United States a walkable nation.

Figure

Goal 2. Design Communities that Make It Safe and Easy to Walk for People of All Ages and Abilities

People should be able to walk almost anywhere. Designing communities to encourage pedestrian activity will make it safer and easier for all users, including those with mobility limitations and other disabilities. Supportive design can be implemented in large and small communities in diverse geographic areas.

Strategy 2A. Design and maintain streets and sidewalks so that walking is safe and easy

Streets can be designed to provide safe and easy places that encourage walking.^157,158 They can include sidewalks; provide space for people to walk, use wheelchairs, bike, and drive; and use trees, curbs, or physical space to separate pedestrians from bicyclists and motor vehicles. Traffic safety can be enhanced by using design features that decrease vehicle speeds (e.g., speed humps, reduced speed zones, signal modifications) and increase the number of safe pedestrian crossings (e.g., medians, pedestrian crossing islands).^90,159,325 Technical guidance and specific information related to the design of walkable urban thoroughfares has been published by the Institute for Transportation Engineers.³²⁶

Figure

Making streets safer and easier for people who walk also makes them safer and easier to use for people of all ages and abilities, including those who use wheelchairs and walkers.³²⁷ In addition, sidewalks and streets can be designed to specifically address barriers for people with disabilities. Examples include using ADA curb cuts to improve accessibility for people with mobility limitations or those who use assistive devices and audible traffic signals for people with vision impairments. Communities should ensure that all sidewalks have a plan for upgrades to comply with the ADA, as required by the U.S. Department of Justice.^328,329

Regular maintenance of sidewalk quality and safety can increase their use. Sidewalks with cracks, holes, or uneven surfaces pose tripping hazards. Other hazards, such as overgrown vegetation, storm runoff, or unplowed snow, may force pedestrians into high-speed traffic. Keeping sidewalks free from hazards is an important long-term commitment for the safety of those who use them. Particular attention should be given to maintenance of sidewalks in low-income and minority communities, where some sidewalks may be more likely to be of lower quality.³³⁰ The appeal of sidewalks can also be improved through the use of street lighting and landscaping (e.g., street trees, planters).¹⁷⁴ The special needs of older pedestrians should also be considered; features such as benches and traffic islands that account for slower walking paces and reduced agility can be added.³³¹

Community planners and designers, community stakeholders, transportation professionals, and government agencies can encourage walk-friendly environments by doing the following:

• Design streets, sidewalks, and crosswalks that encourage walking for people of all ages and abilities.
• Improve traffic safety on streets and sidewalks.
• Keep existing sidewalks and other places to walk free from hazards.

Figure

Photo courtesy of www.pedbikeimages.org/Julia Diana

Strategy 2B. Design communities that support safe and easy places for people to walk

Walkable communities can be created through many community design principles and supportive policies. Community design should encourage developers to build residences, worksites, schools, parks, businesses, shopping districts, public transit systems, and health care facilities within walking distance of each other.^332,333 Community design can also ensure that streets are well-connected, blocks are not too long, and pedestrians can choose from several alternative routes.^121,127,134 Alternative routes can allow pedestrians to avoid heavily trafficked roads that are less safe to cross and are a source of exposure to air pollution. Communities can adopt policies, such as Complete Streets,^158,175,176 that support the routine design and operation of streets that are safe for all pedestrians regardless of age, ability, or mode of transport.

Another way to make walking easier is to support a well-maintained public transit system that is within easy walking distance of residences, worksites, and shopping and entertainment destinations in communities where development patterns have made public transit financially feasible.^130,160 Public transit should be safe, efficient, and easy to use for all users, including people with disabilities. Building walkable communities around transit hubs can further encourage walking.^180,181

Communities can improve safety for pedestrians through design features and traffic laws.^91,294 Reducing vehicle speeds where people walk can improve safety.³³⁴ Beyond physical design features of streets to decrease vehicle speed, states and localities can enforce existing speed limits and consider policies that reduce speed limits where many people walk.³²⁵ Policies intended to reduce other types of risky driving, such as alcohol-impaired driving,³³⁵ can also be enacted.

Communities can also support walking and other outdoor physical activities by implementing and maintaining design features that reduce opportunities for crime and violence and promote a sense of ownership and safety. For example, efforts to clean, plan, and maintain vacant lots have been associated with reductions in violence and crime.³³⁶ In addition, fewer crimes are committed on streets that are appropriately lighted and in clear view of windows.⁹¹

Community planners and designers, transportation professionals, community stakeholders, public health professionals, and government agencies can design safe, easy, and attractive places to walk by doing the following:

• Adopt community planning, land use, development, and zoning policies and plans that support walking for people of all ages and abilities.
• Locate schools, worksites, businesses, parks, recreational facilities, and other places that people regularly use within walkable distance of each other.
• Support crime and violence prevention through environmental design and maintenance.
• Reduce speed limits and enforce traffic laws in areas where walking is common.
• Support safe, efficient, and easy-to-use public transit systems and transit-oriented development.

Goal 3. Promote Programs and Policies to Support Walking Where People Live, Learn, Work, and Play

Walking is easiest when it is built into everyday activities and locations where people spend their time. Two locations that may be especially important are schools and worksites, where youth and adults spend much of their time. Other community locations and organizations—such as colleges and universities, faith-based organizations, health clubs and fitness facilities, parks, recreational centers, nonprofit organizations, community organizations, shopping malls, and senior centers—can also help promote walking through their facilities, programs, and policies.

Strategy 3A. Promote programs and policies that make it easy for students to walk before, during, and after school

Making it safe and easy for students to walk before, during, and after school can create opportunities for youth to get some, if not all, of the recommended amount of daily physical activity on school days. Schools can provide opportunities to be physically active before, during, and after school, such as walk-to-school programs, walking clubs, physical education, recess, and physical activity breaks. Teachers and program leaders can promote and ensure inclusion of all students by modifying physical education and other school programs for students who have disabilities or chronic health conditions.³³⁷

Figure

Photo courtesy of www.pedbikeimages.org/Dan Burden

Schools can increase access to safe places for students and their families to be active by establishing safe routes to after-school activities and negotiating shared use agreements with local parks and recreation departments, Boys & Girls Clubs, YMCAs, or other community organizations and locations. School wellness committees (which include teachers, parents, and community members) should be involved in school walking efforts, and school district wellness policies are important sources of support for these activities.

Strategies that increase walking in school settings have the potential to affect a significant number of adults as well. Schools are a worksite for millions of teachers, administrators, and staff members.²⁰¹ In addition, schools can increase walking among community residents through formal shared use agreements that make school gyms, playgrounds, sport fields, and tracks available after school, on weekends, and during the summer.^210,338

Schools can increase walking by doing the following:

• Implement Safe Routes to School or similar walk-to-school programs.
• Provide daily physical education for students in grades K–12 and daily recess for elementary students.
• Encourage walking opportunities for students and staff as part of regular classroom activities.
• Make gyms, fields, and tracks available before, during, and after school for students and staff and encourage their use through activities such as walking and fitness clubs and other school-related events.
• Establish formal policies or agreements, such as shared use agreements, to make school facilities available to community residents or to allow schools to use nearby community facilities, such as fields and parks.

Strategy 3B. Promote worksite programs and policies that support walking and walkability

Worksites can implement worksite health promotion programs that can improve the health of their employees and their bottom line.^339,340 As part of these efforts, worksites can provide places to walk and implement programs and policies that encourage and support walking.

Worksites with sufficient resources can provide on-site equipment and facilities for walking, such as treadmills, changing areas, and showers. However, lower-cost options—such as promoting walking meetings, walking breaks, and the use of stairs and nearby trails, paths, or walking loops—can be used by most worksites. Employers can also provide maps of nearby walking routes and information about places to walk indoors during inclement weather.

In addition, worksites can provide access to places to walk, and they can implement programs and policies that make it possible for employees to walk and be physically active.²¹⁹ Worksite policies that encourage brief activity breaks, flexible schedules, and walking meetings have been identified by several groups as potential strategies that can support employees’ efforts to be active.^227–229 Incentives, such as free activity trackers or partial subsidies for off-site gym memberships, can help employees meet and sustain their personal physical activity goals. Employers can support the use of health risk appraisals that include feedback and education, individually-adapted health behavior change programs, or social support programs.^217,230,231

Employers can also incorporate approaches that integrate occupational safety and health protection with health promotion programs (e.g., Total Worker Health³⁴¹). These approaches could promote physical activity as a way to help prevent worker injury and illness and advance health and well-being. Worksites should also ensure that their programs consider employees with functional limitations and disabilities and offer incentives that accommodate employees regardless of abilities, work shifts, or location.²²⁹

Finally, walkability and access to public transit are important factors for businesses to consider when selecting new worksite locations. Economic development professionals can help employers look for locations in walkable communities. In established locations, senior business leaders can look for ways to participate in local planning discussions that seek to make the surrounding community more walkable. Employers can also be influential and effective advocates for more walkable communities, which benefit their employees and the entire community.

Employers can increase walking by doing the following:

• Provide access to facilities, locations, and programs to support walking.
• Use policies and incentives to encourage walking, such as flextime, paid activity breaks, or discounts for off-site exercise facilities.
• Establish walking clubs or competitions that encourage and motivate employees to meet individual or team goals.
• Consider walkability and access to public transit when selecting new worksite locations.
• Engage in community planning efforts to make the communities around worksites more walkable.

Strategy 3C. Promote community programs and policies that make it safe and easy for residents to walk

In addition to schools and worksites, other community locations and organizations can also play a role in promoting and supporting walking. These include colleges and universities, faith-based organizations, health clubs and fitness facilities, recreational facilities, parks, shopping malls, nonprofit organizations, and community organizations, such as YMCAs, Boys & Girls Clubs, and senior centers. To foster the use of these locations by people with disabilities, communities should ensure that locations meet ADA design standards¹¹⁸ and work to enhance and maintain locations that are safe and accessible for all users. Ensuring safe routes to locations can further improve accessibility and encourage walking to locations.¹⁹⁷

Locations and organizations can provide access to safe places—such as walking trails, indoor facilities, parks, and playgrounds—where walking can be separated from busy streets. For example, colleges and universities can create pedestrian streets and walkways that provide all users a safe place to walk. For older adults, readily available locations for walking, such as shopping malls and walking paths in retirement communities, provide safe opportunities for walking.³³¹ Malls can be attractive places for walking, especially for middle-aged and older adults, because features such as safe and climate-controlled environments, level surfaces, and well-lit restrooms can help overcome some barriers to walking.³⁰⁹

Organizations can also provide access to walking programs that accommodate a range of interests and abilities and help users overcome barriers to participation. Removing barriers may be particularly effective for less active groups. Organizations can offer programs that are specifically designed for people who may be concerned about how to safely be physically active, such as people with arthritis.^56,149,236 For people with mental health conditions, peer-to-peer support programs for whole health wellness can include such activities as walking groups and sharing of information on how to find community walking spaces that are free or low cost and accessible.³⁴² People for whom cost may be a barrier to participation also need affordable options for physical activity.³⁴³ In addition, organizations that integrate informational outreach or social support into their walking programs may be able to increase participation.

Figure

Community locations and organizations can increase walking by doing the following:

• Provide safe and convenient access for all users to community locations that support walking, such as walking trails, parks, recreational facilities, and college campuses.
• Offer walking programs that address barriers, including physical limitations and safety concerns.
• Promote the availability of safe, convenient, and well-designed community locations and programs that promote walking.
• Offer evidence-based walking programs that are free or low cost.
• Set up walking groups, buddy systems, and other forms of social support for walking that provide multiple opportunities to walk each week.

Goal 4. Provide Information to Encourage Walking and Improve Walkability

Easy-to-understand and relevant information about how walking can provide substantial health benefits can motivate people to walk. To complement health information, local groups can help increase awareness about safe and accessible places to walk in the community. This information is especially effective when it is tailored to individual needs and used in conjunction with community designs, programs, and policies that promote walking. Another way to promote walking is to train current and future professionals from a variety of disciplines about the importance of walking and how to promote it within their profession.

Strategy 4A. Educate people about the benefits of safe walking and places to walk

Education about the importance and benefits of physical activity and walking should be shared by a variety of trusted messengers. Information should be easy to understand and shared through a variety of channels. Special efforts should be made to reach people who are the least physically active, such as girls, older adults, adults with lower levels of education, and people with mobility limitations and other disabilities.^9,147

Health care professionals can assess patients’ physical activity levels and educate patients across their lifespan about the importance of physical activity. They can also help their patients understand that walking is a good way to get the physical activity they need for health. Tracking physical activity as a key piece of health information can help make discussions about physical activity a regular part of a health care visit.^344,345 Clinical programs, such as the Exercise as a Vital Sign initiative, can prompt health care professionals to collect and review patients’ physical activity levels to facilitate counseling and referral.³⁴⁶

Figure

Counseling about walking may be especially important for adults who are at higher risk of chronic disease, such as those who are overweight or obese and who have additional risk factors for cardiovascular disease.^240,241 Many tools and resources are available to help facilitate physical activity counseling, such as the American Academy of Pediatrics’ Bright Futures guidelines and the Exercise is Medicine Healthcare Providers’ Action Guide.^239,250 Resources are also available to help health care professionals discuss physical activity with patients with disabilities.^251,252

Education can take place in a variety of locations, depending on where people spend their time. Physical education and health education classes in schools can provide students in prekindergarten through 12th grade with opportunities to acquire the knowledge, attitudes, and skills necessary to integrate physical activities, including walking, into their daily lives.^347,348 Worksites are a good place to reach employed adults. Educational materials and seminars can help employees learn about the benefits of walking and strategies for incorporating walking into their daily lives. Colleges and universities can promote walking as part of an active lifestyle for students, faculty, and staff. Senior centers, volunteer and nonprofit organizations, and health care organizations can ensure that older adults learn about the benefits of walking for their health, vitality, and independence. Many locations can provide easy-to-read signs and maps to encourage people to walk. Pedestrian safety organizations can provide valuable information, expertise, and education about best practices for pedestrians.^294,349

Teachers and professors, health care professionals, public health professionals, employers, volunteer and nonprofit organizations, community organizations, and transportation departments can help educate people about the benefits of walking by doing the following:

• Establish physical activity as a key health indicator tracked by health care professionals.
• Have health care professionals offer physical activity counseling to their patients, especially those at high risk.
• Integrate walking and other types of physical activity into school, college, and university curricula.
• Provide signs and maps to help people find safe places to walk and provide information on accessibility for people with mobility or other limitations.
• Educate pedestrians about how to walk safely and the risks of alcohol-impaired and distracted walking.
• Provide employees with tailored messages about walking in and around the worksite.

Strategy 4B. Develop effective and consistent messages and engage the media to promote walking and walkability

One way to reach a large number of people with information and motivational messages about walking is through the media. Media outlets can shape public opinion and support efforts to improve community walkability by spotlighting problems and solutions in compelling, credible ways. In 2012, 7 out of every 10 people (71%) in the United States said they watched television news, read a print newspaper, or listened to radio news on the previous day.³⁵⁰ In addition to these mass media channels, social marketing interventions and population-specific media can reach distinct groups.³⁵¹

To be most effective in increasing knowledge and awareness, media campaigns that promote walking and walkability should be used as part of broader community-wide campaigns.¹⁶³ These campaigns can include individually-adapted health behavior change programs and activities, social support and self-help groups, and policy or environmental changes.¹⁶³ Because groups within the general population receive information and are influenced in various ways, an effective media strategy will need to determine which messages resonate best with specific groups in the population and then segment, focus, and tailor appropriate messages for each of these groups.

Important partners for messaging and media efforts include traditional media professionals, as well as those who use social media channels. These partners can do the following:

• Provide public education and awareness campaigns to promote walking and walkability and link these campaigns with other activities meant to increase walking.
• Tailor campaign messages and activities to resonate with specific audiences.
• Use relevant communication channels (mainstream and social media and emerging technologies, such as walking apps and video games) to market walking and walkability.

Strategy 4C. Educate relevant professionals on how to promote walking and walkability through their profession

Health care professionals, teachers, community planners, and transportation professionals can help improve walking and walkability when they have the knowledge and understanding about how to promote walking and walkability. Health care professionals should receive training to help them provide physical activity counseling. Schools should offer professional development training to teachers and administrators on ways to incorporate physical activity into regular classroom activities and throughout the school day.^337,352,353

Colleges and universities are in an ideal position to educate and train future professionals to recognize their role in promoting walking and walkable communities to benefit people of all ages and abilities. This training can be directed to students in health disciplines, such as health care and public health, as well as to students in fields such as architecture, transportation, urban design, and business. In addition, physical activity, public health, and urban and regional planning programs can provide opportunities for students to be introduced to healthy community design principles during their training and to learn how to best work together to create and maintain walkable communities.

Figure

Interdisciplinary training through continuing education is also needed for current community planners, economic development professionals, and public health practitioners. Urban and regional planners will benefit if they are able to analyze and use physical activity and health data.^322,323 Public health professionals need to understand the intricacies of the built environment and how to best use data resources across different disciplines, as well as how to work with city planners and transportation engineers.^354,355

Public health professionals, health care professionals, employers, community planners, school districts, teachers, and academic institutions can support the training of professionals by doing the following:

• Include information on physical activity and behavioral counseling in the training, continuing education, and accreditation process for all health care professionals.
• Provide training to administrators and classroom teachers on ways to incorporate walking throughout the school day.
• Integrate walking and walkability as part of the higher education curricula across majors to promote interdisciplinary training.
• Offer continuing education opportunities that promote walking and walkability for relevant professionals.

Goal 5. Fill Surveillance, Research, and Evaluation Gaps Related to Walking and Walkability

To increase walking and support walkable communities, decision makers need information to help them plan, implement, and evaluate interventions. Data can help decision makers learn who is walking, where they are walking, and for what purposes; what walking supports already exist in the community and what supports are needed; what interventions can be used to increase walking; how well these interventions work once implemented; and what influence these interventions have on pedestrian injuries. Data can also be used to determine the costs and cost benefits of interventions.

Strategy 5A. Improve the quality and consistency of surveillance data collected about walking and walkability

To help with planning and evaluation, decision makers at local, state, and national levels need easy access to data on walking and walkability. Measures of walking and walkability should be valid and reliable across different data systems, settings, and research studies. Systematically collecting data on the characteristics of people who walk and those who do not walk, the places where people walk and why, and the reasons why people do not walk will help decision makers identify high-need areas for interventions and assess how current interventions are working.

In addition to better data on pedestrian activity and volume, many communities also need better data on the circumstances of vehicle crashes involving pedestrians. They also need better guidance on best practices for implementing pedestrian counting programs, and projects such as the Federal Highway Administration’s Bicycle-Pedestrian Count Technology Pilot Program are working to address these needs.²⁸⁴

Conducting surveillance of community walkability can be challenging. Although data resources are available for assessing some features of walkability (e.g., distance to transit, block density, land use diversity),^278,279 no current surveillance system routinely and comprehensively monitors local neighborhood features of a walkable community. Additional research is needed to develop brief survey and on-the-ground audit tools or technological approaches that capture the most relevant aspects of walkability to measure and monitor. Surveillance of supports for walking and walkability may be especially important in settings where adults and youth spend the majority of their time, such as worksites and schools.

Partners in transportation, community design and planning, physical activity, public health, information technology, engineering, business, education, and academic research can work together to do the following:

• Establish standard and valid measures of walking and expand their use in health, transportation, and other relevant surveillance systems at national, state, and local levels.
• Develop feasible surveillance tools and methods to measure supports for walking in various settings, such as the community, worksites, and schools.
• Collect data on pedestrian exposure and pedestrian injury through relevant national, state, and local surveillance systems.
• Add measures of walkability to national, state, and local surveillance systems.
• Make user-friendly data easily available to decision makers.

Strategy 5B. Address research gaps to promote walking and walkability

Much is known about the benefits of walking, but less is known about the types of community approaches that help people walk more. More studies are needed to identify the individual elements of broadly defined multicomponent interventions that are most effective in improving walking or walkability. Studies are needed to determine what motivational and communication strategies best help people initiate and maintain walking. In addition, studies are needed to examine the relative effectiveness and cost-effectiveness of different types of walking interventions, whether these effects vary by population or setting characteristics, and the costs of implementing interventions.

Figure

Studies are needed to explore how aspects of the built environment interact with community interventions to improve walking or walkability. Studies are also needed to examine the relationship of increased walking or improved walkability with the risk of pedestrian injury. Researchers can take advantage of data from natural experiments to answer some of these questions.¹⁶³ In addition, data that link environmental and policy supports with walking behavior are needed to guide best practices for walkable communities.

Partners in transportation, community design and planning, public health, information technology, engineering, and academic research can work together to do the following:

• Develop a collaborative research agenda with partners across sectors.
• Determine what specific aspects of community approaches are most important for improving walking and walkability.
• Identify which walking interventions work best in different types of settings and communities, especially those in which people have low levels of physical activity.
• Determine the relationship between increased walking and pedestrian injury risk and how other factors influence this relationship.
• Determine the costs and cost benefits of walking interventions for individuals and communities.
• Further define the links between environmental and policy supports and walking.

Strategy 5C. Evaluate community interventions to promote walking and walkability

Communities across the country are implementing a variety of interventions that are intended to promote walking, but many of these interventions are not being adequately evaluated. During program planning and implementation, evaluation findings can help decision makers identify and correct problems in a continuous improvement cycle. Ultimately, outcome evaluation results can determine whether the intervention increased walking and whether it was cost-effective.

Evaluation results are often needed to maintain funding and justify the continued existence of an intervention. When evaluation results are shared broadly, others implementing similar interventions can incorporate lessons learned into their own work. Results can be shared through informal networks, written reports, or tool kits that outline best practices for implementing an intervention.

Health and economic assessment tools can help when planning and evaluating an intervention. During the planning phase, health impact assessments can be used to estimate the potential health outcomes of an intervention before it is implemented.^356,357 Economic assessment tools, such as the Health Economic Assessment Tool³⁵⁸ and the Integrated Transport and Health Impact Modelling Tool,³⁵⁹ can help assess the economic effects of policies and interventions and model the future effects of planned interventions.

Partners in transportation, community design and planning, public health, information technology, engineering, education, business, and academic research can work together to do the following:

• Include plans and resources for evaluation in the intervention planning process.
• Use real-time evaluation results to improve interventions and their implementation.
• Include standard measures for walking, walkability, and costs in evaluations to improve the comparability of results.
• Develop, improve, and use tools, such as audit tools, health impact assessments, and economic assessments, to enhance planning and evaluation processes.
• Create a clearinghouse or similar mechanism to broadly share evaluation results, best practices, and other tools developed as a result of evaluations.

Conclusion

Physical activity can help prevent and reduce the effects of serious, common, and costly chronic diseases, and it has many additional health benefits.⁷ The 2008 Physical Activity Guidelines for Americans outlines the amount of physical activity needed to achieve substantial health benefits.⁶ However, many people across the United States do not get enough physical activity to realize these benefits. Only one-half of all U.S. adults and one-quarter of all high school students meet the guideline for aerobic physical activity.^9,10

Promoting walking offers a powerful public health strategy to increase physical activity. With this report, the U.S. Surgeon General calls on Americans to be physically active and for the nation to better support walking and walkability for people of all ages and abilities. To improve walking and walkability, communities need to be designed to make walking safer and easier; programs and policies need to be available to support and encourage walking; and individuals and families need to support each other to become and stay active.

Implementing this vision will not be a small task. Many partners are already involved, but more engagement is needed to increase the reach, breadth, and impact of these efforts. The dedication, ingenuity, skill, and concerted efforts of many partners across many different sectors will be required. Walking is an easy and inexpensive way to improve the health and well-being of all Americans. Now is the time to step it up and make walking a national priority.

Figure

References

1.

Ward BW, Schiller JS, Goodman RA. Multiple chronic conditions among U.S. adults: a 2012 update. Prev Chronic Dis. 2014;11:130389. [PMC free article: PMC3992293] [PubMed: 24742395]

2.

U.S. Burden of Disease Collaborators. The state of U.S. health, 1990-2010: burden of diseases, injuries, and risk factors. JAMA. 2013;310(6): 591–608. [PMC free article: PMC5436627] [PubMed: 23842577]

3.

Gerteis J, Izrael D, Deitz D, et al. Multiple Chronic Conditions Chartbook. AHRQ Publications No, Q14-0038. Rockville, MD: Agency for Healthcare Research and Quality; 2014.

4.

U.S. Department of Agriculture; U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th ed. Washington, DC: U.S. Dept of Agriculture and U.S. Dept of Health and Human Services; 2010. [PMC free article: PMC3090168] [PubMed: 22332062]

5.

U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress. A Report of the Surgeon General. Atlanta, GA: Office of the Surgeon General, U.S. Dept of Health and Human Services; 2014. Printed with corrections January 2014. [PubMed: 24455788]

6.

U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans. Washington, DC: U.S. Dept of Health and Human Services; 2008.

7.

Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advisory Committee Report, 2008. Washington, DC: U.S. Dept of Health and Human Services; 2008.

8.

Centers for Disease Control and Prevention. Physical Activity and Health: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 1996.

9.

Blackwell DL, Lucas JW, Clarke TC. Summary health statistics for U.S. adults: National Health Interview Survey, 2012. Vital Health Stat. 2014;10(260). [PubMed: 24819891]

10.

Centers for Disease Control and Prevention. Youth risk behavior surveillance — United States, 2013. MMWR Morbid Mortal Wkly Rep. 2014; 63(suppl 4):1–168.

11.

Federal Highway Administration. A Resident’s Guide for Creating Safe and Walkable Communities. Washington, DC: Federal Highway Administration, U.S. Dept of Transportation; 2008. FHWA-SA-07-016.

12.

National Prevention Council. National Prevention Strategy. Washington, DC: Office of the Surgeon General, U.S. Dept of Health and Human Services; 2011.

13.

White House Task Force on Childhood Obesity. Solving the Problem of Childhood Obesity Within a Generation. Washington, DC: White House Task Force on Childhood Obesity; 2010. [PubMed: 20942695]

14.

Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services. Healthy People 2020 website. http://www​.healthypeople.gov/. Accessed April 14, 2015.

15.

Let’s Move! America’s Move to Raise a Healthier Generation of Kids website. http://www​.letsmove.gov/. Accessed April 15, 2015.

16.

Herman SW. Go4life: http://go4life​.nia.nih.gov. J Consum Health Internet. 2014;3:271–278. doi: 10.1080/15398285.2014.932184. [CrossRef]

17.

U.S. Department of Transportation. Safer People, Safer Streets: Pedestrian and Bicycle Safety Initiative website. http://www​.dot.gov/policy-initiatives​/ped-bike-safety​/safer-people-safer-streets-pedestrian-and-bicycle-safety. Accessed March 20, 2015.

18.

Council of Environment Quality. America’s Great Outdoors Initiative website. http://www​.whitehouse​.gov/administration​/eop/ceq/initiatives/ago. Accessed April 15, 2015.

19.

U.S. Department of Housing and Urban Development; U.S. Department of Transportation; U.S. Environmental Protection Agency. Partnership for Sustainable Communities website. Livability Principles. http://www​.sustainablecommunities​.gov/mission​/livability-principles. Accessed April 15, 2015.

20.

National Physical Activity Plan. http://www​.physicalactivityplan​.org/NationalPhysicalActivityPlan.pdf. Accessed March 20, 2015.

21.

Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation. 2014;129(3):e28–e292. [PMC free article: PMC5408159] [PubMed: 24352519]

22.

Centers for Disease Control and Prevention. Prevalence of stroke — United States, 2006-2010. MMWR Morbid Mortal Wkly Rep. 2012;61(20):379–382. [PubMed: 22622094]

23.

Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and its Burden in the United States, 2014. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2014.

24.

CDC WONDER Database. United States Cancer Statistics: 1999-2011 Incidence Request. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2014. http://wonder​.cdc.gov/cancer-v2011.html. Accessed April 7, 2015.

25.

SEER Cancer Statistics Review 1975-2011. Bethesda, MD: Surveillance, Epidemiology, and End Results (SEER) Program, National Cancer Institute; 2014. http://seer​.cancer.gov/csr/1975_2011. Based on November 2013 SEER data submission. Accessed May 1, 2015.

26.

Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 2014;311(8):806–814. [PMC free article: PMC4770258] [PubMed: 24570244]

27.

Franks PW, Hanson RL, Knowler WC, et al. Childhood predictors of young-onset type 2 diabetes. Diabetes. 2007;56(12):2964–2972. [PMC free article: PMC6419722] [PubMed: 17720898]

28.

May AL, Kuklina EV, Yoon PW. Prevalence of cardiovascular disease risk factors among US adolescents, 1999−2008. Pediatrics. 2012;129(6):1035–1041. [PubMed: 22614778]

29.

Freedman DS, Dietz WH, Srinivasan SR, Berenson GS. The relation of overweight to cardiovascular risk factors among children and adolescents: The Bogalusa Heart Study. Pediatrics. 1999;103(6):1175–1182. [PubMed: 10353925]

30.

Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T. Do obese children become obese adults? A review of the literature. Prev Med. 1993;22(2):167–177. [PubMed: 8483856]

31.

Biro FM, Wien M. Childhood obesity and adult morbidities. Am J Clin Nutr. 2010;91(5):1499S–1505S. [PMC free article: PMC2854915] [PubMed: 20335542]

32.

Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med. 1997;337(13):869–873. [PubMed: 9302300]

33.

National Heart, Lung, and Blood Institute. Managing Overweight and Obesity in Adults: Systematic Evidence Review from the Obesity Expert Panel, 2013. Bethesda, MD: National Institutes of Health, U.S. Dept of Health and Human Services; 2013.

34.

Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: Mental Health Findings. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013.

35.

National Institute of Mental Health. Depression website. http://www​.nimh.nih.gov​/health/topics/depression/index.shtml. Accessed October 29, 2014.

36.

Centers for Disease Control and Prevention. Diabetes — United States, 2006 and 2010. MMWR Morbid Mortal Wkly Rep. 2013;62(suppl 3): 99–104.

37.

Centers for Disease Control and Prevention. CDC health disparities and inequalities report — United States, 2013. MMWR Morbid Mortal Wkly Rep. 2013;62(suppl 3):1–2.

38.

Centers for Disease Control and Prevention. Prevalence of hypertension and controlled hypertension — United States, 2007-2010. MMWR Morbid Mortal Wkly Rep. 2013;62(suppl 3):144–148.

39.

Cohen S. Statistical brief #455: The concentration of health care expenditures and related expenses for costly medical conditions, 2012. Agency for Healthcare Research and Quality. http://meps​.ahrq.gov​/mepsweb/data_files/publications​/st455/stat455.shtml. Accessed April 7, 2015. [PMC free article: PMC470837] [PubMed: 29281226]

40.

Lee IM, Shiroma EJ, Lobelo F, et al. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012;380(9838):219–229. [PMC free article: PMC3645500] [PubMed: 22818936]

41.

Yang Q, Cogswell ME, Flanders WD, et al. Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults. JAMA. 2012;307(12):1273–1283. [PMC free article: PMC9004324] [PubMed: 22427615]

42.

Fransen M, McConnell S, Hernandez-Molina G, Reichenbach S. Exercise for osteoarthritis of the hip. Cochrane Database Syst Rev. 2014;(4):CD007912. [PubMed: 24756895]

43.

Cooney GM, Dwan K, Greig CA, et al. Exercise for depression. Cochrane Database Syst Rev. 2013;(9):CD004366. [PMC free article: PMC9721454] [PubMed: 24026850]

44.

Carek PJ, Laibstain SE, Carek SM. Exercise for the treatment of depression and anxiety. Int J Psychiatry Med. 2011;41(1):15–28. [PubMed: 21495519]

45.

Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2015;(1):CD004376. [PMC free article: PMC10094004] [PubMed: 25569281]

46.

Heran BS, Chen JM, Ebrahim S, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2011;(7):CD001800. [PMC free article: PMC4229995] [PubMed: 21735386]

47.

American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl 1):S14–S80. [PubMed: 24357209]

48.

Whitworth JA; World Health Organization, International Society of Hypertension Writing Group. 2003 World Health Organization (WHO)/International Society of Hypertension (ISH) statement on management of hypertension. J Hypertens. Vol 212003:1983–1992. [PubMed: 14597836]

49.

Hagberg JM, Park JJ, Brown MD. The role of exercise training in the treatment of hypertension: an update. Sports Med. 2000;30(3):193–206. [PubMed: 10999423]

50.

Colberg SR, Sigal RJ, Fernhall B, et al. Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statement executive summary. Diabetes Care. 2010;33(12):2692–2696. [PMC free article: PMC2992214] [PubMed: 21115771]

51.

Thompson PD, Buchner D, Piña IL, et al. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity). Circulation. 2003;107(24):3109–3116. [PubMed: 12821592]

52.

Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(25 suppl 2):S76–S99. [PubMed: 24222015]

53.

Cosman F, de Beur SJ, LeBoff MS, et al. Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int. 2014;25(10):2359–2381. [PMC free article: PMC4176573] [PubMed: 25182228]

54.

Rock CL, Doyle C, Demark-Wahnefried W, et al. Nutrition and physical activity guidelines for cancer survivors. CA Cancer J Clin. 2012;62(4): 243–274. [PubMed: 22539238]

55.

Barbour KE, Helmick CG, Theis KA, et al. Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation — United States, 2010-2012. MMWR Morbid Mortal Wkly Rep. 2013;62(14):869–873.

56.

Centers for Disease Control and Prevention. Physical Activity for Arthritis Fact Sheet website. http://www​.cdc.gov/arthritis​/pa_factsheet.htm. Accessed January 15, 2015.

57.

Bize R, Johnson JA, Plotnikoff RC. Physical activity level and health-related quality of life in the general adult population: a systematic review. Prev Med. 2007;45(6):401–415. [PubMed: 17707498]

58.

Brown DR, Carroll DD, Workman LM, Carlson SA, Brown DW. Physical activity and health-related quality of life: U.S. adults with and without limitations. Qual Life Res. 2014;23(10):2673–2680. [PMC free article: PMC4857196] [PubMed: 24952110]

59.

Penedo FJ, Dahn JR. Exercise and well-being: a review of mental and physical health benefits associated with physical activity. Curr Opin Psychiatry. 2005;18(2):189–193. [PubMed: 16639173]

60.

Windle G, Hughes D, Linck P, Russell I, Woods B. Is exercise effective in promoting mental well-being in older age? A systematic review. Aging Ment Health. 2010;14(6):652–669. [PubMed: 20686977]

61.

Steinmo S, Hagger-Johnson G, Shahab L. Bidirectional association between mental health and physical activity in older adults: Whitehall II prospective cohort study. Prev Med. 2014;66:74–79. [PubMed: 24945691]

62.

Larun L, Nordheim LV, Ekeland E, Hagen KB, Heian F. Exercise in prevention and treatment of anxiety and depression among children and young people. Cochrane Database Syst Rev. 2006;(3):CD004691. [PubMed: 16856055]

63.

Biddle SJ, Asare M. Physical activity and mental health in children and adolescents: a review of reviews. Br J Sports Med. 2011;45(11):886–895. [PubMed: 21807669]

64.

Brown HE, Pearson N, Braithwaite RE, Brown WJ, Biddle SJH. Physical activity interventions and depression in children and adolescents. Sports Med. 2013;43(3):195–206. [PubMed: 23329611]

65.

Galvão DA, Newton RU. Review of exercise intervention studies in cancer patients. J Clin Oncol. 2005;23(4):899–909. [PubMed: 15681536]

66.

Schmitz KH, Courneya KS, Matthews C, et al. American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc. 2010;42(7):1409–1426. [PubMed: 20559064]

67.

Rasberry CN, Lee SM, Robin L, et al. The association between school-based physical activity, including physical education, and academic performance: a systematic review of the literature. Prev Med. 2011;52:S10–S20. [PubMed: 21291905]

68.

Centers for Disease Control and Prevention. The Association Between School Based Physical Activity, Including Physical Education, and Academic Performance. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2010.

69.

Heikkinen R-L. The Role of Physical Activity in Healthy Ageing. Geneva, Switzerland: Ageing and Health Programme, World Health Organization; 1998.

70.

Cress ME, Buchner DM, Prohaska T, et al. Physical activity programs and behavior counseling in older adult populations. Med Sci Sports Exerc. 2004;36(11):1997–2003. [PubMed: 15514518]

71.

National Institute on Aging. Exercise and Physical Activity: Your Everyday Guide from the National Institute of Aging. Gaithersburg, MD: National Institute on Aging, U.S. Dept of Health and Human Services; 2009. Publication No. 09-4258.

72.

National Blueprint: increasing physical activity among adults age 50 and older. J Aging Phys Activ. 2001;9(suppl):1–28.

73.

Smith JC, Nielson KA, Woodard JL, Seidenberg M, Rao SM. Physical activity and brain function in older adults at increased risk for Alzheimer’s disease. Brain Sci. 2013;3(1):54–83. [PMC free article: PMC4061823] [PubMed: 24961307]

74.

Sofi F, Valecchi D, Bacci D, et al. Physical activity and risk of cognitive decline: a meta-analysis of prospective studies. J Intern Med. 2011;269(1):107–117. [PubMed: 20831630]

75.

Blazer DG, Yaffe K, Liverman CT, eds. Cognitive Aging: Progress in Understanding and Opportunities for Action. Washington, DC: The National Academies Press; 2015. [PubMed: 25879131]

76.

Carlson SA, Fulton JE, Pratt M, Yang Z, Adams EK. Inadequate physical activity and health care expenditures in the United States. Prog Cardiovasc Dis. 2015;57:315–323. [PMC free article: PMC4604440] [PubMed: 25559060]

77.

Colditz GA. Economic costs of obesity and inactivity. Med Sci Sports Exerc. 1999;31(suppl 11):S663–S667. [PubMed: 10593542]

78.

Pratt M, Macera CA, Wang G. Higher direct medical costs associated with physical inactivity. Phys Sportsmed. 2000;28(10):63–70. [PubMed: 20086598]

79.

Pronk NP, Goodman MJ, O’Connor PJ, Martinson BC. Relationship between modifiable health risks and short-term health care charges. JAMA. 1999;282(23):2235–2239. [PubMed: 10605975]

80.

U.S. Department of Health and Human Services. HP2020 Objective Data Search website. Physical Activity. http://www​.healthypeople​.gov/2020/data-search​/Search-the-Data?f​%5B%5D=field_topic_area​%3A3504&pop​=&ci=&se=. Accessed March 20, 2015.

81.

Lee IM, Buchner DM. The importance of walking to public health. Med Sci Sports Exerc. 2008;40(suppl 7):S512–S518. [PubMed: 18562968]

82.

Morris JN, Hardman AE. Walking to health. Sports Med. 1997;23(5):306–332. [PubMed: 9181668]

83.

Martin-Diener E, Brugger O, Martin B. Physical Activity Promotion and Injury Prevention: Relationship in Sports and Other Forms of Physical Activity. Berne, Switzerland: bfu - Swiss Council for Accident Prevention; 2010. bfu-report no. 64.

84.

Watson KB, Frederick GM, Harris CD, Carlson SA, Fulton JE. U.S. adults’ participation in specific activities, Behavioral Risk Factor Surveillance System—2011. J Phys Act Health. 2015;12(suppl 1):S3–S10. [PMC free article: PMC4589138] [PubMed: 25157914]

85.

Brener ND, Eaton DK, Kann LK, et al. Behaviors related to physical activity and nutrition among U.S. high school students. J Adolesc Health. 2013;53(4):539–546. [PMC free article: PMC4486334] [PubMed: 23796969]

86.

U.S. Department of Transportation, Federal Highway Administration. National Household Travel Survey website. Online Analysis Tools. http://nhts​.ornl.gov/tools.shtml. Accessed December 5, 2014.

87.

Centers for Disease Control and Prevention. Vital signs: walking among adults — United States, 2005 and 2010. MMWR Morbid Mortal Wkly Rep. 2012;61(31):595–601. [PubMed: 22874838]

88.

Paul P, Carlson SA, Carroll DD, Berrigan D, Fulton JE. Walking for transportation and leisure among U.S. Adults – National Health Interview Survey 2010. J Phys Act Health. 2015;12(suppl 1):S62–S69. [PMC free article: PMC4582654] [PubMed: 25133651]

89.

Karsch HM, Hedlund JH, Tison J, Leaf WA. Review of Studies on Pedestrian and Bicyclist Safety, 1991-2007. Washington, DC: National Highway Traffic Safety Administration; 2012. Report No. DOT HS 811 614.

90.

Pollack KM, Bailey MM, Gielen AC, et al. Building safety into active living initiatives. Prev Med. 2014;69(suppl 1):S102–S105. [PMC free article: PMC6553947] [PubMed: 25117526]

91.

Johns Hopkins Center for Injury Research and Policy, New York City Department of Health and Mental Hygiene, Society for Public Health Education. Active Design Supplement: Promoting Safety. Version 2. 2013.

92.

Dimaggio C, Li G. Effectiveness of a safe routes to school program in preventing school-aged pedestrian injury. Pediatrics. 2013;131(2):290–296. [PMC free article: PMC3557410] [PubMed: 23319533]

93.

Watson M, Dannenberg AL. Investment in safe routes to school projects: public health benefits for the larger community. Prev Chronic Dis. 2008;5(3):A90. [PMC free article: PMC2483559] [PubMed: 18558040]

94.

Leyden KM. Social capital and the built environment: the importance of walkable neighborhoods. Am J Public Health. 2003;93(9):1546–1551. [PMC free article: PMC1448008] [PubMed: 12948978]

95.

Frank L, Engelke P. Multiple impacts of the built environment on public health: walkable places and the exposure to air pollution. Int Reg Sci Rev. 2005;28(2):193–216.

96.

Federal Highway Administration. Nonmotorized Transportation Pilot Program: Continued Progress in Developing Walking and Bicycling Networks. Washington, DC: Federal Highway Administration, U.S. Dept of Transportation; 2014.

97.

Mumford KG, Contant CK, Weissman J, Wolf J, Glanz K. Changes in physical activity and travel behaviors in residents of a mixed-use development. Am J Prev Med. 2011;41(5):504–507. [PubMed: 22011422]

98.

U.S. Environmental Protection Agency. Smart Growth and Economic Success: Benefits for Real Estate Developers, Investors, Businesses and Local Governments. Washington, DC: U.S. Environmental Protection Agency; 2012.

99.

U.S. Environmental Protection Agency. Smart Growth and Economic Success: Strategies for Local Governments. Washington, DC: U.S. Environmental Protection Agency; 2014.

100.

Smart Growth America. National Complete Streets Coalition. Safer Streets, Stronger Economies: Complete Streets Project Outcomes from Across the Country. Washington, DC: Smart Growth America; 2015.

101.

Lee C, Ory MG, Yoon J, Forjuoh SN. Neighborhood walking among overweight and obese adults: age variations in barriers and motivators. J Community Health. 2013;38(1):12–22. [PubMed: 22811072]

102.

Brownson RC, Baker EA, Housemann RA, Brennan LK, Bacak SJ. Environmental and policy determinants of physical activity in the United States. Am J Public Health. 2001;91(12):1995–2003. [PMC free article: PMC1446921] [PubMed: 11726382]

103.

American Time Use Survey—2013 Results [news release]. Washington, DC: Bureau of Labor Statistics, U.S. Dept of Labor; June 18, 2014. http://www​.bls.gov/news​.release/pdf/atus.pdf. Accessed April 8, 2015.

104.

Church TS, Thomas DM, Tudor-Locke C, et al. Trends over 5 decades in U.S. occupation-related physical activity and their associations with obesity. PLoS One. 2011;6(5):e19657. [PMC free article: PMC3102055] [PubMed: 21647427]

105.

Institute of Medicine. Educating the Student Body: Taking Physical Activity and Physical Education to School. Washington, DC: The National Academies Press; 2013. [PubMed: 24851299]

106.

Centers for Disease Control and Prevention. Results from the School Health Policies and Practices Study 2012. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2013.

107.

Rideout VJ, Foehr UG, Roberts DF. Generation M2: Media in the Lives of 8- to 18-Year-Olds. A Kaiser Family Foundation Study. Menlo Park, CA: Henry J. Kaiser Family Foundation; 2010.

108.

Community Preventive Services Task Force. The Guide to Community Preventive Services website. Obesity Prevention and Control: Behavioral Interventions that Aim to Reduce Recreational Sedentary Screen Time Among Children. http://www​.thecommunityguide​.org/obesity/behavioral.html. Accessed May 6, 2015.

109.

National Highway Traffic Safety Administration. 2013 Motor vehicle crashes: overview. Traffic Safety Facts. Research Note. 2014; DOT HS 812 101.

110.

National Highway Traffic Safety Administration. Pedestrians. Traffic Safety Facts 2013 Data. 2015; DOT HS 812 124.

111.

Alliance for Biking and Walking. Bicycling and Walking in the United States. 2014 Benchmarking Report. Washington, DC: Alliance for Biking and Walking; 2014.

112.

City of New York. Vision Zero website. http://www​.nyc.gov/VisionZero. Accessed December 5, 2014.

113.

World Health Organization. Pedestrian Safety: A Road Safety Manual for Decision Makers and Practitioners. Geneva, Switzerland: World Health Organization; 2013.

114.

Roberts I, Marshall R, Lee-Joe T. The urban traffic environment and the risk of child pedestrian injury: a case-crossover approach. Epidemiol. 1995;6(2):169–171. [PubMed: 7742404]

115.

Heinonen J, Eck JE. Pedestrian Injuries and Fatalities. Washington, DC: Office of Community Oriented Policing Services, U.S. Dept of Justice; 2007.

116.

Schwebel DC, Stavrinos D, Byington KW, Davis T, O’Neal EE, de Jong D. Distraction and pedestrian safety: how talking on the phone, texting, and listening to music impact crossing the street. Accid Anal Prev. 2012;45:266–271. [PMC free article: PMC3266515] [PubMed: 22269509]

117.

Schroeder P, Wilbur M. 2012 National Survey of Bicyclist and Pedestrian Attitudes and Behavior. Volume 1: Summary Report. Washington, DC: National Highway Traffic Safety Administration, U.S. Dept of Transportation; 2013. Report No. DOT HS 811 841 A.

118.

United States Access Board website. http://www​.access-board.gov/. Accessed April 5, 2015.

119.

Beck LF, Greenspan AI. Why don’t more children walk to school? J Safety Res. 2008;39(5):449–452. [PubMed: 19010117]

120.

Centers for Disease Control and Prevention. Barriers to children walking to or from school — United States, 2004. MMWR Morbid Mortal Wkly Rep. 2005;54(38):949–952. [PubMed: 16195692]

121.

McCormack GR, Shiell A. In search of causality: a systematic review of the relationship between the built environment and physical activity among adults. Int J Behav Nutr Phys Act. 2011;8:125. [PMC free article: PMC3306205] [PubMed: 22077952]

122.

Owen N, Humpel N, Leslie E, Bauman A, Sallis JF. Understanding environmental influences on walking: review and research agenda. Am J Prev Med. 2004;27(1):67–76. [PubMed: 15212778]

123.

Foster S, Knuiman M, Hooper P, Christian H, Giles-Corti B. Do changes in residents’ fear of crime impact their walking? Longitudinal results from RESIDE. Prev Med. 2014;62:161–166. [PubMed: 24552845]

124.

Centers for Disease Control and Prevention. Neighborhood safety and the prevalence of physical inactivity — selected states, 1996. MMWR Morbid Mortal Wkly Rep. 1999;48(07):143–146. [PubMed: 10077460]

125.

McDonald NC. The effect of objectively measured crime on walking in minority adults. Am J Health Promot. 2008;22(6):433–436. [PubMed: 18677884]

126.

Gomez JE, Johnson BA, Selva M, Sallis JF. Violent crime and outdoor physical activity among inner-city youth. Prev Med. 2004;39(5):876–881. [PubMed: 15475019]

127.

Bauman AE, Bull FC. Environmental Correlates of Physical Activity and Walking in Adults and Children: A Review of Reviews. London, England: National Institute of Health and Clinical Excellence; 2007.

128.

Mason P, Kearns A, Livingston M. “Safe Going”: the influence of crime rates and perceived crime and safety on walking in deprived neighbourhoods. Soc Sci Med. 2013;91:15–24. [PubMed: 23849234]

129.

Ewing R, Cervero R. Travel and the built environment: a meta-analysis. J Am Plann Assoc. 2010;76(3):265–294.

130.

Transportation Research Board. Does the Built Environment Influence Physical Activity? Examining the Evidence. Washington, DC: Transportation Research Board, Institute of Medicine of the National Academies; 2005. Special Report 282.

131.

Schlossberg M, Agrawal AW, Irvin K, Bekkouche VL. How Far, By Which Route, and Why? A Spatial Analysis of Pedestrian Preference. San Jose, CA: Mineta Transportation Institute; 2007. MTI Report 06-06.

132.

Yang Y, Diez-Roux AV. Walking distance by trip purpose and population subgroups. Am J Prev Med. 2012;43(1):11–19. [PMC free article: PMC3377942] [PubMed: 22704740]

133.

Saelens BE, Handy SL. Built environment correlates of walking: a review. Med Sci Sports Exerc. 2008;40(suppl 7):S550–S566. [PMC free article: PMC2921187] [PubMed: 18562973]

134.

Saelens BE, Sallis JF, Frank LD. Environmental correlates of walking and cycling: findings from the transportation, urban design, and planning literatures. Ann Behav Med. 2003;25(2):80–91. [PubMed: 12704009]

135.

Safe Routes to School National Partnership. Mode Share and Travel Behavior website. http://www​.saferoutespartnership​.org/mediacenter​/research/231317. Accessed June 13, 2013.

136.

Wong BY-M, Faulkner G, Buliung R. GIS measured environmental correlates of active school transport: a systematic review of 14 studies. Int J Behav Nut Phys Act. 2011;8(1):39. [PMC free article: PMC3112372] [PubMed: 21545750]

137.

National Center for Safe Routes to School. How Children Get to School: School Travel Patterns from 1969 to 2009. Chapel Hill, NC: National Center for Safe Routes to School; 2011.

138.

Lachapelle U, Frank L, Saelens BE, Sallis JF, Conway TL. Commuting by public transit and physical activity: where you live, where you work, and how you get there. J Phys Act Health. 2011;8(suppl 1):S72–S82. [PubMed: 21350265]

139.

Lachapelle U, Frank LD. Transit and health: mode of transport, employer-sponsored public transit pass programs, and physical activity. J Public Health Policy. 2009;30(suppl 1):S73–S94. [PubMed: 19190584]

140.

Wener RE, Evans GW. A morning stroll: levels of physical activity in car and mass transit commuting. Environ Behav. 2007;39(1):62–74.

141.

Brown BB, Werner CM. A new rail stop: tracking moderate physical activity bouts and ridership. Am J Prev Med. 2007;33(4):306–309. [PubMed: 17888857]

142.

Hoehner CM, Brennan Ramirez LK, Elliott MB, Handy SL, Brownson RC. Perceived and objective environmental measures and physical activity among urban adults. Am J Prev Med. 2005;28(suppl 2):105–116. [PubMed: 15694518]

143.

Besser LM, Dannenberg AL. Walking to public transit: steps to help meet physical activity recommendations. Am J Prev Med. 2005;29(4):273–280. [PubMed: 16242589]

144.

Freeland AL, Banerjee SN, Dannenberg AL, Wendel AM. Walking associated with public transit: moving toward increased physical activity in the United States. Am J Public Health. 2013;103(3):536–542. [PMC free article: PMC3673499] [PubMed: 23327281]

145.

Greenberg M, Renne J, Lane R, Zupan J. Physical activity and use of suburban train stations: an exploratory analysis. Journal of Public Transportation. 2005;8(3):89–116.

146.

Litman T. Evaluating Public Transportation Health Benefits. Victoria, Canada: Victoria Transport Policy Institute; 2015.

147.

Centers for Disease Control and Prevention. Vital signs: disability and physical activity — United States, 2009-2012. MMWR Morbid Mortal Wkly Rep. 2014;63(18):407–413. [PMC free article: PMC5779402] [PubMed: 24807240]

148.

Rimmer JH, Riley B, Wang E, Rauworth A, Jurkowski J. Physical activity participation among persons with disabilities: barriers and facilitators. Am J Prev Med. 2004;26(5):419–425. [PubMed: 15165658]

149.

Centers for Disease Control and Prevention. Physical Activity and Arthritis Overview website. http://www​.cdc.gov/arthritis​/pa_overview.htm. Accessed January 15, 2015.

150.

Laumbach RJ, Kipen HM. Acute effects of motor vehicle traffic-related air pollution exposures on measures of oxidative stress in human airways. Ann NY Acad Sci. 2010;1203:107–112. [PMC free article: PMC4043285] [PubMed: 20716291]

151.

Perez L, Lurmann F, Wilson J, et al. Near-roadway pollution and childhood asthma: implications for developing “win-win” compact urban development and clean vehicle strategies. Environ Health Perspect. 2012;120(11):1619–1626. [PMC free article: PMC3556611] [PubMed: 23008270]

152.

Frieden TR. A framework for public health action: the health impact pyramid. Am J Public Health. 2010;100(4):590–595. [PMC free article: PMC2836340] [PubMed: 20167880]

153.

Community Preventive Services Task Force. The Guide to Community Preventive Services website. Increasing Physical Activity: Environmental and Policy Approaches. http://www​.thecommunityguide​.org/pa/environmental-policy​/index.html. Accessed November 5, 2014.

154.

Centers for Disease Control and Prevention. Increasing physical activity. A report on recommendations of the Task Force on Community Preventive Services. MMWR Recomm Rep. 2001;50(RR-18):1–14. [PubMed: 11699650]

155.

Heath GW, Brownson RC, Kruger J, et al. The effectiveness of urban design and land use and transport policies and practices to increase physical activity: a systematic review. J Phys Act Health. 2006;3(suppl 1):S55–S76. [PubMed: 28834525]

156.

Berrigan D, Pickle LW, Dill J. Associations between street connectivity and active transportation. Int J Health Geogr. 2010;9:20. [PMC free article: PMC2876088] [PubMed: 20412597]

157.

Smart Growth America. National Complete Streets Coalition website. Policy Atlas. http://www​.smartgrowthamerica​.org/complete-streets​/changing-policy​/complete-streets-atlas. Accessed November 5, 2014.

158.

Laplante J, McCann B. Complete Streets: we can get there from here. ITE Journal. 2008:24–28.

159.

Federal Highway Administration. Resource materials. Resource sheet 7: engineering solutions to improve pedestrian safety. In: A Resident’s Guide for Creating Safe and Walkable Communities. Washington, DC: Federal Highway Administration, U.S. Dept of Transportation; 2008.

160.

National Institute for Health and Clinical Excellence. Physical Activity and the Environment. NICE Public Health Guidance 8. London, England: National Institute for Health and Clinical Excellence; 2015.

161.

Kahn EB, Ramsey LT, Brownson RC, et al. The effectiveness of interventions to increase physical activity. A systematic review. Am J Prev Med. 2002;22(suppl 4):73–107. [PubMed: 11985936]

162.

Soler RE, Leeks KD, Buchanan LR, Brownson RC, Heath GW, Hopkins DH. Point-of-decision prompts to increase stair use. A systematic review update. Am J Prev Med. 2010;38(suppl 2):S292–S300. [PubMed: 20117614]

163.

Centers for Disease Control and Prevention. Promoting Physical Activity. A Guide for Community Action. 2nd ed. Champaign, IL: Human Kinetics; 2009.

164.

Kassavou A, Turner A, French DP. Do interventions to promote walking in groups increase physical activity? A meta-analysis. Int J Behav Nutr Phys Act. 2013;10:18. [PMC free article: PMC3585890] [PubMed: 23388115]

165.

Partnership for Prevention. Social support for physical activity: establishing a community-based walking group program to increase physical activity among youth and adults. An action guide. In: The Community Health Promotion Handbook: Action Guides to Improve Community Health. Washington, DC: Partnership for Prevention; 2009.

166.

Hillsdon M, Foster C, Thorogood M. Interventions for promoting physical activity. Cochrane Database Syst Rev. 2005;(1):CD003180. [PMC free article: PMC4164373] [PubMed: 15674903]

167.

Task Force on Community Preventive Services. The Guide to Community Preventive Services: What Works to Promote Health. New York, NY: Oxford University Press; 2005.

168.

Task Force on Community Preventive Services. Recommendations to increase physical activity in communities. Am J Prev Med. 2002;22 (suppl 4):67–72. [PubMed: 11985935]

169.

Baker PR, Francis DP, Soares J, Weightman AL, Foster C. Community wide interventions for increasing physical activity. Cochrane Database Syst Rev. 2015;(1):CD008366. [PMC free article: PMC9508615] [PubMed: 25556970]

170.

U.S. Department of Transportation, Federal Highway Administration website. About: Who We Are. http://www​.fhwa.dot.gov/about/. Accessed February 5, 2015.

171.

U.S. Department of Transportation, Federal Highway Administration website. Coordinating Land Use and Transportation: What Is the Role of Transportation? http://www​.fhwa.dot.gov​/planning/processes/land_use/. Accessed November 5, 2014.

172.

American Planning Association website. What Is Planning? http://www​.planning.org​/aboutplanning/whatisplanning.htm. Accessed February 5, 2015.

173.

Federal Highway Administration. Bicycle & Pedestrain website. United States Department of Transportation policy statement on bicycle and pedestrian accommodation regulations and recommendations. http://www​.fhwa.dot.gov​/environment/bicycle_pedestrian​/overview/policy_accom.cfm. Accessed April, 20, 2015.

174.

New York City Department of City Planning, New York City Department of Design and Construction, New York City Department of Health and Mental Hygiene, New York City Department of Transportation. Active Design: Shaping the Sidewalk Experience. New York, NY: City of New York; 2013.

175.

McCann B, Rynne S. Complete Streets: Best Policy and Implementation Practices. Chicago, IL: American Planning Association Advisory Service; 2010.

176.

Smart Growth America. National Complete Streets Coalition website. Complete Streets A to Z. http://www​.smartgrowthamerica​.org/complete-streets/a-to-z. Accessed November 5, 2014.

177.

Durand CP, Andalib M, Dunton GF, Wolch J, Pentz MA. A systematic review of built environment factors related to physical activity and obesity risk: implications for smart growth urban planning. Obes Rev. 2011;12(5):e173–e182. [PMC free article: PMC3079793] [PubMed: 21348918]

178.

U.S. Environmental Protection Agency. Smart Growth website. http://www​.epa.gov/smartgrowth/index.htm. Accessed November 25, 2014.

179.

Smart Growth America. National Complete Streets Coalition website. Complete Streets Policy Adoption. http://www​.smartgrowthamerica​.org/documents​/cs/policy/cs-chart-allpolicies.pdf. Accessed April 9, 2015.

180.

Reconnecting America. Why Transit-Oriented Development and Why Now? Oakland, CA: Center for Transit-Oriented Development, Reconnecting America; 2011. TOD 101.

181.

Evans JE, Pratt RH. Chapter 17: Transit oriented development. In: TCRP Report 95. Traveler Response to Transportation System Changes Handbook. Washington, DC: Transportation Research Board; 2007.

182.

Kennedy M, Leonard P. Dealing with Neighborhood Change: A Primer on Gentrification and Policy Choices. Discussion paper prepared for the Brookings Institution Center on Urban and Metropolitan Policy and PolicyLink; 2001.

183.

Bates L. Gentrification and Displacement Study: Implementing an Equitable Inclusive Development Strategy in the Context of Gentrification. Commissioned by City of Portland Bureau of Planning and Sustainability; 2013.

184.

Office of Sustainable Communities, Office of Environmental Justice. Creating Equitable, Healthy, and Sustainable Communities: Strategies for Advancing Smart Growth, Environmental Justice, and Equitable Development. Washington, DC: Office of Sustainable Communities, Office of Environmental Justice, U.S. Environmental Protection Agency; 2013. EPA 231-K-10-005.

185.

Marshall JD, Brauer M, Frank LD. Healthy neighborhoods: walkability and air pollution. Environ Health Perspect. 2009;117(11):1752–1759. [PMC free article: PMC2801167] [PubMed: 20049128]

186.

Governing. America’s Poor Neighborhoods Plagued by Pedestrian Deaths: A Governing Research Report. Washington, DC: Governing; 2014.

187.

Ho C-H, Payne L, Orsega-Smith E, Godbey G. Parks, recreation, and public health. Parks & Recreation. 2003;38:18–27.

188.

Kaczynski A, Henderson K. Environmental correlates of physical activity: a review of evidence about parks and recreation. Leisure Sci. 2007;29(4):315–354.

189.

National Park Service. About Us: Frequently Asked Questions website. http://www​.nps.gov/faqs.htm. Accessed November 5, 2014.

190.

America’s State Parks. About America’s State Parks website. http://www​.americasstateparks.org/About. Accessed January 9, 2015.

191.

Centers for Disease Control and Prevention. State Indicator Report on Physical Activity, 2014. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2014. [PMC free article: PMC4224211] [PubMed: 25398737]

192.

Rails-to-Trails Conservancy. National and State Rail Statistics website. http://www​.railstotrails​.org/ourWork/trailBasics/trailStats​.html. Accessed November 10, 2014.

193.

Cohen DA, Ashwood JS, Scott MM, et al. Public parks and physical activity among adolescent girls. Pediatrics. 2006;118(5):e1381–e1389. [PMC free article: PMC2239262] [PubMed: 17079539]

194.

Cohen DA, McKenzie TL, Sehgal A, Williamson S, Golinelli D, Lurie N. Contribution of public parks to physical activity. Am J Public Health. 2007;97(3):509–514. [PMC free article: PMC1805017] [PubMed: 17267728]

195.

Li F, Fisher KJ, Brownson RC, Bosworth M. Multilevel modelling of built environment characteristics related to neighbourhood walking activity in older adults. J Epidemiol Community Health. 2005;59(7):558–564. [PMC free article: PMC1757084] [PubMed: 15965138]

196.

Giles-Corti B, Broomhall MH, Knuiman M, et al. Increasing walking: how important is distance to, attractiveness, and size of public open space? Am J Prev Med. 2005;28(suppl 2):169–176. [PubMed: 15694525]

197.

National Recreation and Park Association. Safe Routes to Parks: Improving Access to Parks Through Walkability. Ashburn, VA: National Recreation and Park Association; 2015.

198.

Cohen DA, Han B, Derose KP, Williamson S, Marsh T, McKenzie TL. Physical activity in parks: a randomized controlled trial using community engagement. Am J Prev Med. 2013;45(5):590–597. [PMC free article: PMC4091686] [PubMed: 24139772]

199.

International Health, Racquet & Sportsclub Association. About the Industry: Health Club Industry Overview website. http://www​.ihrsa.org/about-the-industry/. Accessed November 5, 2014.

200.

Buckworth J, Dishman RK. Determinants of physical activity behavior. In: Exercise Psychology. Champaign, IL: Human Kinetics Publishers; 2002:205.

201.

Snyder TD, Dillow SA. Digest of Education Statistics 2012. Washington, DC: National Center for Education Statistics, U.S. Dept of Education; 2013. NCES 2014-015.

202.

National Center for Education Statistics. Digest of Education Statistics website. Table 203.90, Schools and Staffing Survey (SASS), Public School Data File, 2007-08 and 2011-12. http://nces​.ed.gov/programs​/digest/d13/tables/dt13_203​.90.asp. Accessed November 10, 2014.

203.

Physical Activity Guidelines for Americans Midcourse Report Subcommittee of the President’s Council on Fitness Sports & Nutrition. Physical Activity Guidelines for Americans Midcourse Report: Strategies to Increase Physical Activity Among Youth. Washington, DC: U.S. Dept of Health and Human Services; 2012.

204.

Kriemler S, Meyer U, Martin E, van Sluijs EM, Andersen LB, Martin BW. Effect of school-based interventions on physical activity and fitness in children and adolescents: a review of reviews and systematic update. Br J Sports Med. 2011;45(11):923–930. [PMC free article: PMC3841814] [PubMed: 21836176]

205.

Salmon J, Booth ML, Phongsavan P, Murphy N, Timperio A. Promoting physical activity participation among children and adolescents. Epidemiol Rev. 2007;29:144–159. [PubMed: 17556765]

206.

National Center for Safe Routes to School website. http://www​.saferoutesinfo.org/. Accessed April 10, 2015.

207.

National Center for Safe Routes to School. Trends in Walking and Bicycling to School from 2007 to 2012. Chapel Hill, NC: National Center for Safe Routes to School, University of North Carolina Highway Safety Research Center; 2013.

208.

National Center for Safe Routes to School. Pedestrian and Bicycle Information Center. The Walking School Bus: Combining Safety, Fun and the Walk to School. Chapel Hill, NC: National Center for Safe Routes to School, University of North Carolina Highway Safety Research Center; 2010.

209.

Vincent JM. Joint use of public schools: a framework for promoting healthy communities. J Plan Educ Res. 2014;34(2):153–158.

210.

Choy LB, McGurk MD, Tamashiro R, Nett B, Maddock JE. Increasing access to places for physical activity through a joint use agreement: a case study in urban Honolulu. Prev Chronic Dis. 2008;5(3):1–8. [PMC free article: PMC2483555] [PubMed: 18558041]

211.

Durant N, Harris SK, Doyle S, et al. Relation of school environment and policy to adolescent physical activity. J Sch Health. 2009;79(4):153–159. [PubMed: 19292847]

212.

Lafleur M, Gonzalez E, Schwarte L, et al. Increasing physical activity in under-resourced communities through school-based, joint-use agreements, Los Angeles County, 2010-2012. Prev Chronic Dis. 2013;10:e89. [PMC free article: PMC3675908] [PubMed: 23721790]

213.

Farley TA, Meriwether RA, Baker ET, Watkins LT, Johnson CC, Webber LS. Safe play spaces to promote physical activity in inner-city children: results from a pilot study of an environmental intervention. Am J Public Health. 2007;97(9):1625–1631. [PMC free article: PMC1963283] [PubMed: 17666701]

214.

Ginder SA, Kelly-Reid JE. 2012-13 Integrated Postsecondary Education Data System (IPEDS) Methodology Report. Washington, DC: National Center for Education Statistics; 2013. NCES 2013-293.

215.

Bopp M, Kaczynski A, Wittman P. Active commuting patterns at a large, midwestern college campus. J Am Coll Health. 2011;59(7):605–611. [PubMed: 21823955]

216.

U.S. Department of Labor, Bureau of Labor Statistics. Economic News Release: Employment Situation Summary Table A. Household data, seasonally adjusted. http://www​.bls.gov/news​.release/empsit.a.htm. Accessed April 15, 2015.

217.

Blake H, Zhou D, Batt ME. Five-year workplace wellness intervention in the NHS. Perspect Public Health. 2013;133(5):262–271. [PubMed: 23771680]

218.

Dodson EA, Lovegreen SL, Elliott MB, Haire-Joshu D, Brownson RC. Worksite policies and environments supporting physical activity in Midwestern communities. Am J Health Promot. 2008;23(1):51–55. [PMC free article: PMC3973737] [PubMed: 18785375]

219.

Matson-Koffman DM, Brownstein JN, Neiner JA, Greaney ML. A site-specific literature review of policy and environmental interventions that promote physical activity and nutrition for cardiovascular health: what works? Am J Health Promot. 2005;19(3):167–193. [PubMed: 15693346]

220.

Neuhaus M, Eakin EG, Straker L, et al. Reducing occupational sedentary time: a systematic review and meta-analysis of evidence on activity-permissive workstations. Obes Rev. 2014;15(10):822–838. [PubMed: 25040784]

221.

Parry S, Straker L, Gilson ND, Smith AJ. Participatory workplace interventions can reduce sedentary time for office workers—a randomised controlled trial. PLoS One. 2013;8(11):e78957. [PMC free article: PMC3827087] [PubMed: 24265734]

222.

Thompson WG, Foster RC, Eide DS, Levine JA. Feasibility of a walking workstation to increase daily walking. Br J Sports Med. 2008;42(3):225–228. [PubMed: 17717060]

223.

Gazmararian JA, Elon L, Newsome K, Schild L, Jacobson KL. A randomized prospective trial of a worksite intervention program to increase physical activity. Am J Health Promot. 2013;28(1):32–40. [PubMed: 23470188]

224.

Conn VS, Hafdahl AR, Cooper PS, Brown LM, Lusk SL. Meta-analysis of workplace physical activity interventions. Am J Prev Med. 2009;37(4): 330–339. [PMC free article: PMC2758638] [PubMed: 19765506]

225.

von Thiele Schwarz U, Hasson H. Employee self-rated productivity and objective organizational production levels: effects of worksite health interventions involving reduced work hours and physical exercise. J Occup Environ Med. 2011;53(8):838–844. [PubMed: 21785369]

226.

Barr-Anderson DJ, AuYoung M, Whitt-Glover MC, Glenn BA, Yancey AK. Integration of short bouts of physical activity into organizational routine: a systematic review of the literature. Am J Prev Med. 2011;40(1):76–93. [PubMed: 21146772]

227.

National Coalition for Promoting Physical Activity. CEO Pledge website. Workplace Wellness Strategies. http://www​.ncppa.org​/ceo-pledge%E2%84%A0-0. Accessed January 09, 2015.

228.

American Council on Exercise. FIT Facts website. Fostering a Workplace Culture of Physical Activity. http://www​.acefitness​.org/acefit/fitness-fact-article​/3120/fostering-a-workplace-culture-of/. Accessed January 9, 2015.

229.

Centers for Disease Control and Prevention. Steps to Wellness: A Guide to Implementing the 2008 Physical Activity Guidelines for Americans in the Workplace. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2012.

230.

Soler RE, Leeks KD, Razi S, et al. A systematic review of selected interventions for worksite health promotion. The assessment of health risks with feedback. Am J Prev Med. 2010;38(suppl 2):S237–S262. [PubMed: 20117610]

231.

Task Force on Community Preventive Services. Recommendations for worksite-based interventions to improve workers’ health. Am J Prev Med. 2010;38(suppl 2):S232–S236. [PubMed: 20117609]

232.

Brissette I, Fisher B, Spicer DA, King L. Worksite characteristics and environmental and policy supports for cardiovascular disease prevention in New York state. Prev Chronic Dis. 2008;5(2). [PMC free article: PMC2396985] [PubMed: 18341773]

233.

Kruse M. From the basics to comprehensive programming. In: Pronk N, ed. ACSM’s Worksite Health Handbook. 2nd ed. Champaign, IL: Human Kinetics; 2009:296–307.

234.

Roger K, Blackwood A, Pettijohn S. The Nonprofit Almanac. Baltimore, MD: Urban Institute Press; 2012.

235.

Girl Trek website. http://www​.girltrek.org/. Accessed November 5, 2014.

236.

Arthritis Foundation. Walk with Ease Program website. http://www​.arthritis​.org/living-with-arthritis​/tools-resources/walk-with-ease/. Accessed May 1, 2015.

237.

Bloom B, Jones LI, Freeman G. Summary health statistics for U.S. children: National Health Interview Survey, 2012. Vital Health Stat 10. 2013;259:1–81. [PubMed: 24784481]

238.

Jacobson DM, Strohecker L, Compton MT, Katz DL. Physical activity counseling in the adult primary care setting: position statement of the American College of Preventive Medicine. Am J Prev Med. 2005;29(2):158–162. [PubMed: 16005814]

239.

Hagan J, Shaw J, Duncan P. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008:147–154.

240.

Lin JS, O’Connor EA, Evans CV, Senger CA, Rowland MG, Groom HC. Behavioral Counseling to Promote a Healthy Lifestyle for Cardiovascular Disease Prevention in Persons with Cardiovascular Risk Factors: An Evidence Update for the U.S. Preventive Services Task Force. Evidence Synthesis No. 113. Rockville, MD: Agency for Healthcare Research and Quality; 2014. AHRQ Publication No. 13-05179-EF-1. [PubMed: 25232633]

241.

U.S. Preventive Services Task Force. Recommendation Summary website. Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults with Cardiovascular Risk Factors: Behavioral Counseling. August 2014. http://www​.uspreventiveservicestaskforce​.org/Page/Topic/recommendation-summary​/healthy-diet-and-physical-activity-counseling-adults-with-high-risk-of-cvd. Accessed November 5, 2014. [PubMed: 25155419]

242.

Moyer VA; U.S. Preventive Services Task Force. Screening for and management of obesity in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(5):373–378. [PubMed: 22733087]

243.

U.S. Preventive Services Task Force; Barton M. Screening for obesity in children and adolescents: US Preventive Services Task Force recommendation statement. Pediatrics. 2010;125(2):361–367. [PubMed: 20083515]

244.

Lin JS, O’Connor E, Whitlock EP, Beil TL. Behavioral counseling to promote physical activity and a healthful diet to prevent cardiovascular disease in adults: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2010;153(11):736–750. [PubMed: 21135297]

245.

Moyer VA, on behalf of U.S. Preventive Services Task Force. Behavioral counseling interventions to promote a healthful diet and physical activity for cardiovascular disease prevention in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(5):367–371. [PubMed: 22733153]

246.

U.S. Preventive Services Task Force. Recommendation Summary website. Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults: Behavioral Counseling. June 2012. http://www​.uspreventiveservicestaskforce​.org/Page/Topic/recommendation-summary​/healthful-diet-and-physical-activity-for-cardiovascular-disease-prevention-in-adults-behavioral-counseling?ds​=1&s=. Accessed November 5, 2014.

247.

Eakin EG, Smith BJ, Bauman AE. Evaluating the population health impact of physical activity interventions in primary care—are we asking the right questions? J Phys Act Health. 2005;2:197–215.

248.

Hong Y, Ory MG, Lee C, Wang S, Pulczinksi J, Forjuoh SN. Walking and neighborhood environments for obese and overweight patients: perspectives from family physicians. Fam Med. 2012;44(5):336–341. [PubMed: 23027116]

249.

Lamarche K, Vallance J. Prescription for physical activity: a survey of Canadian nurse practitioners. Can Nurse. 2013;109(8):22–26. [PubMed: 24283149]

250.

American College of Sports Medicine. Exercise Is Medicine. Healthcare Providers’ Action Guide. Indianapolis, IN: American College of Sports Medicine; 2014.

251.

Durstine JL, Moore GE, Painter PL, Roberts SO. ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities. Indianapolis, IN: American College of Sports Medicine; 2009.

252.

Centers for Disease Control and Prevention. Increasing Physical Activity Among Adults with Disabilities website. http://www​.cdc.gov/disabilities/pa. Accessed April 6, 2015.

253.

The Nielsen Company. An Era of Growth. The Cross-Platform Report. March 2014. The Cross Platform Series Q4 2013. New York, NY: The Nielsen Company; 2014.

254.

McAfee T, Davis KC, Alexander RL, Jr., Pechacek TF, Bunnell R. Effect of the first federally funded US antismoking national media campaign. Lancet. 2013;382(9909):2003–2011. [PubMed: 24029166]

255.

Wakefield MA, Loken B, Hornik RC. Use of mass media campaigns to change health behaviour. Lancet. 2010;376(9748):1261–1271. [PMC free article: PMC4248563] [PubMed: 20933263]

256.

Bala MM, Strzeszynski L, Topor-Madry R, Cahill K. Mass media interventions for smoking cessation in adults. Cochrane Database Syst Rev. 2013;(6).CD004704.pub3. [PubMed: 23744348]

257.

Maher CA, Lewis LK, Ferrar K, Marshall S, De Bourdeaudhuij I, Vandelanotte C. Are health behavior change interventions that use online social networks effective? A systematic review. J Med Internet Res. 2014;16(2):e40. [PMC free article: PMC3936265] [PubMed: 24550083]

258.

Community Preventive Services Task Force. The Guide to Community Preventive Services website. Increasing Physical Activity: Campaigns and Informational Approaches. http://www​.thecommunityguide​.org/pa/campaigns/index.html. Accessed November 5, 2014.

259.

Brown DR, Soares J, Epping JM, et al. Stand-alone mass media campaigns to increase physical activity: a Community Guide updated review. Am J Prev Med. 2012;43(5):551–561. [PubMed: 23079180]

260.

Huhman ME, Potter LD, Duke JC, Judkins DR, Heitzler CD, Wong FL. Evaluation of a national physical activity intervention for children: VERB campaign, 2002-2004. Am J Prev Med. 2007;32(1):38–43. [PubMed: 17218189]

261.

Reger B, Cooper L, Booth-Butterfield S, et al. Wheeling Walks: a community campaign using paid media to encourage walking among sedentary older adults. Prev Med. 2002;35(3):285–292. [PubMed: 12202072]

262.

Reger-Nash B, Bauman A, Cooper L, et al. WV Walks: replication with expanded reach. J Phys Act Health. 2008;5(1):19–27. [PubMed: 18209251]

263.

American Public Health Association website. What is Public Health? http://www​.apha.org/what-is-public-health. Accessed February 9, 2014.

264.

American Public Health Association website. Advancing Efforts to Enumerate and Characterize the Nation’s Public Health Workforce. http://www​.apha.org/policies-and-advocacy​/public-health-policy-statements​/policy-database​/2014/07/08​/07/50/advancing-efforts-to-enumerate-and-characterize-the-nations-public-health-workforce. Accessed February 10, 2015.

265.

Centers for Disease Control and Prevention. National Public Health Performance Standards (NPHPS) website. The Public Health System and the 10 Essential Public Health Services. http://www​.cdc.gov/nphpsp​/essentialservices.html. Accessed November 5, 2014.

266.

World Health Organization. The Ottawa Charter for Health Promotion website. http://www​.who.int/healthpromotion​/conferences​/previous/ottawa/en/index.html. Accessed October 31, 2014.

267.

Thacker SB, Berkelman RL. Public health surveillance in the United States Epidemiol Rev. 1988;10(1):164–190. [PubMed: 3066626]

268.

Santos A, McGuckin N, Nakamoto HY, Gray D, Liss S. Summary of Travel Trends: 2009 National Household Travel Survey. Washington, DC: Federal Highway Administration, U.S. Dept of Transportation; 2011. FHWA-PL-ll-022.

269.

Mokdad AH. The Behavioral Risk Factors Surveillance System: past, present, and future. Annu Rev Public Health. 2009;30(1):43–54. [PubMed: 19705555]

270.

McDonald NC. Active transportation to school: trends among U.S. schoolchildren, 1969-2001. Am J Prev Med. 2007;32(6):509–516. [PubMed: 17533067]

271.

McDonald NC, Brown AL, Marchetti LM, Pedroso MS. U.S. school travel, 2009: an assessment of trends. Am J Prev Med. 2011;41(2):146–151. [PubMed: 21767721]

272.

Federal Highway Administration. Pedestrian and Bicycle Data Collection: Task 2 - Assessment. Washington, DC: Federal Highway Administration, U.S. Dept of Transportation; 2011. DTFH61-11-F-00031.

273.

Ryus P, Ferguson E, Laustsen KM, et al. Guidebook on Pedestrian and Bicycle Volume Data Collection. Washington, DC: Transportation Research Board of The National Academies; 2014. Report No. 797.

274.

Pedestrian and Bicycle Information Center. Walkability Checklist. Chapel Hill, NC: Pedestrian and Bicycle Information Center; 2010.

275.

United States Access Board. Chapter R3: Technical Requirements website. http://www​.access-board​.gov/guidelines-and-standards​/streets-sidewalks​/public-rights-of-way​/proposed-rights-of-way-guidelines​/chapter-r3-technical-requirements. Accessed April 19, 2015.

276.

U.S. Census Bureau. 2010 Geographic Terms and Concepts - Block Groups website. http://www​.census.gov​/geo/reference/gtc/gtc_bg.html. Accessed April 27, 2015.

277.

U.S. Census Bureau. 2010 Geographic Terms and Concepts - Block website. http://www​.census.gov​/geo/reference/gtc/gtc_block.html. Accessed April 27, 2015.

278.

U.S. Environmental Protection Agency. Smart Location Mapping website. Interactive maps and data for measuring location efficiency and the built environment. http://www​.epa.gov/smartgrowth​/smartlocationdatabase.htm. Accessed January 21, 2015.

279.

U.S. Department of Housing and Urban Development; U.S. Department of Transportation; Sustainable Communities. Location Affordability Portal Version 2 website. Understanding the Combined Cost of Housing and Transportation. http://www​.locationaffordability.info/. Accessed April 7, 2015.

280.

U.S. Department of Housing and Urban Development; U.S. Department of Transportation. Data and Methodology: Location Affordability Index Version 2.0. Washington, DC: U.S. Dept of Housing and Urban Development, U.S. Dept of Transportation; 2014.

281.

National Center for Health Statistics. DRAFT 2015 NHIS Questionnaire - Cancer Control Supplement. Hyattsville, MD: National Center for Health Statistics, Centers for Disease Control and Prevention; 2015.

282.

Brownson RC, Hoehner CM, Day K, Forsyth A, Sallis JF. Measuring the built environment for physical activity: state of the science. Am J Prev Med. 2009;36(suppl 4):S99–S123.e112. [PMC free article: PMC2844244] [PubMed: 19285216]

283.

Sallis JF, Kerr J, Carlson JA, et al. Evaluating a brief self-report measure of neighborhood environments for physical activity research and surveillance: physical activity neighborhood environment scale (PANES). J Phys Act Health. 2010;7:533–540. [PubMed: 20683096]

284.

U.S. Department of Transportation. Road Safety Assessments website. http://www​.dot.gov/policy-initiatives​/ped-bike-safety​/road-safety-assessments. Accessed April 18, 2015.

285.

Hara K, Le V, Froehlich J. Combining crowdsourcing and Google Street View to identify street-level accessibility problems. Proceedings of the SIGCHI Conference on Human Factors in Computing Systems. 2013:631–640.

286.

Rundle AG, Bader MD, Richards CA, Neckerman KM, Teitler JO. Using Google Street View to audit neighborhood environments. Am J Prev Med. 2011;40(1):94–100. [PMC free article: PMC3031144] [PubMed: 21146773]

287.

Bader MD, Mooney SJ, Lee YJ, et al. Development and deployment of the Computer Assisted Neighborhood Visual Assessment System (CANVAS) to measure health-related neighborhood conditions. Health Place. 2015;31:163–172. [PMC free article: PMC4315325] [PubMed: 25545769]

288.

Wilson JS, Kelly CM, Schootman M, et al. Assessing the built environment using omnidirectional imagery. Am J Prev Med. 2012;42(2):193–199. [PMC free article: PMC3263366] [PubMed: 22261217]

289.

Kelly CM, Wilson JS, Baker EA, Miller DK, Schootman M. Using Google Street View to audit the built environment: inter-rater reliability results. Ann Behav Med. 2013;45(suppl 1):S108–S112. [PMC free article: PMC3549312] [PubMed: 23054943]

290.

Zenk SN, Schulz AJ, Matthews SA, et al. Activity space environment and dietary and physical activity behaviors: a pilot study. Health Place. 2011;17(5):1150–1161. [PMC free article: PMC3224849] [PubMed: 21696995]

291.

Berrigan D, Hipp JA, Hurvitz PM, et al. Geospatial and contextual approaches to energy balance and health. Annals of GIS. 2015: Published Online: March 13, 2015 (doi: 10.1080/19475683.2015.1019925). [PMC free article: PMC4827348] [PubMed: 27076868] [CrossRef]

292.

Linnan L, Bowling M, Childress J, et al. Results of the 2004 National Worksite Health Promotion Survey. Am J Public Health. 2008;98(8):1503–1509. [PMC free article: PMC2446449] [PubMed: 18048790]

293.

Jacobsen PL. Safety in numbers: more walkers and bicyclists, safer walking and bicycling. Inj Prev. 2003;9(3):205–209. [PMC free article: PMC1731007] [PubMed: 12966006]

294.

Goodwin A, Kirley B, Sandt L, et al. Countermeasures That Work: A Highway Safety Countermeasure Guide for State Highway Safety Offices, 2013. Washington, DC: National Highway Traffic Safety Administration; 2013. DOT HS 811 727.

295.

Wu J, Austin R, Chen C. Incidence Rates of Pedestrian and Bicyclist Crashes by Hybrid Electric Passenger Vehicles: An Update. Washington, DC: National Highway Traffic Safety Administration; 2011. DOT HS 811 526.

296.

Sleet DA, Pollack K, Rivara F, Frattaroli S, Peek-Asa C. It wouldn’t hurt to walk: promoting pedestrian injury research. Inj Prev. 2010;16(3):211–212. [PubMed: 20570990]

297.

Rothman L, Buliung R, Macarthur C, To T, Howard A. Walking and child pedestrian injury: a systematic review of built environment correlates of safe walking. Inj Prev. 2013;20:41–49. [PubMed: 23710061]

298.

Patel MS, Asch DA, Volpp KG. Wearable devices as facilitators, not drivers, of health behavior change. JAMA. 2015;313(5):459–460. [PubMed: 25569175]

299.

Mayne SL, Auchincloss AH, Michael YL. Impact of policy and built environment changes on obesity-related outcomes: a systematic review of naturally occurring experiments. Obes Rev. 2015;16(5):362–375. [PMC free article: PMC4789114] [PubMed: 25753170]

300.

Centers for Disease Control and Prevention. Framework for program evaluation in public health. MMWR Recomm Rep. 1999;48(RR-11):1–40. [PubMed: 10499397]

301.

Davis JC, Verhagen E, Bryan S, et al. 2014 Consensus statement from the first Economics of Physical Inactivity Consensus (EPIC) Conference (Vancouver). Br J Sports Med. 2014;48(12):947–951. [PubMed: 24859181]

302.

Laine J, Kuvaja-Kollner V, Pietila E, Koivuneva M, Valtonen H, Kankaanpaa E. Cost-effectiveness of population-level physical activity interventions: a systematic review. Am J Health Promot. 2014;29(2):71–80. [PubMed: 25361461]

303.

Wu S, Cohen D, Shi Y, Pearson M, Sturm R. Economic analysis of physical activity interventions. Am J Prev Med. 2011;40(2):149–158. [PMC free article: PMC3085087] [PubMed: 21238863]

304.

Snyder R. The Economic Value of Active Transportation. Los Angeles, CA: Ryan Snyder Associates, LLC; 2004.

305.

Campbell R, Wittgens M. The Business Case for Active Transportation. The Economic Benefits of Walking and Cycling. Gloucester, Ontario: Health Canada; 2004.

306.

Gotschi T, Mills K. Active Transportation for America: The Case for Increased Federal Investment in Bicycling and Walking. Washington, DC: Rails to Trails Conservancy; 2008.

307.

Gotschi T. Costs and benefits of bicycling investments in Portland, Oregon. J Phys Act Health. 2011;8(suppl 1):S49–S58. [PubMed: 21350262]

308.

Guo JY, Gandavarapu S. An economic evaluation of health-promotive built environment changes. Prev Med. 2010;50(suppl 1):S44–S49. [PubMed: 19840817]

309.

Belza B, Allen P, Brown D, et al. Mall Walking: A Program Resource Guide. Seattle, WA: University of Washington Health Promotion Research Center; 2015.

310.

David-Ferdon C, Simon TR. Preventing Youth Violence: Opportunities for Action. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2014.

311.

Federal Highway Administration. A Resident’s Guide for Creating Safer Communities for Walking and Biking. Washington, DC: Federal Highway Administration, U.S. Dept of Transportation; 2015. FHWA-SA-14-099.

312.

Pan American Health Organization, Vía RecreActiva of Guadalajara, University of the Andes, Centers for Disease Control and Prevention. Car Free Sundays (Ciclovía Recreativa) Implementation and Advocacy Manual. Washington, DC: Pan American Health Organization; 2009.

313.

Partnership for Prevention. Places for Physical Activity: Facilitating Development of a Community Trail and Promoting Its Use to Increase Physical Activity Among Youth and Adults. An Action Guide. Washington, DC: Partnership for Prevention; 2008.

314.

Walkable and Livable Communities Institute. Walkability Workbook. Port Townsend, WA: Walkable and Livable Communities Institute; 2012.

315.

Lee V, Srikantharajah J, Mikkelsen L. Fostering Physical Activity for Children and Youth: Opportunities for a Lifetime of Health. Oakland, CA: Convergence Partnership, Prevention Institute; 2010.

316.

Centers for Disease Control and Prevention. User’s Guide. Promoting Physical Activity Guidelines for Americans in Your Community: A Guide to Building Awareness and Participation. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2008. ODPHP publication U0039.

317.

Colorado Department of Public Health and Environment. Older Adult Resource Kit. Implementation Guide for the Colorado Physical Activity and Nutrition State Plan 2010. Denver, CO: Colorado Dept of Public Health and Environment; 2010.

318.

American College of Sports Medicine; Nike Inc.; International Council of Sport Science and Physical Education. Designed to Move: A Physical Activity Action Agenda. Beaverton, OR: Nike, Inc.; 2013.

319.

Partnership for Active Transportation. Safe Routes to Everywhere: Building Healthy Places for Healthy People Through Active Transportation Networks. Washington, DC: Partnership for Active Transportation; 2014.

320.

Convergence Partnership. Healthy People Healthy Places website. http://www​.convergencepartnership.org. Accessed November 5, 2014.

321.

Every Body Walk! The Campaign to Get America Walking website. http:​//everybodywalk.org/. Accessed November 5, 2014.

322.

Lyons W, Morse L, Nash L, Strauss R. Statewide Transportation Planning for Healthy Communities. Washington, DC: Federal Highway Administration, U.S. Dept of Transportation; 2014. DOT-VNTSC-FHWA-14-01.

323.

Lyons W, Peckett H, Khurana M, Nash L. Metropolitan Area Transportation Planning for Healthy Communities. Washington, DC: Federal Highway Administration, U.S. Dept of Transportation; 2012. DOT-VNTSC-FHWA-13-01.

324.

American Academy of Pediatrics Committee on Environmental Health. The built environment: designing communities to promote physical activity in children. Pediatrics. 2009;123:1591. [PubMed: 19482771]

325.

Retting RA, Ferguson SA, McCartt AT. A review of evidence-based traffic engineering measures designed to reduce pedestrian-motor vehicle crashes. Am J Public Health. 2003;93(9):1456–1463. [PMC free article: PMC1447993] [PubMed: 12948963]

326.

Institute of Transportation Engineers. Design Walkable Urban Thoroughfares: A Context Sensitive Approach. Washington, DC: Institute of Transportation Engineers; 2010.

327.

Clifton KJ, Bronstein S, Morrisey S. The Path to Complete Streets in Underserved Communities. Lessons from U.S. Case Studies. Portland, OR: Portland State University; 2014

328.

U.S. Department of Justice. 2010 ADA Standards for Accessible Design. Washington, DC: Dept of Justice; 2010.

329.

United States Access Board. Proposed Accessibility Guidelines for Pedestrian Facilities in the Public Right-of-Way. Washington, DC: United States Access Board; 2011.

330.

Kelly CM, Schootman M, Baker EA, Barnidge EK, Lemes A. The association of sidewalk walkability and physical disorder with area-level race and poverty. J Epidemiol Community Health. 2007;61(11):978–983. [PMC free article: PMC2465610] [PubMed: 17933956]

331.

Partnership for Prevention. Creating Communities for Active Aging: A Guide to Developing a Strategic Plan to Increase Walking and Biking by Older Adults in Your Community. Washington, DC: Partnership for Prevention; 2001.

332.

Sugiyama T, Neuhaus M, Cole R, Giles-Corti B, Owen N. Destination and route attributes associated with adults’ walking: a review. Med Sci Sports Exerc. 2012;44(7):1275–1286. [PubMed: 22217568]

333.

McCormack GR, Giles-Corti B, Bulsara M. The relationship between destination proximity, destination mix and physical activity behaviors. Prev Med. 2008;46(1):33–40. [PubMed: 17481721]

334.

Leaf WA, Preusser DF. Literature Review on Vehicle Travel Speeds and Pedestrian Injuries. Washington, DC: National Highway Traffic Safety Administration, U.S. Dept of Transportation; 1999.

335.

Community Preventive Services Task Force. The Guide to Community Preventive Services website. Motor Vehicle-Related Injury Prevention: Reducing Alcohol-Impaired Driving. http://www​.thecommunityguide​.org/mvoi/AID/index.html. Accessed January 15, 2015.

336.

Branas CC, Cheney RA, MacDonald JM, Tam VW, Jackson TD, Ten Have TR. A difference-in-differences analysis of health, safety, and greening vacant urban space. Am J Epidemiol. 2011;174(11):1296–1306. [PMC free article: PMC3224254] [PubMed: 22079788]

337.

Centers for Disease Control and Prevention. School health guidelines to promote healthy eating and physical activity. MMWR Recomm Rep. 2011;60(RR05):1–71. [PubMed: 21918496]

338.

ChangeLab Solutions. Shared Use website. http:​//changelabsolutions​.org/childhood-obesity/joint-use. Accessed November 5, 2014.

339.

Baicker K, Cutler D, Song Z. Workplace wellness programs can generate savings. Health Aff. 2010;29(2):304–311. [PubMed: 20075081]

340.

Henke RM, Goetzel RZ, McHugh J, Isaac F. Recent experience in health promotion at Johnson & Johnson: lower health spending, strong return on investment. Health Aff (Millwood). 2011;30(3):490–499. [PubMed: 21383368]

341.

Schill AL, Chosewood LC. The NIOSH Total Worker Health program: an overview. J Occup Environ Med. 2013;55(suppl 12):S8–S11. [PubMed: 24284752]

342.

Druss BG, Zhao L, von Esenwein SA, et al. The Health and Recovery Peer (HARP) Program: a peer-led intervention to improve medical self-management for persons with serious mental illness. Schizophr Res. 2010;118(1–3):264–270. [PMC free article: PMC2856811] [PubMed: 20185272]

343.

Kruger J, Carlson SA, Kohl HW, 3rd. Fitness facilities for adults: differences in perceived access and usage. Am J Prev Med. 2007;32(6):500–505. [PubMed: 17533065]

344.

Coleman KJ, Ngor E, Reynolds K, et al. Initial validation of an exercise “vital sign” in electronic medical records. Med Sci Sports Exerc. 2012;44(11):2071–2076. [PubMed: 22688832]

345.

Greenwood JL, Joy EA, Stanford JB. The Physical Activity Vital Sign: a primary care tool to guide counseling for obesity. J Phys Act Health. 2010;7(5):571–576. [PubMed: 20864751]

346.

Grant RW, Schmittdiel JA, Neugebauer RS, Uratsu CS, Sternfeld B. Exercise as a vital sign: a quasi-experimental analysis of a health system intervention to collect patient-reported exercise levels. J Gen Intern Med. 2014;29(2):341–348. [PMC free article: PMC3912279] [PubMed: 24309950]

347.

Trudeau F, Shephard RJ. Contribution of school programmes to physical activity levels and attitudes in children and adults. Sports Med. 2005;35(2):89–105. [PubMed: 15707375]

348.

Tappe M, Burgeson CR. Physical education: a cornerstone for physically active lifestyles. J Teach Phys Educ. 2004;23(4):281–299.

349.

Levi S, De Leonardis DM, Antin J, Angel L. Identifying Countermeasure Strategies to Increase Safety of Older Pedestrians. Washington, DC: National Highway Traffic Safety Administration, U.S. Dept of Transportation; 2013. DOT HS 811 798.

350.

Kohut A, Doherty C, Dimock M, Keeter S. In Changing News Landscape, Even Television Is Vulnerable. Trends in News Consumption: 1991-2012. Washington DC: Pew Research Center for the People and the Press; 2012.

351.

Gordon R, McDermott L, Stead M, Angus K. The effectiveness of social marketing interventions for health improvement: what’s the evidence? Public Health. 2006;120(12):1133–1139. [PubMed: 17095026]

352.

Lee SM, Burgeson CR, Fulton JE, Spain CG. Physical education and physical activity: results from the School Health Policies and Programs Study 2006. J Sch Health. 2007;77(8):435–463. [PubMed: 17908102]

353.

National Association for Sport and Physical Education. Moving into the Future: National Standards for Physical Education. 2nd ed. Reston, VA: McGraw-Hill Humanities/Social Sciences/Languages; 2004.

354.

Association of Schools and Programs of Public Health. Public Health Trends and Redesigned Education. Blue Ribbon Public Health Employers’ Advisory Board: Summary of Interviews. Washington, DC: Association of Schools and Programs of Public Health; 2013.

355.

National Network of Public Health Institutes, Centers for Disease Control and Prevention, Georgia Institute of Technology. Public Health and Community Design Cross-Sectoral Workforce Development. Final Report. Atlanta, GA: Georgia Institute of Technology; 2013.

356.

Rutt CD, Pratt M, Dannenberg AL, Cole BL. Connecting public health and planning professionals: health impact assessment. Places. 2005;17(1):85–87.

357.

Dannenberg AL, Bhatia R, Cole BL, et al. Growing the field of health impact assessment in the United States: an agenda for research and practice. Am J Public Health. 2006;96(2):262–270. [PMC free article: PMC1470491] [PubMed: 16380558]

358.

World Health Organization. Health Economic Assessment Tool (HEAT) website. http://www​.heatwalkingcycling.org/. Accessed April 15, 2015.

359.

Centre for Diet and Activity Research. Integrated Transport and Health Impact Modelling Tool (ITHIM) website. http://www​.cedar.iph​.cam.ac.uk/research/modelling/ithim/. Accessed March 20, 2015.

Suggested citation:

U.S. Department of Health and Human Services. Step It Up! The Surgeon General’s Call to Action to Promote Walking and Walkable Communities. Washington, DC: U.S. Dept of Health and Human Services, Office of the Surgeon General; 2015.

Website addresses of nonfederal organizations are provided solely as a service to our readers. Provision of an address does not constitute an endorsement by the U.S. Department of Health and Human Services (HHS) or the federal government, and none should be inferred. HHS is not responsible for the content of other organizations’ web pages.