Madeline Lasell

CRD 298

IMPROVING CHATHAM COUNTY ACCESS TO LONG-TERM

EMPLOYMENT: A HEALTH IMPACT ASSESSMENT

EXECUTIVE SUMMARY

OUTLINE. The purpose of this HIA is to assess the public health implications relative to
improved access to long-term employment in Chatham County, Georgia. The Chatham
County Comprehensive Plan and the Chatham Community Blueprint documents served as
the primary basis for this assessment. While the comprehensive plan included the results
from a recent community needs assessment survey, other aspects of these two documents
served as a proxy for the community’s input.

The screening portion of this HIA includes results from the community survey to address
the greatest needs, as defined by Chatham County residents. Further, this section provides
health-relevant context by identifying aspects of Chatham County’s geographic region and
its community-wide demographics. Lastly, three domains from the county’s comprehensive
plan are included to indicate the potential policies that contribute to job accessibility and
are worth assessing in terms of health impact.

Under the scoping section, three key health indicators serve as metrics for the health
impacts that result from long-term employment. These indicators are: income and
socioeconomic status, recidivism and incarceration, and food accessibility. The indicators
are discussed in relation to their impact on two health outcomes—chronic disease and
mental health.

The assessment subheading quantifies the county’s current health outcomes with respect
to chronic disease and mental health. Further, this section includes data pertaining to the
three key health indicators, which serve as baseline data metrics that can be used for
assessing the impact of this HIA in the future.

The recommendations included in this HIA are specific to improving access to

employment opportunities in ways that complement the visions embedded within Chatham
County’s comprehensive plan. Namely, transitional job programs, bike path and walkway
connectivity, and expanded transit each align with the community’s defined needs and will
contribute to efforts improving access to employment opportunities in the county.

This HIA document serves as an avenue of reporting the results of this assessment and is
intended for all invested community partners and county residents to have access to.

The monitoring and evaluation steps are outlined at the conclusion of this HIA.
Specifically, the relevant key health indicators are discussed in terms of how frequently
they should be monitored over time to assess improvements in community health outcomes,
as well as the impact of this particular HIA.
Madeline Lasell
CRD 298

SCREENING - IDENTIFYING A TARGET POPULATION AND PLAN

GEOGRAPHY. The City of Savannah is nestled within Chatham County, Georgia, which
is then further divided into two developments—East Chatham and West Chatham.
Savannah city is urbanized with large areas of mixed use development, while the
surrounding areas of East and West Chatham each maintain their own unique land use
infrastructure. East Chatham is largely marshland with a lower population density as
compared to the rest of the county. In contrast, West Chatham supplies the largest rate of
population growth in the county. Historically an agricultural, forested, and undeveloped
area, this region now sees the bulk of Chatham County’s continual population increase.

With Savannah’s successful preservation of its rich, historical roots, the city has a lot to
offer in terms of its economy and quality of life. City founder James Oglethorpe’s original
plan for Savannah was heavily pedestrian-oriented with ample open space and tree
canopies. In addition, the cultural and historical character of the community draws in
tourists and boosts the economy. According to the Historic Savannah Foundation, “historic
preservation goes hand-in-hand with economic progress.” The historic districts and
rehabilitation also create and attract more jobs. Thus, Savannah and Chatham County at
large are focused on preserving and revitalizing historic and cultural areas for the economic
viability of the entire county. Despite its flourishing downtown hub, there are many other
regions within Chatham County that do not maintain this historical framework or draw in
tourism. Therefore, these areas call for additional attention toward their economic
development and potential job opportunities.

Part of this preservation includes the several squares embedded within Savannah’s
downtown region. These squares offer up open green space, city-wide beautification, and
traffic-calming routes that are ideal for bicyclists and pedestrians. Areas outside of the
downtown area, however, are car-dependent with minimal biking infrastructure.6 Per its
comprehensive plan, Chatham intends to incorporate a transit system that allows
individuals without cars to gain access to other regions throughout the county.

TARGET DEMOGRAPHIC. Chatham county is home to primarily African American and

Caucasian citizens. While Savannah residents are 54% African American, West and East
Chatham are 71% Caucasian.2 As of 2010, approximately 50% of the population in
Chatham county was considered Caucasian.2 Nearly 40% were considered African
American, only about 5% were Hispanic, and less than 3% were Asian.2 In the county, the
overall poverty rate was 18% in 2015 with a median household income of $48,885.2 Only
13.9% of employed Chatham County residents are living in poverty, while 40.8% of the
unemployed residents are living in poverty.2

In terms of chronic disease, Georgia has the 20th highest obesity rate in the nation.
Throughout the state, 31.4% of adults are obese, 12.1% are diabetic, and 36.2% are
considered hypertensive.5 Chatham County is comparable to the rest of the state with
respect to the prevalence of its chronic conditions—it has an adult diabetes rate of 11% and
an adult obesity rate of 31.3% (both as of 2013).4

COMMUNITY NEEDS ASSESSMENT. Within its comprehensive plan, Chatham

County includes the results of a 2016 community survey, which showcases the areas that
Madeline Lasell
CRD 298

Chatham County residents are most interested in addressing. Details surrounding how the
survey was administered and how many residents responded were not included in the plan,
making it difficult to quantify how representative the respondents were of the different
regions within and socioeconomic groups throughout Chatham County. However, there are
several quotes that assert that the needs of low-income families and homeless individuals
are not being met, specifically with regard to job availability and affordable housing.
According to the survey, a total of 74% of respondents indicated that the availability of high
paying jobs is not adequate within the community. With regard to transportation, 60% of
survey respondents indicated that the current system is inadequate. Over 70% of
responders indicated that there should be a significant increase in the investment of
sidewalks, trails, road maintenance, and parks or open space. Only 37% of respondents
favored an increase in road expansion. Though the minority, nearly a third of respondents
indicated that the current infrastructure should remain the same. Over 70% of respondents
supported quality of life initiatives such as community gardens, walking and bicycling, and
protecting the tree canopies.

JOB ECONOMY. In its sections pertaining to economy and education, the Chatham
County plan emphasizes the need for an increased number of job opportunities and
improved academic training for these jobs. Through the development of apprenticeships
and vocational programs, Chatham County intends to maximize the number of quality jobs
available to members of the community, including individuals in poverty, young adults, ex-
offenders, and those with mental illness.

HEALTH & QUALITY OF LIFE. Savannah already prides itself in its existing high
quality of life, which the city attributes to a temperate climate, wildlife, and beautiful
scenery. In the Chatham Community Blueprint, the strategic plan for quality of life
includes: building environments that encourage active lifestyles and neighborhood
connectivity, improving the delivery of social services and expanding the continuum of
those services, and consolidating government to ensure that procedures are executed
efficiently and with transparency. Regarding health, the Blueprint strategic plan centers
around addressing mental health, improving health equity, and increasing food access
among the food insecure.

TRANSPORTATION. The county’s comprehensive plan is strong in that it explicitly

recognizes that community health is largely influenced by transportation planning. For
instance, the plan asserts that, without adequate modes or routes of transportation,
residents are unable to reach healthy foods and even places of employment. A large portion
of the community survey respondents indicated the need for more sidewalks, trails, and
parks with open space. While the downtown Savannah area offers many bike paths and
exceptional walkability, East and West Chatham are the communities most in need of
policies that meet this plan’s transportation objectives.

Of the transportation goals included in the county’s “Total Mobility Plan,” there are many
objectives that stand out in terms of meeting the community’s identified needs: to maximize
regional population and employment accessibility, to encourage use of transit and non-
motorized modes of transportation, and to expand transit service areas and frequency for
areas with low-rates of automobile ownership or high rates of elderly and disabled
individuals. The plan identifies the Coastal Region Metropolitan Planning Organization
Madeline Lasell
CRD 298

(CORE MPO) as the federally designated planning organization responsible for region-wide
transportation planning surrounding Chatham County. In 2012, each region in Georgia
identified projects to focus funding towards in the form of a one-cent sales tax. The Coastal
Region did not approve the tax, which has hampered funding for efforts proposes by various
transportation agencies in the region.

SCOPING - IDENTIFYING RELEVANT HEALTH IMPACTS

INTRODUCTION. A Health Impact Assessment (HIA) is the formal process of evaluating

both the positive and negative public health implications associated with a plan, project, or
policy prior to its implementation.1 Further, this assessment tool examines how decisions
will affect vulnerable populations. Ultimately, an HIA provides the opportunity to
recommend approaches that will maximize positive health effects across a community while
minimizing negative health implications. To accomplish this, the following steps must be
completed when conducting a health impact assessment:

1. Screening - Identifying a target population and plan.

2. Scoping - Identifying relevant health impacts.
3. Assessment – Quantifying baseline health and HIA impacts.
4. Recommendations – Proposing actions that maximize health benefits.
5. Reporting – Relaying results to relevant and invested populations.
6. Monitoring and Evaluation – Determining HIA impact on policy and health.

This HIA specifically addresses the health impacts of long-term employment access.
Chatham County has identified its need for a greater number of employment opportunities
for all members of society, especially poverty-stricken individuals, young adults, ex-
offenders, and the mentally ill or disabled. In addition, the county has identified the need
for greater neighborhood connectivity and adequate routes or modes of transportation that
will allow for greater accessibility to jobs.

A survey of the existing literature helped identify three key indicators that may determine
the impact of long-term employment on health outcomes specific to chronic disease and/or
mental health. The three health indicators are listed below.

KEY INDICATORS ASSOCIATED WITH CHRONIC DISEASE AND MENTAL

HEALTH

Income. Long-term, secure employment corresponds with a steady income and higher
socioeconomic status (SES). With greater income comes the potential for greater health.7
The literature supports that even slight increases in income will result in slightly better
health outcomes. Adler and Ostrove (1999) examined trends in the data pertaining to SES
status and health over the decades, starting in 1970s.7 In particular, the prevalence of some
chronic diseases—as well as mortality related to these chronic disease states—appears to
decrease in the event that income, and, therefore, SES increases. Specifically, higher SES
correlates with reduced rates of cardiovascular disease, diabetes, metabolic syndrome, and
arthritis.7 Interestingly, increases in SES are also associated with reduced rates of
smoking, lower cholesterol levels, and lesser likelihood of a sedentary lifestyle.7 Adler and
Madeline Lasell
CRD 298

Ostrove further indicate that certain racial groups (e.g. African Americans) have
historically experienced low SES status, which has consequently resulted in poorer health
outcomes among these individuals when compared to White, non-minority groups with
higher SES status.7

Regarding mental health, socioeconomic status can further affect stress levels. While
employment itself can be stressful, the higher socioeconomic status that results from
employment is associated with less stress than lower socioeconomic groups experience.8
This stress can lead to other forms of mental illness, such as depression and generalized
anxiety. Low SES is also associated with a greater prevalence of mental illness or other
behaviors that impair health and are associated with the chronic social and environmental
stress experienced among lower SES communities.8,9 Baseline community measures of
income and SES will be evaluated using the American Community Survey and
benchmarked against the national averages of income and SES as determined by the
United States Census.

Recidivism and incarceration. Chatham County aims to reduce crime, repeated crime
offenses, and the number of incarcerated individuals by increasing access to job
opportunities. Recidivism and incarceration are linked to chronic disease and mental health
in that over 80% of re-incarcerated individuals experience chronic physical, mental, and/or
substance abuse conditions.10 Moreover, individuals with multiple criminal offenses tend to
experience more physical health problems than individuals who have committed fewer
crimes due to repeated jail time.10 Incarcerated individuals are also much more likely to
have a mental health condition as compared to the non-incarcerated.11 For the purposes of
this HIA, baseline recidivism and incarceration rates will be evaluated using the annual
report from the Chatham County Sherriff’s Office. To determine the long-term mental
health effects related to the proposed policy’s progress, mental health questionnaire results
administered at various local healthcare settings would be benchmarked against nation-
wide mental health data collected at the national level from the Centers for Disease Control
and Prevention (CDC).

Food access. Individuals who are subject to food insecurity have an increased risk of
chronic disease development (i.e. metabolic syndrome, diabetes).12 This can, in part, be
attributed to the inadequate intake of nutrient-dense foods.12 Moreover, food insecurity
among individuals who already live with chronic disease makes it difficult to manage their
disease.12 In the case of diabetes, individuals who are food insecure may not be able to
control their blood sugar by virtue of being unable to afford food. Ultimately, an individual
who lacks access to food at one point in time increases the likelihood that he or she will
experience poor health outcomes in the future.12 Additionally, food insecurity can contribute
to significant levels of stress, which can, in turn affect the mental health and well-being of
an individual.12 Chronic stress due to consistent food insecurity can further initiate
metabolic stress responses that can, again, greatly impact physical health.12 For this HIA,
baseline food access (i.e. grocery store access), utilization of food assistance programs, and
diet-related health outcomes will be assessed using the USDA Food Atlas Database. To
benchmark policy progress, the findings at the county level will be compared to national
data averages on diet-related health outcomes (i.e. obesity, diabetes) from the CDC, food
assistance program utilization rates (WIC, SNAP), and accessibility to grocery stores the
using USDA Food Atlas Database compared to other counties throughout Georgia.
Madeline Lasell
CRD 298

Policy Key Health

Change Indicators Outcomes

Reduced risk of
CVD, diabetes,
metabolic
syndrome, arthritis
Increased income
and SES
Reduced rates of
smoking and
sedentary lifestyles

Improved mental
health
Decreased
Access to long-term
recidivism and
employment
incarceration
Fewer chronic
physical health
problems

Reduced risk of
chronic disease
development or
mismanagement
Increased food
security
Reduced stress and
mental health
problems

Figure 1: Key indicators related to improved health outcomes as related to long-term

employment.

ASSESSMENT - QUANTIFYING BASELINE HEALTH AND HIA IMPACTS

INCOME AND SES. From the 2016 census data, 116,757 members of the population were
considered employable (over the age of 16), and only 73,662 were in the labor force.3
Unfortunately, 20.1% of the population had an income below the poverty level within the
past 12 months.3 The median earnings associated with educational attainment levels for
both females and males, combined. As listed above, the median household income for the
entire population is $37,108.3
Madeline Lasell
CRD 298

OF 90,973 MEMBERS OF THE POPULATION 25 YEARS OF AGE OR OLDER : 3

• Approx. 12,000 (13%) never graduated high school (median income: $16,910),
• 24,828 (27%) graduated high school (median income: $21,707),
• Approx. 29,000 (32%) completed some college or an associate degree (median income
$25,396),
• 15,601 (17%) graduated with a bachelor’s degree (median income: $37,228), and
• 9,575 (~11%) completed a graduate or professional degree (median income: $47,734).

RECIDIVISM AND INCARCERATION. In 2016, there were a total of 15,478 individuals

were placed in the Chatham County Detention Center, which equates to an average of
1,290 individuals per month.13 On average, there were approximately 1,630 inmates per
day.13 Additionally, 68% of the inmates in the Chatham County Jail were felons who had
prior arrests in Chatham County.13

FOOD ACCESS. Approximately 58,000 members of the population have low access to a
grocery store in 2015 – this is nearly 12% of an increase in population since the last
measure of access in 2010.4 In 2015, approximately 18,000 African American citizens had
low access to grocery stores whereas approximately 36,500 Caucasian citizens had low
access to grocery stores.4 With respect to food assistance data, over 16% of Chatham county
residents utilized Supplemental Nutrition Assistance Program (SNAP) benefits in 2016,
under 3% utilized the Women, Infants, and Children (WIC) program in 2015, and under 2%
utilized the Child and Adult Care services in 2015.4 Overall, Chatham household food
insecurity averaged out to be nearly 15% from 2013-15.4 Chatham County also has an adult
diabetes rate of 11% and an adult obesity rate of 31.3% (both as of 2013). 4

RECOMMENDATIONS - ACTIONS THAT MAXIMIZE HEALTH BENEFITS

To best ensure greater access to job opportunities within Chatham County, this HIA
includes recommendations for the adoption of policies pertaining to transitional job
programs, bike path and walkway connectivity, and expanding public transit options. In the
county plan’s community survey, the need for each of these policies were reflected to some
extent in the community’s responses.

TRANSITIONAL JOB PROGRAMS. A total of 74% of respondents indicated that the

availability of high paying jobs is not adequate within the community. To address this,
Chatham County indicated in their comprehensive plan that they would develop
apprenticeships and vocational programs. These and transitional job programs are intended
to provide wages, skills training, and support to individuals who experience barriers to the
workforce or who are otherwise disadvantaged.14 These programs promote job security,
especially among those most in need.

While a transitional job program may address the lack of job availability in Chatham,
associated health risks are hard to quantify given the diversity of jobs that may be made
available. While work can provide income, de-incentivizes recidivism and incarceration, and
may improve food insecurity and access (due to overall increased income levels that might
either allow for food purchases without assistance or the provision of transportation modes
Madeline Lasell
CRD 298

that can improve access to other grocery store locations), different work environments can
differently contribute to the health, well-being, and safety of an individual.15 Workplace
hazards and safety protocol, length of work days, and productivity demands are all aspects
to be considered of any workplace, and, they will vary from place to place. 15 So, while a
transitional job program may provide may benefits on an individual and community-wide
level, it does not come without its risks.

BIKE PATHS AND WALKWAYS. Over 70% of community survey respondents supported
the addition of walking and bicycling initiatives in Chatham County. Savannah maintains
its traffic-calming bike paths, but the surrounding areas of East and West Chatham do not.
The comprehensive plan includes several maps of proposed bikeways for the county areas
that would benefit from them. More bike pathways and walkways allow for greater
neighborhood connectivity, which Chatham County residents appear to highly value. Not
only can neighborhood connectivity contribute to social cohesion, but it can simply allow for
more people to access sites of employment, grocery stores and markets, or other services.
Moreover, these paths offer avenues for physical activity and active transport.16 Physical
activity is known to improve health outcomes, so providing more routes that enable
residents to walk or bike will likely increase activity levels and demonstrate positive health
effects—both mental and physical—over time.16

However, placement matters when adding new infrastructures. Depending on where the
most vulnerable members of the community are living, a bike path or additional walkways
may not contribute any community-perceived value to the area. For instance, some
individuals may not be able to afford a bike and the distances may be too far for some
individuals to walk. These pathways may be more desirable to outside residents who may,
in turn, displace the vulnerable individuals altogether.15 Furthermore, while there are
physical benefits to biking and walking, there are also physical risks. Being outdoors
exposes one’s risk of inhaling air pollutants or becoming injured by car collision.15

TRANSIT EXPANSION. In the county’s “Total Mobility Plan,” the community aims to
maximize regional population and employment accessibility through the use of transit and
non-motorized modes of transportation, while also expanding transit service areas and
frequency for areas with low-rates of automobile ownership or high rates of elderly and
disabled individuals. The third HIA recommendation echoes the need for this community
initiative as it can ensure that any and all members are able to commute from one
neighborhood to another for work, as necessary. For members of the community who do not
have bikes or who are physically incapable of biking, transit may also improve the
accessibility of job opportunities. Moreover, transit expansion could lead to additional job
opportunities for county residents at the various station locations themselves.

As a new infrastructure, transit service areas may impose unintended consequences among
certain vulnerable communities.15 Certain communities may prefer not to have transit
stations nearby due the number of people it may attract or because of environmental
concerns. The costs of implementing a transit system will also likely be imposed on the
region’s taxes, which the county may, again, not agree to. It will be imperative for the
county to ensure appropriate dissemination of this plan by engaging community members
as much as possible in the decision-making process. While this recommendation aims to
Madeline Lasell
CRD 298

improve accessibility for low-income, disabled, and low mobility individuals, access to the
additional service areas may still be burdensome for certain residents to get to.

Transitional
Increased
Job Job security
income
Program

Improved
Bike Paths, Improved job
access and
mental and
Walkways food access
physical
health

Transit Mobilization
for elderly and
Improved job
access and
Expansion diabled food access

Figure 2: Positive potential outcomes related to HIA policy prescription recommendations.

MONITORING & EVALUATION - IMPACT ON POLICY AND HEALTH

Monitoring progress on the proposed programs and initiatives will allow for adequate
evaluation and, subsequently, a sufficient impact assessment. Impact can be assessed with
regard to other policies or collective community health outcomes.

TRANSITIONAL JOB PROGRAMS. In the event that a transitional job program is

adopted by Chatham County, monitoring must take place to determine whether it is indeed
positively affecting the community. Residents involved in the program will be followed up
with over time to assess their progress in relation to income and SES, recidivism and
incarceration, and food access. Baseline measures of these indicators will be established
from initial in-person surveys with participants who are enrolled. Income for each resident
that participates should serve as the primary indicator when evaluating this particular
program. Income data can be collected annually through follow-up phone or paper surveys
administered to the enrolled residents. This data will then be used to extrapolate data on
poverty and variations between the county’s socioeconomic status groups. This data can
then assist in determining whether any changes regarding its prevalence have occurred
since the initiation of the program. Recidivism and food access might be considered
annually as secondary outcomes in these participant surveys in order to determine how
increasing job availability has resulted in changes regarding crime and food insecurity—
two metrics that Chatham County specifically identified in their comprehensive plan.
Madeline Lasell
CRD 298

BIKE PATHS, WALKWAYS, TRANSIT EXPANSION. Bike paths, walkways, and

transit service areas should be incrementally incorporated within the community in order
to monitor whether accessibility to job sites improve after each new addition. Specifically,
the mileage of paths and the number of county residents who utilize the walkways to access
either a transit system or their place of work will be collected to monitor how path distance
correlates with the number of path travelers. If residents indicate an improved ability to
travel from their neighborhood to another for the purposes of work or other services (i.e. if
more residents report using the paths or walkways), then the county might consider
proceeding with more infrastructures. Furthermore, the paths, walkways, and transit could
not only result in increased access to jobs, but increased job opportunities themselves.
These policy developments could hire residents to build and maintain the paths and
walkways, in addition to running the transit service stations. The number of jobs that are
created as a result of these developments will be monitored over time to further assess job
opportunities and accessibility.

Ultimately, while “access to jobs” may serve as a short-term indicator of policy progress
regarding these developments, long-term indicators would include income (due to improved
access to employment), recidivism (due to improved access to employment), and food access
(due to increased access to income opportunities) in order to determine the relationship
between overall improved job access and health outcomes (i.e. chronic disease status and
mental health).
Madeline Lasell
CRD 298

REFERENCES

1. Centers for Disease Control. (2016). Health Impact Assessment. Retrieved from
https://www.cdc.gov/healthyplaces/hia.htm.
2. Chatham County-Savannah Metropolitan Planning Committee. (2016). Chatham
County-Savannah Comprehensive Plan. Retrieved from
http://www.thempc.org/Dept/Comp.
3. American Community Survey. Retrieved from
https://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml.
4. USDA Food Atlas. Retrieved from https://www.ers.usda.gov/foodatlas/.
5. The State of Obesity. (2016). The State of Obesity in Georgia. Retrieved from
https://stateofobesity.org/states/ga/.
6. Walkscore. Retrieved from https://www.walkscore.com/GA/Savannah.
7. Adler, N. (1999). Socioeconomic status and health: What we know and what we
don't. Annals of the New York Academy of Sciences., 896(1), 3-15.
8. Baum, A. (1999). Socioeconomic status and chronic stress. Does stress account for
SES effects on health? Annals of the New York Academy of Sciences., 896(1), 131-44.
9. Lopes, B., Kaumau C., Jaspal, R. (2018). The roles of socioeconomic status,
occupational health and job rank on the epidemiology of different psychiatric
symptoms in a sample of UK workers. Community Mental Health Journal.,1-14.
10. Mallik-Kane K, Visher C. (2008). Health and prisoner reentry: how physical, mental,
and substance abuse conditions shape the process of reintegration. Urban Institute.
Retrieved from https://www.urban.org/sites/default/files/publication/31491/411617-
Health-and-Prisoner-Reentry.PDF.
11. James DJ, Glaze LE. (2006). Mental Health Problems of Prison and Jail Inmates.
Bureau of Justice Statistics Special Report. Retrieved from
https://www.bjs.gov/content/pub/pdf/mhppji.pdf.
12. Laraia, B.A. (2013). Food insecurity and chronic disease. Advanced Nutrition., 4,
203-212.
13. Chatham County Sheriff Office. Annual Report (2016). Retrieved from
http://www.chathamsheriff.org/Portals/Sheriff/Community/Community%20Report.pdf.
14. Heartland Alliance. (2017). National Transitional Jobs Network. Retrieved from
https://www.heartlandalliance.org/nationalinitiatives/our-initiatives/national-
transitional-jobs/.
15. Dannenberg, A.L. (2011). Making Healthy Places: Designing and Building for
Health, Well-being, and Sustainability.
16. Mueller, N., Rojas-Rueda, D., Cole-Hunter, T., de Nazelle, A., Dons, E., Gerike, R.,
Gotschi, T., Panis, L.I., Kahlmeier, S., Nieuwenhuisjsen, M. (2015). Health impact
assessment of active transportation: a systematic review. Preventative Medicine.,
76(2015), 103-114.