Built Environment

The built environment refers to human-made (versus natural) resources and infrastructure designed to support human activity, such as buildings, roads, parks, and other amenities. The characteristics of the built environment can affect the health of residents in multiple ways. This focus area seeks to measure the availability of healthy food and recreational facilities in the local built environment.

As obesity rates have increased over the past decades, interest in looking at local food and recreational environments as potential contributors to obesity has also increased. The variety, price, and availability of healthy foods in the local environment can play a role in whether those foods are consumed. Additionally, the availability of recreational facilities can influence individuals’ and communities’ choices to engage in physical activity.

Why Do We Measure It?

Better information on the availability of healthy food and recreational facilities within the built environment will enable communities to take action to reduce the adverse health outcomes associated with poor diet, lack of physical activity, and obesity.

Though research on the food environment is still in its early stages, a systematic review of existing literature found strong evidence that access to supermarkets rather than smaller grocery/convenience stores correlates with lower prevalence of overweight, obesity, and hypertension.[1] Conversely, proximity to small grocery or convenience stores was associated with a higher prevalence of these factors.[1]

Similarly, recent research demonstrates a strong relationship between access to recreational facilities and physical activity among adults and children.[2-6] Studies have demonstrated that proximity to places with recreational opportunities is associated with higher physical activity levels.[5] Evaluations of interventions intended to improve or create access to places where people can be physically active showed strong evidence of effectiveness, measured by improved aerobic capacity and greater frequency of physical activity in targeted areas.[6] The evidence for the effectiveness of improving access to recreational facilities is so strong that the Centers for Disease Control and Prevention (CDC) recommend it as one of 24 environmental- and policy-level strategies to reduce obesity in its Common Community Measures for Obesity Prevention Project.[7]

Access to Healthy Foods

Researchers have used a variety of strategies for measuring the food environment and access to recreational facilities ranging from geographic information systems to observational assessments.

Although multiple studies have shown that many characteristics of the local environment correlate with health behaviors related to food choice, there has not been a study to compare and contrast the various methods for measuring the food environment. There is also a lack of focus on characteristics of a defined food environment, such as store design or product placement, that may affect individual behavior.[9]

One study uses a novel methodology to measure accessibility to health-related community resources, including supermarkets. Pearce et al. developed a geographic information system (GIS) technique to measure the time it takes residents to travel to 16 types of health-related community resources in New Zealand. The researchers argue that using GIS techniques to measure health outcomes based on neighborhood characteristics allows greater precision in analyzing variations in access to resources.[10]

Other researchers agree that geographic and global positioning technology should play a role in understanding the food environment, but say that simply looking at the distance to the store is not sufficient. Researchers need to look at how many shopping opportunities an individual has in order to compare prices and selection.[11] Sharkey advocates for a standard policy of "ground-truthed" methodology for measuring the rural food environment, which includes on-site observation and collection of global positioning system (GPS) data.[12]

Other literature indicates that the size and type of grocery stores influences the consumption of produce and healthy foods. Supermarkets have been shown to have a greater selection of fruits and vegetables and lower prices than smaller, non-chain grocery stores.[13] Because data on outlet size is not reliable, the County Health Rankings measurement includes all grocery stores as well as the number of produce stands or farmers’ markets in a county.

Researchers have used several methods to capture important aspects of the built environment that affect physical fitness and activity levels. One way to assess access to such facilities is to ask people in communities about their environment; however, studies using self-reported data collected by interviewers may be less reliable compared to other methods of assessing the built environment and expensive to conduct on a large scale. Another approach involves sending teams of auditors to communities to measure built environment features using specific criteria and tools. Although this methodology improves reliability of data compared with self-reported surveys, it can be time consuming, expensive, and subject to measurement error due to differences in skills among data collectors. Some studies have attempted to use geographic information systems (GIS) data to create objective measures of the built environment. To date, these methods show strong promise for collecting reliable and objective data; however, many communities do not have detailed GIS information available and the staff and resources needed to collect and analyze such data are expensive.[3] It is likely that the utility and availability of GIS data for informing communities about the status of the local built environment will increase over time.

Access to recreational facilities such as parks, sports fields and facilities, biking trails, public pools, and playgrounds can be improved by locating them closer to homes and schools, lowering costs to use the facilities, increasing hours of operation, and ensuring access to people with various ability levels and limitations.[6] No source of data or index currently captures all these elements of the built environment.

The County Health Rankings uses two sets of US Census’s Bureau Business Patterns data for these measures. For the Food Environment, the Rankings use 2008 ZIP Code Business Patterns data to calculate the percentage of residential ZIP codes in a county without a “healthy food outlet.” Healthy food outlets are identified by their North American Industry Classification System (NAICS) code. Those food outlets considered “healthy” include grocery stores (NAICS 445110) and produce stands or farmers’ markets (NAICS 445230). Because healthy food outlets often are clustered in wealthier neighborhoods, leaving only limited healthy food access in poorer communities, the County Health Rankings measure is intended to estimate the distribution of healthy food outlets in a county.
To measure access to recreational facilities, the County Health Rankings replicates the measure used by the USDA Food Environment Atlas, using the most current County Business Patterns data set (2008). The Food Environment Atlas presents a measure of recreational facilities per population, in which recreational facilities are identified by the NAICS code 713940. This industry class includes establishments primarily engaged in operating fitness and recreational sports facilities, featuring exercise and other active physical fitness conditioning or recreational sports activities, such as swimming, skating, or racquet sports. The measure reported by the County Health Rankings is recreational facilities per 100,000 population in the county. More detailed information about the social and cultural environments in communities may lead to a better understanding about what will improve physical fitness levels, but presence of recreational facilities is the best indicator of the built environment that is currently available across all counties in the U.S.

Access to Healthy Foods

Many studies found an unequal distribution of supermarkets and smaller grocery stores in minority and low-income neighborhoods. While white neighborhoods had more supermarkets, minority and low-income neighborhoods were routinely found to have fewer supermarkets and more small grocery stores.[17-20] In smaller, non-chain grocery stores, the prices for high quality, nutritious foods such as fresh produce are higher than in chain grocery stores, which presents an additional barrier for people with low incomes.[21]

Another study found that obesity prevalence was lower in areas with supermarkets and higher in areas with small grocery stores/fast food restaurants.[19] Similarly, there is evidence that household fruit and vegetable use among Supplemental Nutrition Assistance Program (SNAP) participants increased when there was easy access to supermarket shopping.[22]

The food environment is a factor not only in urban neighborhoods but also in rural communities. A study that compared supermarkets and convenience stores in a rural area found that healthy food was much more prevalent at supermarkets and grocery stores compared to convenience stores. Researchers in this study found that low-fat milk, apples, and high-fiber bread were available in 75% to 100% of supermarkets compared with 4% to 29% of convenience stores.[23]

While the evidence indicates that there are positive health benefits associated with proximity to supermarkets, few studies offer before/after comparisons of adding a healthy food source to the community. Those studies that considered this factor found limited evidence that a new supermarket prompted increased fruit and vegetable consumption in the community.[24,25]

Other researchers point out that “neighborhood” is difficult to define. Most people move between multiple environments on a daily basis (e.g., school, work, home, entertainment), making it difficult to pin down a specific “neighborhood” to which they belong. Defining “neighborhood” based on census tracts or ZIP codes makes assumptions about how people shop and does not include social, cultural, educational, and financial considerations regarding behavior. Instead, it is necessary to consider the relative influences of different environments or neighborhoods as well as how an individual participates in those environments.[26,27] One study reviewed by Lytle found that 14.4% of respondents shopped outside their census tract areas and that low-income people were less likely to buy recommended nutritious food items even though they were available in stores.[17]

Access to a supermarket alone may not adequately explain the local food environment. One study analyzed the shelf space devoted to types of food in grocery stores across the country and found that different regions have different mixes of foods in grocery stores.[28] This study also argues against using NAICS codes to classify food outlets because they do not distinguish between supermarkets, medium-sized food stores and small food stores that likely have different mixes of foods.

Many studies have measured the presence of recreational facilities in communities.[2,4] In studies that reported reliability, physical environment indicators were found to be easier to collect than social environmental characteristics such as crime and social capital.[6] However, the physical presence of a facility does not necessarily translate into easy access or frequent use by community members.[3] Although they are difficult to measure at the community level, cost barriers, safety issues, and knowledge about how to use facilities are important aspects that influence a community’s likelihood to use facilities located nearby.[4]

Another drawback of the County Business Patterns data is that the method used to identify recreational facilities does not include YMCAs and intramural/amateur sports clubs, both of which may be important venues for physical activity in many communities, and especially for low- and middle-income members of communities. Furthermore, this measure does not account for the opportunity to engage in natural fitness activities, such as parks or other public areas. These other venues and opportunities for recreation vary in importance depending on characteristics of the community such as proximity to other urban and rural areas, socioeconomic composition, and weather patterns.[4] In the absence of other measures of physical fitness and recreational opportunities at the county level, the rate of recreational facilities per 100,000 population is a suitable measure for comparing across communities.