• Feature

    Getting Around: Community Mobility

    APTA's Strategic Plan envisions transforming society by reducing barriers to movement. Enhancing community mobility is a key element. Many PTs already are helping to achieve the vision.

    Feature Community

    Community mobility has been defined as "planning and moving around the community and using public or private transportation, such as driving, walking, bicycling, or accessing and riding in buses, taxi cabs, or other transportation systems."1 Yet, as a report by the US Census Bureau observes, "Much of the developed landscape in the United States was designed to accommodate automobile travel, complicating travel by walking or bicycling in many areas."2 Further, traffic congestion and poor road design is hampering even auto travel in many cities.

    But community mobility is more than getting from Point A to Point B. It also involves opportunities for exercise, relaxation, and transport alternatives to the automobile.

    Thus, the Centers for Disease Control and Prevention, in "Overcoming Barriers to Physical Activity," cites a "lack of parks, sidewalks, bicycle trails, or safe and pleasant walking paths convenient to homes or offices" as a deterrent to community mobility.3

    Other research has shown that when communities are designed with movement in mind, there are more opportunities for physical activity. In "Tracking Physical Activity Around the World," the National Institutes of Health analyzes a study of steps data captured by smartphone apps. "Data from 69 US cities showed that higher walkability scores were associated with lower activity inequality," the document notes. "These scores measure city block length and other factors that affect how easy it is to walk to shops and parks. Higher walkability was associated with significantly more daily steps regardless of age, gender, or body mass index."4,5

    So, figuratively if not literally, how do communities get from Point A to Point B?

    The physical therapy profession needs to be more involved in making sure people of all ages and abilities have places to be active, says Chris Hinze, PT, DPT, a physical therapist (PT) at Grand Traverse Pavilions in Traverse City, Michigan. After all, he points out, APTA's vision for the profession is "Transforming society by optimizing movement to improve the human experience."

    "We do a good job of encouraging 1 patient at a time to be physically active," Hinze says, "but PTs and physical therapist assistants (PTAs) could do better. PTs need to provide more support from a community-design standpoint." PTs and PTAs traditionally aren't active in urban planning, he notes. Nor do enough people in the profession realize the extent to which the planned environment can encourage people to be active. Those are areas in which the profession's expertise would be valuable, Hinze says.

    "As a profession, we should push our communities to be ready for our patients and clients—citizens at large—to walk, roll, or ride the sidewalks, streets, and trails," says Sarah Greenhagen, PT, DPT. Greenhagen, a board-certified clinical specialist in geriatric physical therapy, is cofounder of Catalyst Physiotherapy, Performance and Wellness in Sandwich, Illinois.

    In 2015, APTA's Michigan delegation, led by Hinze, advanced motions to amend the association's position statements on the roles of the profession and APTA in advocating for prevention, wellness, fitness, health promotion, and management of disease and disability. The delegation proposed adding language supporting APTA and its members in advocating for "appropriate efforts that enhance community design to promote safe physical activity and active forms of transportation for individuals and populations of all ages and abilities."6,7 The motions passed APTA's House of Delegates in June 2016.

    "From the association's perspective, when we talk about advocacy, we talk about any opportunity to better position PTs and PTAs so they can have an effective role," says Justin Elliott, APTA's vice president of government affairs. Those opportunities can arise at the individual, organizational, community, chapter, and national levels.

    APTA's Strategic Plan for 2017 includes the society-facing goal that "Barriers to movement will be reduced at population, community, workplace, home, and individual levels." Anita Bemis-Dougherty, PT, DPT, MAS, APTA's vice president of practice, says, "Our focus always has been on reducing barriers, to allow people to continue to function and participate within their community, whether they are going to school, work, or recreation." Traditionally, PTs and PTAs have focused on individualized care for their patients. A shift is needed to include an emphasis on influencing the health behaviors of entire communities.

    What's Hindering Community Mobility?

    Advocating for community mobility begins by acknowledging the barriers that separate people from activity. Perceived lack of safety is a primary reason people choose not to venture outside their homes. That feeling can come from the physical environment, such as cracked sidewalks, or even a lack of sidewalks that makes walking hazardous. Lack of curbs that are level with the road and absence of pedestrian-friendly crosswalks also make mobility hazardous.

    Cycling frequently is cited as another means of community mobility. While some cities have taken the initiative and installed bike lanes, such lanes can be dangerous if they aren't properly separated from traffic.

    Lack of safety also can arise from psychosocial factors. When Nicole Stotts, PT, DPT, prepares her patients for the end of their plan of care, she encourages them to walk. But often they won't, she reports, because they fear for their personal safety. Stotts, a board-certified clinical specialist in geriatric physical therapy, practices at Ingalls Memorial Hospital in Harvey, Illinois. "In the community my hospital serves, there are areas of poverty and crime. At times, people are afraid to go outside," she says—explaining that, with some residential areas affected by vacancy and disrepair, the environment is not always safe. Additionally, some public areas lack accommodations for people with limited mobility to maneuver safely.

    With patients who are geriatric, cognitive issues can be an additional barrier to community mobility, Stotts says. Getting around in the community can require the help of another person, and that isn't always a possibility. Some patients aren't able to drive or call a taxi. If their surrounding environment doesn't support safe walking as a mode of transportation, they simply don't leave their homes.

    Community mobility also is hindered by a lack of awareness and resources. "There's definitely an equity issue when it comes to safe places to be active," Hinze says. He observes that designated walking and biking trails are not as common in rural areas and in areas with lower socioeconomic populations.

    Models of Community Mobility

    Zachary Rethorn, PT, DPT, of BenchMark Physical Therapy in Chattanooga, Tennessee, asks, "What is a person's social and cultural environment? What is being modeled?" When Rethorn has traveled to Europe, he's seen bike lanes "everywhere." Those communities are built around walking and biking as safe, environmentally friendly modes of transit—in contrast to the car-centric culture of most of America. It can take patients without cars 2 to 3 hours to get to Rethorn's clinic. The surrounding environment was not built to support alternative means of transportation.

    In Global Age-Friendly Cities: A Guide, the World Health Organization (WHO) writes, "The outside environment and public buildings have a major impact on the mobility, independence, and quality of life of older people."8 The report cites public green spaces, walkways, and cycle paths as factors that encourage safe and healthy aging.

    Walkways and sidewalks should be designed or modified to serve the mobility needs of as many people as possible, WHO says. That includes widening them so people in wheelchairs can maneuver, creating a smooth, level surface that makes walking or rolling easy, and lowering curbs to become more even with roads.

    Accessible and affordable transit, including free or low-cost services for seniors, also is a factor that determines age-friendly cities. "Being able to move about the city determines social and civic participation, and access to community and health services," the report says.

    Hinze agrees. "We need to shift design principles away from designing for automobiles and toward designing for people."

    What can PTs and PTAs do to promote these types of change?

    "Every PT has a potential role to play," Elliott says. "It's up to individuals to determine where they think they can be most effective, based on their expertise, their interests, and the needs of their community, town, or city."

    Education and encouragement are the first steps in getting around those barriers. "As a profession, we strive to increase a person's ability to engage in their surroundings and meaningful activities," Greenhagen says.

    That can be as simple as advising people to walk if their trip is under a certain distance, suggests Jennifer Ryan, PT, DPT, MS, program coordinator in critical care at University of Chicago Medicine and education chair of the Cardiovascular and Pulmonary Section of APTA. In Ryan's home town of Chicago, the city's Safe Passage program stations adult volunteers at corners along the route to school. Kids then can feel safe as they walk and get in some physical activity for the day. Rethorn's Chattanooga had success incorporating a river walk—a car-free walking and biking path.

    With patients who are older, "Exercise can alleviate symptoms of depression," says Stotts, noting that staying inside the home all day can cause people to be lonely and depressed. According to a recent study, the more times community-dwelling elders leave their home, the more positive correlations there are to health status.9 Regardless of age, as Ryan puts it, "Your body and brain need you to move."

    Community centers offer a wide range of recreation opportunities, including exercise classes for senior citizens. "It's a huge benefit, especially for those without social support. They look forward to meeting with each other," notes Stotts. Since not everyone can afford expensive gym memberships, community facilities should be accessible, both physically and financially, she says. That includes the availability of affordable community transportation options.

    PTs and PTAs also can speak for populations that have a more difficult time moving, including those who rely on mobility aids such as wheelchairs and walkers. "People with disabilities often are underserved," Stotts observes. Her main focuses are on quality of life and independence—giving people the tools they need to get out of their homes and have something to look forward to.

    What Is the Value of Inclusive Community Design?

    Community planners should design buildings and neighborhoods that are safe and accessible for everyone, according to both research and the PTs interviewed for this article. "Appropriate community planning and design can open up the availability of a town's businesses, parks, schools, and churches to all of the members of the community," says Greenhagen.

    Getting involved at the planning stages of projects is a way PTs and PTAs can advocate for community mobility resources. Ryan shares the experience of a fellow PT who saw flaws in her church's plans to build a new, round building in which attendees would have to walk downhill to approach the altar. The PT saw that the proposed church floor would be too steep for those who use assistive devices. She used her disability awareness to collaborate with those with construction knowledge to develop a better option.

    PTs and PTAs also can use their knowledge of human movement to speak up and become involved on a civic and community level. Ryan suggests PTs and PTAs attend public hearings on potential modifications to public buildings. They can help ensure that such changes meet the criteria for people who use assistive devices. Bemis-Dougherty notes that "APTA encourages its members to help engineers figure out how to make cities more accessible places for people with disabilities."

    Rethorn has spoken before his city's department of transportation about the relationship between lowered speed limits and leisure and fitness walking. He offers his services as an advocate and has spoken to city council members on the topic.

    Ryan gives the example of a town debating whether to repave bike paths. "A PT should be the person who brings his or her expertise to the city council." She continues, "People need opportunities to move but need to be able to fit it into their lives." If physical activity is easily integrated into daily living, it will feel less like a time burden. Advocating for active transportation, such as the means to walk or cycle to get from place to place, is a way to offer such opportunities.

    Stotts, who teaches at Kankakee Community College, last year had her PTA students educate other students on campus on fall risk factors and common safety measures. The students, she reports, were amazed at how many people were unfamiliar with simple precautions. A key element: being conscientious and creating awareness.

    Greenhagen founded the WellBatavia Initiative in Batavia, Illinois. The program is designed to improve residents' health literacy and make residents and city leaders aware of how urban planning decisions affect health and wellness. To encourage exercise and mobility, the program hosts free fitness classes, healthy living seminars, and wellness fairs. "Community surveys provide valuable information and insight on how members of the community access amenities and what limitations are present," she notes.

    WellBatavia Initiative leaders have spoken before the city council advocating for pedestrian-friendly crosswalks and other city planning decisions that improve the walkability of the town. Greenhagen notes, "Recently we were awarded a grant to further our goal of improving the accessibility to our town, regardless of method of transportation [ie, walking, biking, cane/walker, wheelchair, or stroller]. We will complete this analysis by the end of 2017."

    Hinze is on the board of the nonprofit Norte! in Traverse City, Michigan, founded by a husband and wife who are both PTs. Norte! focuses on cycling and hosts "bike trains," where kids meet before and after school to ride together. It also teaches bike safety in urban settings. And it has an advocacy program—for instance, it supports dedicated and separate bike lanes. "My role is to ramp up advocacy efforts," Hinze says. "We saw a need for the organization to be a stronger voice in the community for a safe place for kids to bike."

    The program started as a grassroots movement and is growing. Elected leaders listen to large numbers of voters, Hinze explains, so mobilizing support is crucial. "We've become a voice in city hall on why these issues are important." Other cities have similar organizations that promote safe biking or safe walking. Hinze points to these as good opportunities for PT and PTA involvement.

    Ryan agrees that cycling is a great opportunity for exercise and for environmentally friendly transportation. PTs and PTAs can educate consumers on proper bike fitting, and on making safe choices such as wearing helmets.

    APTA's Role

    On an association level, APTA's volunteer group pool offers members the chance to volunteer to serve on national panels, work groups, and task forces on different mobility and wellness topics when such opportunities arise.

    "APTA is doing a good job at looking at opportunities for other groups with whom to collaborate," Hinze says. One example is the National Physical Activity Plan Alliance (NPAPA), of which APTA is a member. NPAPA oversees the National Physical Activity Plan, a series of policies and programs that support the organizations' vision: "One day, all Americans will be physically active, and they will live, work and play in environments that encourage and support regular physical activity."

    The plan includes a section on transportation, land use, and community design. It calls for designs that support safe biking and walking, and affordable public transit.

    "Physical activity and public health organizations should advocate for funding and policies that increase active transportation and physical activity through greater investment in bicycle and pedestrian infrastructure and transit," the plan states.

    "Every PT should advocate for safe places to engage in physical activity," Rethorn says. "Community resources should be available to everyone." Whether those resources are walking trails, bike paths, or community centers, PTs and PTAs can be voices for stronger community mobility.

    Danielle Bullen Love is a freelance writer.

    References

    1. The occupational therapy role in driving and community mobility across the lifespan. The American Occupational Therapy Association. http://www.aota.org/About-Occupational-Therapy/Professionals/CY/Driving-Across-Lifespan.aspx. Accessed September 3, 2017.
    2. McKenzie B. Modes less traveled—bicycling and walking to work in the United States: 2008-2012. American Community Survey Reports ACS-25. May 2014. http://www.census.gov/prod/2014pubs/acs-25.pdf. Accessed September 3, 2017.
    3. Overcoming barriers to physical activity. Centers for Disease Control and Prevention. http://www.cdc.gov/physicalactivity/basics/adding-pa/barriers.html. Accessed September 3, 2017.
    4. Tracking physical activity around the world. NIH Research Matters. July 25, 2017. National Institutes of Health. http://www.nih.gov/news-events/nih-research-matters/tracking-physical-activity-around-world. Accessed September 3, 2017.
    5. Althoff T, Sosič R, Hicks JL, et al. Large-scale physical activity data reveal worldwide activity inequality. Nature. [Epub ahead of print]. 2017;547(7663):336-339. doi: 10.1038/nature23018. Accessed October 4, 2017.
    6. The association's role in advocacy for prevention, wellness, fitness, health promotion, and management of disease and disability. HOD P06-16-05-06. http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Practice/AssociationRoleAdvocacy.pdf. Accessed September 5, 2017.
    7. Physical therapists' role in prevention, wellness, fitness, health promotion, and management of disease and disability. HOD P06-16-06-05. http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Practice/PTRoleAdvocacy.pdf. Accessed September 5, 2017.
    8. Global Age-friendly Cities: A Guide. World Health Organization; 2007. http://www.who.int/kobe_centre/publications/age_friendly_cities_guide/en/. Accessed September 3, 2017.
    9. Mura G, Cargo, MG. Physical activity in depressed elderly, a systematic review. Clin Pract EpidemiolMent Health. 2013(9):125-135. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3758953/pdf/CPEMH-9-125.pdf. Accessed September 3, 2017.

    Making Communities More Livable

    AARP and the Walkable and Livable Communities Institute have published a collection of 11 "Livability Fact Sheets" for use in helping make communities safer, healthier, more walkable, and more livable for people of all ages. There are many areas in which PTs and PTAs are, or could become, involved.

    Within the fact sheets are these suggested strategies:

    Bicycling. Half of all trips taken in the United States are 3 miles or less, but only 3% of commuting trips are by bicycle. Surveys indicate that 60% of Americans would ride a bike if they felt safe doing so, and 8 out of 10 agree that bicycling is a healthy, positive activity.

    According to the fact sheet on bicycling, "Bicycle-friendly features increase safety for all road users, including motor vehicles." It points to action by New York City in 2010 to remove a traffic lane and paint a 2-way bicycle path with a 3-foot parking lane buffer next to Brooklyn's Prospect Park. Weekday bicycling traffic tripled, speeding by all vehicles dropped from 74% to 20%, crashes for all road users dropped 16%, and injuries fell by 21%—all without a change in corridor travel time.

    The fact sheet suggests that bicycle advocates build support for a public process that develops a pilot project, provides adequate bicycle parking, creates routes and wayfaring signs, and establishes a bike share program.

    Density. The larger the number of housing units per acre, the higher the density. The AARP fact sheet on density supports dense, mixed-use developments—which, it explains, "come in a variety of forms, from small-lot detached homes to condo buildings and townhouses in a suburban town center, to apartments atop downtown retail shops."

    The document cites studies that found that when the housing market declined in 2007, the neighborhoods that held their property values best were high-density communities that featured a mix of uses. The reason, it explains, "is that many baby boomers and young adults are choosing to settle in walkable neighborhoods that offer a mix of house and transportation options and are in close proximity to jobs, schools, shopping, entertainment, and parks." Further, it adds, "The nation's decreasing birthrate and aging population will continue to boost the demand for smaller homes in more compact neighborhoods."

    The fact sheet urges: Build support for a public process; inspire the public with model projects; ensure that any new development complements a neighborhood's existing homes and streetscape; develop the right design for the area (which may include smaller single-family homes on small lots, with rear-access garages or street parking); and use form-based codes (not conventional zoning) that consider the relationship between buildings and the street, pedestrians and vehicles, public and private spaces, and the size and types of streets and blocks.

    Modern roundabouts. Every day in the United States, more than 20 people are killed at traffic intersections, and many more are seriously injured. The fact sheet on modern roundabouts says that these circular intersections that move traffic counterclockwise around a central island can help reduce deaths and injuries. Roundabouts can handle 30% to 50% more traffic than can conventional intersections. Roughly the size of a baseball infield, modern roundabouts differ from rotaries or traffic circles, which can be as big as an entire outfield. The US Department of Transportation has called modern roundabouts a "proven safety countermeasure."

    In particular, they can improve safety for bicyclists, pedestrians, and older adults, the fact sheet says. For example, after installing a string of 5 roundabouts, San Diego, California, was able to reduce the number of vehicle lanes in the road from 5 to 2 while reducing travel time, adding on-street parking, and attracting new businesses. The number of people walking rose, noise pollution fell, and the increase in walking, bicycling, and street life brought new business to retailers.

    Tips for advocating for roundabouts include: Adopt a roundabout-first (rather than intersections) policy, build support for a public process, design for speeds lower than 20 miles per hour, keep dimensions tight, and make it beautiful.

    Revitalization without displacement. The AARP fact sheet on revitalization cautions: "Mixed-use revitalization—and its potential to restore health and prosperity to a community—also carries with it the potential to increase property values and, therefore, real estate prices. While many in the community will profit from the improvements and rising values, others may not." It continues: "It behooves all redeveloping communities to ensure that revitalization increases community health and stability by providing such features as affordable housing, robust transit services and access to transit, as well as a range of needed services and shops within walking and bicycling distance."

    Addressing walkability, the AARP Public Policy Institute issues a caution regarding the mobility impact on older residents who are displaced into areas that are not as livable or walkable: "In areas far from transit, areas with few community features and services nearby, and areas with poor transit service, losing mobility can mean losing independence." Further, it notes that low-income families spend 55% of their household budget on transportation costs. "Revitalized places made walkable and accessible to transit can reduce these expenses, which makes the community more supportive of all people."

    For advocates of mixed-use revitalization, the fact sheet says the goal "is best achieved when a municipality plans for and financially supports affordable housing for all income levels in the community." Steps may include encouraging employer-assisted housing, creating home ownership programs, and adopting inclusionary zoning—requiring developers to build affordable units, usually in exchange for increased development rights or subsidies.

    Sidewalks. People who live in neighborhoods with sidewalks are 47% more likely than are residents of areas without sidewalks to be active at least 30 minutes a day, according to a study cited in the fact sheet on sidewalks. Another study concluded that safe, accessible, well-maintained sidewalks are a fundamental community investment that enhances public health and maximizes social capital. A third study found that 8 in 10 Americans prefer being in a community that offers sidewalks and good places to walk.

    The fact sheet also offers success stories, such as the experience of Austin, Texas. The city has built almost 100 miles of new sidewalks since 2005 to encourage walking as a viable mode of transportation, and to improve safety, accessibility, and pedestrian mobility. Austin prioritizes compliance with the Americans with Disabilities Act; sidewalks that allow children to walk safely to school; a connected network of sidewalks, trails, and bikeways; and sidewalks that serve bus stops.

    Among the tips for those advocating for sidewalks are: Engage neighbors and the community, make the sidewalk wide enough, use a site-appropriate design, and prioritize high-use areas and connectivity.

    Resources

    AARP Livable Communities

    AARP
    Enhancing Mobility Options for Older Americans

    The Alzheimer Association Public Policy Division and The National Highway Traffic Safety Administration
    Community Mobility and Dementia

    American Federation for the Blind

    Community Transportation Association of America
    Resources

    Magee Rehabilitation Hospital
    Day in the Life: Community Mobility

    National Aging and Transportation and Disability Center
    Checklist for Assessing the Accessibility of Transportation and Mobility

    World Health Organization
    Global Age-friendly Cities: A Guide

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