Fresno Dowtown Neighborhoods Community Plan Health Impact Assessment

health impact assessment fresno downtown neighborhoods

Prepared for: Prepared by:

Local Government Commission

Raimi + Associates and Meredith Glaser March 2011

fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t

CONTENTS Contents ......................................................................................................................................................... 1 Executive Summary ......................................................................................................................................... 3 Introduction & Overview ................................................................................................................................. 5 What is Health Impact Assessment? ............................................................................................................ 6 What is the rationale for this HIA? ............................................................................................................... 7 What are the community’s health priorities? ............................................................................................... 8 What are the key health issues analyzed? .................................................................................................... 9 Background ................................................................................................................................................... 10 Who Lives in Fresno? ................................................................................................................................. 11 Who Lives in the Downtown Neighborhoods? ........................................................................................... 13 Vulnerable populations .......................................................................................................................... 14 What are the current health conditions in Fresno? .................................................................................... 16 Leading Causes of Death ........................................................................................................................ 16 Obesity & Overweight ............................................................................................................................ 18 Heart-Related Conditions ....................................................................................................................... 20 Physical Activity ..................................................................................................................................... 21 Asthma & Respiratory Conditions ........................................................................................................... 22 Summary of Health Conditions ............................................................................................................... 25 What is the Downtown Neighborhoods Community Plan? ......................................................................... 26 Values .................................................................................................................................................... 26 Strategies ............................................................................................................................................... 26 Plan Components ................................................................................................................................... 27 Goals & Policy Directions........................................................................................................................ 28 Methods ....................................................................................................................................................... 29 Interviews & Community Meetings ............................................................................................................ 30 Academic & Professional Guidance ............................................................................................................ 31 Literature Review ...................................................................................................................................... 32 Assessment of Existing Conditions ............................................................................................................. 32 Assessment of Key Health Issues ................................................................................................................... 33 Determinant 1: Regular Physical Activity .................................................................................................... 33 Regular physical Activity | Existing Conditions ........................................................................................ 35 Final Report – March 2011

fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t

Regular physical Activity | Community Input .......................................................................................... 39 Regular Physical Activity | Supported Policies & Actions in the Plan ....................................................... 39 Regular physical Activity | Plan analysis.................................................................................................. 39 Regular Physical Activity | Recommended Revisions for the Plan ........................................................... 43 Determinant 2: Diet & Nutrition ................................................................................................................ 44 Diet & Nutrition | Existing conditions ..................................................................................................... 45 Diet & nutrition | Community input ....................................................................................................... 49 Diet & nutrition | Supported Policies & Actions in the Plan .................................................................... 50 Diet & nutrition | Plan analysis............................................................................................................... 50 Diet & nutrition | Recommended Revisions for the Plan ........................................................................ 51 Determinant 3: Environmental Pollutants .................................................................................................. 52 Environmental Pollutants | Existing Conditions ...................................................................................... 54 Environmental Pollutants | Community input ........................................................................................ 57 Environmental Pollutants | Supported Policies & Actions in the Plan...................................................... 57 Environmental Pollutants | Plan analysis ................................................................................................ 58 Environmental Pollutants | Recommended Revisions for the Plan .......................................................... 60 Determinant 4: Social and economic stability ............................................................................................ 61 Social & Economic Stability | Existing conditions .................................................................................... 63 Social & Economic Stability | Community input ...................................................................................... 70 Social & Economic Stability | Supported Policies & Actions in the Plan ................................................... 70 Social & Economic Stability | Plan Analysis ............................................................................................. 71 Social & Economic Stability | Recommended Revisions for the Plan ....................................................... 73 Recommendations ........................................................................................................................................ 74 Summary of impacts & Recommendations ................................................................................................ 74 Social & Economic Stability .................................................................................................................... 74 Diet & Nutrition ..................................................................................................................................... 75 Environmental Pollutants ....................................................................................................................... 76 Regular Physical Activity ......................................................................................................................... 77 Next Steps ................................................................................................................................................. 78 References .................................................................................................................................................... 79

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t

EXECUTIVE SUMMARY According to the City of Fresno’s Planning Department, the Downtown Neighborhoods Community (DNC) Plan and Fulton Corridor Specific Plan “represent an important opportunity revitalize these areas, focusing on rehabilitation, aesthetics, infrastructure, incorporation of a high speed rail station, and attraction and expansion of businesses.” The Downtown Neighborhoods Community Plan is a comprehensive update to the older and more limited Central Area Plan of 1989, where issues of environmental justice, health outcomes, or other direct health impacts were not addressed. The DNC Plan’s ultimate goal is to “regenerate the Downtown Neighborhoods of Fresno in a manner that brings lasting prosperity, social improvement, and physical consolidation.”

Land use planning + health More and more evidence demonstrates the connection between land use planning decisions and community health outcomes. The quality of the pedestrian or bicycle environment, such as sidewalks, bicycle lanes, signals, and crosswalks, can impact a resident’s decision to walk or bike, which in turn influences physical activity levels. Similarly, neighborhood parks and open space provide an avenue for increased physical activity. Access to full-service grocery stores and farmer’s markets is also correlated with improved consumption of fruits and vegetables. The physical presence and distribution of health care providers and facilities influence how easily people can access health care. The Downtown Neighborhoods Community Plan has a great potential to create a more livable, sustainable, and vibrant community and provide an example for other cities facing similar challenges.

Recognizing the indisputable health challenges faced by many Downtown Neighborhoods residents and the importance of planning for a healthy community, the City of Fresno agreed for the need of a Health Impact Assessment on the Plan. Residents of the City of Fresno, Fresno County, and the San Joaquin Valley in general experience greater health burdens and worse health outcomes than the rest of California—and in some instances, the nation. Moreover, disparities in health outcomes exist between social groups and those of lower socioeconomic levels, communities of color, and other vulnerable populations are bearing the brunt of these health burdens. Health disparities are a growing concern in the Fresno Metropolitan Area and represent a relevant discussion topic for the Downtown Neighborhoods Community Plan because it comprises of an area with increasingly sensitive populations and the most concentrated poverty in the County.

Health Impact Assessment The overall purpose of a Health Impact Assessment (HIA) is to incorporate health objectives into the agenda of decision makers. By doing so, the process engages the public health community into policymaking and raises awareness to city leaders of the health impacts associated with their decisions. Addressing public health in the Downtown Neighborhoods Community Plan acknowledges the profound effects of the built environment, transportation network, and land use on community health outcomes. It also provides an opportunity to prevent further disease and injury and sustains healthy lifestyle choices through the design of the built environment.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t Purpose of this report The aim of this report is three-fold: to provide a solid literature base of each assessment area, to provide existing conditions of associated indicators for the Fresno Downtown Neighborhoods, and to provide recommended revisions based on the findings to incorporate into the final draft of the Community Plan.

This report is organized by four major health determinants that were gathered through stakeholder interviews, community meetings, and information from previously published reports. Included are the following health determinants: (1) regular physical activity, (2) diet and nutrition, (3) environmental pollutants, and (4) social and economic stability. Within each of these determinants, an in-depth literature review provided a lens to analyze the most important 2-4 risk factors, which were identified and used to establish a variety of health indicators that could be investigated or measured and chronicled in the existing conditions profile. A summary of the health determinants analyzed is represented in the graphic below. The DNC Plan has the great opportunity to embrace the recommendations illustrated in this report and duly consider the health impacts associated with these changes to create a livable, prosperous Downtown that is a hub for healthy living and the heart of the San Joaquin Valley.

Regular Physical Activity •Unsafe streets •Public spaces for physical activity •Active transportation options

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Diet & Nutrition •Physical access to healthy food sources •Exposure, consumption of unhealthy foods

Environmental Pollutants

Social & Economic Stability

•Exposure to air pollution •Exposure to toxic pollutants

•Employment opportunties •Adequate, healthy housing •Crime rates

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t

INTRODUCTION & OVERVIEW A well established and growing body of evidence supports the idea that our environments have a strong impact on our health. Man-made elements of the environment—such as transportation options, parks, medical facilities, and the design and composition of streets and buildings—are a few examples of physical frameworks for our neighborhoods and communities. Urban planning tools like zoning, General Plans, and Community and Specific Plans provide a powerful structure for the economic, social, and physical health of our cities and those who live, work, and play within The Fresno Downtown Neighborhoods them. These building blocks sculpt our daily routines, impact our behaviors and choices, and ultimately can Community Plan is very comprehensive, affect our health and longevity. long-term, and comprises of a major

portion of the city where there are the

Increasing rates of chronic illnesses in the US have highest rates of chronic illnesses, paralleled higher levels of physical inactivity, autoindustrial land uses, pollution, and dependence, and consumption of foods high in some of the lowest income households calories and low in nutrients; since 1980, obesity and in the city…

Type 2 Diabetes prevalence have doubled.1 Additionally, disparities in health outcomes among lower-income communities and communities of color are a growing concern.2 Increasingly researchers are showing that these health disparities are linked to inequalities of the built environment—such as access to parks and open space, schools and jobs, the zoning of food retail, or the presence and quality of sidewalks and pedestrian amenities.3 Recent responses to these endemic health challenges include incorporating health objectives into goals and policies that have a particular focus on enhancing features of the built environment. Long-term, comprehensive plans such as General Plans or Community Plans are policy documents that set a vision for a city or community by identifying key strategies and corresponding implementation action items aimed to guide land use decisions. The Downtown Neighborhoods Community Plan has a great potential to create a more livable, sustainable and vibrant community and provide an example for other cities facing similar challenges. Recognizing the indisputable health challenges faced by many Downtown Neighborhoods residents and the importance of planning for a healthy community, the City of Fresno agreed for the need of a Health Impact Assessment on the Plan. This HIA represented a unique opportunity to evaluate the potential health effects of a comprehensive Community Plan with the anticipation of influencing the final draft of the Plan by incorporating health objectives into the policy framework.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t WHAT IS HEALTH IMPACT ASSESSMENT? The overall purpose of a Health Impact Assessment (HIA) is to incorporate health objectives into the agenda of decision makers. By doing so, the process engages the public health community into policymaking and raises awareness to city leaders of the health impacts associated with their decisions. The World Health Organization defines HIA as “a combination of procedures, methods and tools by which a policy, program or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population.”4 HIA continues to gain considerable recognition as a relevant community- and neighborhood-based land-use management tool. At a minimum, HIA aims to disclose overlooked positive and HIA “is concerned with the health of negative health impacts of a project, program, or policy populations and attempts to predict the future consequences of health decisions and, at best, can alter decisions to promote healthier affecting health decisions that have not places and people through its findings and yet been implemented.”4 recommendations.

Health Impact Assessment has been used in other countries for decades, while in the US the process is relatively new. The HIA process strives to make the health impacts of social decisions more explicit by using diverse methods and tools to identify and characterize the health effects of policies. 5 HIA draws upon diverse sources of knowledge, expertise, and experience in conducting the assessment. The goal of an HIA is also to offer alternatives or improvements to policy decisions to enhance positive health impacts and mitigate or eliminate negative health impacts. A typical HIA is a multi-stage process that includes screening, scoping, assessment, communicating the results, and finally monitoring and evaluation. 5 Figure 1, Steps in the HIA process, summarizes the steps.

Figure 1. Steps in the HIA process

Screening

Scoping

Assessment

Communicate

•Determine if the HIA is necessary, feasible, timely •Determine how the HIA will add value to the planning process

•Create a plan, timeline •Define priorities, methods, data sources

•Create existing conditions profile •Evaluate health impacts •Develop recommendations

•Document the results •Communicate the results to the public

Evaluation & Monitoring •Conduct periodic evaluations of the progress •Monitor results

Adapted from: Dannenburg et al. 2007.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t WHAT IS THE RATIONALE FOR THIS HIA? According to the City of Fresno’s Planning Department, the Downtown Neighborhoods Community Plan and Fulton Corridor Specific Plan “represent an important opportunity revitalize these areas, focusing on rehabilitation, aesthetics, infrastructure, incorporation of a high speed rail station, and attraction and expansion of businesses.”6 The planning documents are a “critical piece of the City’s effort to revitalize our Downtown and alleviate the concentrated poverty in surrounding neighborhoods.”

The Downtown Neighborhoods Community Plan is a comprehensive update to the older and more limited Central Area Plan of 1989, the Edison Community Plan of 1977 (covering SW Fresno) and the Roosevelt Community Plan of 1992 (covering SE Fresno). None of the community plans specifically mention health issues and there is little mention of social equity issues. The Edison and Roosevelt Community Plans (from 1977 and 1992, respectively) briefly mention the concentration of incompatible industrial uses (salvage yards, sanitary landfill, wastewater treatment facility, and the Chandler DT Airport) but does not link the uses to environmental justice, health outcomes, or other direct impacts. The Central Area Plan addresses the “major problem” of homelessness in the downtown area as its own chapter, but focuses entirely on deconcentrating the homeless social services from the downtown area so that the “burden of responsibility” is shared among the entire City. The Plan recommends the construction of a social service facility south of WHAT IS THE PURPOSE OF THIS HIA? Santa Clara Street, which lies in the middle of heavy industry, the intersection of two major The goal of the Downtown Neighborhoods Community freeways, and in close proximity what is now Plan Health Impact Assessment is to influence the final called “Tent City”—where over 2,000 homeless version of the Fresno Downtown Neighborhoods live. The overall goal of the associated policies Community Plan by contributing a public health with this chapter indicates “free*ing+ the central perspective to the planning process. area of the negative impacts resulting” from the homeless population. Homelessness remains a The objectives of this HIA are to raise awareness of persistent problem today and will, again, be a the dire health issues residents face, to connect with focal point of the Downtown Neighborhoods the community and stakeholders about these issues, Community Plan as well. The Plan has the and finally to provide recommended revisions for the potential to significantly impact the health and draft of the DNC Plan, including mitigations for any wellbeing of residents in the Downtown unanticipated negative health impacts.

Neighborhoods and therefore it’s imperative to analyze and address these issues.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t WHAT ARE THE COMMUNITY’S HEALTH PRIORITIES? After a series of community meetings and stakeholder interviews (see Methods, Chapter XX), it was clear that the community had a variety of health concerns. Prioritizing their health issues was the first step in drawing connections between health and the built environment and how the Plan might address those issues.

At the top of the community’s list of health concerns was Concentrated poverty in Fresno will be concentrated poverty—neighborhoods with more than 40% discussed throughout this report, as it of the residents live below the poverty level—is a principle is often cited as a critical issue for the issue for the City of Fresno. According to a Brookings City and poverty status is a strong predictor of health status and Institute publication, 43.5% of individuals in Fresno live in outcomes. neighborhoods where more than 40% of residents live in poverty—the highest in the country. Families in neighborhoods with high poverty rates are thought to experience cyclical disadvantages: disinvestment in these neighborhoods have lead to depressed employment and local economy, lower performing schools, higher crime rates, and increased costs of goods and public services. At each of those steps, health is greatly impacted. Figure 2, Diagram of the cyclical nature of poverty and health outcomes, illustrates how the pattern of poverty can potentially influence a range of social, economic, and health outcomes. This health impact assessment paid particular attention to potential disproportionate effects placed on individuals and neighborhoods already suffering from the disadvantages associated with poverty and concentrated poverty.

Figure 2. Diagram of the cyclical nature of poverty and negative health outcomes

Depleted workforce

Economic decline and disinvestment

Disease, malnutrition, dealth

Depressed personal income

Hunger, poor sanitation, exposure to harm

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Fewer resources for good health

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t At each community meeting, certain topics were broached time and again, clearly demonstrating precedence over other topics. The following list consolidates and summarizes their concerns.        

Concentrations of poverty. The Downtown Neighborhoods have some of the highest concentrations of poverty in the San Joaquin Valley.

High levels of asthma and respiratory health issues. The residents, and many youth, in the Plan area suffer from asthma and respiratory illnesses.

Lack of quality housing and insufficient code enforcement. High renter-occupancy and low rents in the area have allowed landlords to defer maintenance and neglect the needs of their tenants. Mold, roaches, improper ventilation, cooling, and heating are pervasive problems.

Lack of access to grocery stores. The Plan area has an abundance of food outlets and residents articulated a need for nutritious, affordable food retail choices.

Limited access to parks and open spaces. Designated open space is severely lacking in the downtown core and the eastern neighborhoods. Residents have a strong desire for places to gather and play.

High rates of homelessness and unmet social service needs. Homelessness is concentrated in the southern neighborhoods adjacent to Downtown. Most social services are located in this portion of downtown, contributing to the concentration of homelessness in the area.

Lack of access to transportation options. Plan area residents object to the limited, inefficient transit, lack of cycling lanes, or poorly maintained sidewalks.

Real and perceived crime. Residents cite poverty, homelessness, and gangs as a cause of crime in the Downtown Neighborhoods, creating an undesirable environment.

WHAT ARE THE KEY HEALTH ISSUES ANALYZED? From the information gathered through community meetings, scoping interviews with stakeholders, existing reports and evidence, and relevant and supporting empirical literature, four categories of built environment determinants were identified: (1) regular physical activity, (2) diet and nutrition, (3) environmental pollutants, and (4) social and economic stability. Under each category, the assessment focused on a couple risk factors that guided the subsequent indicator analyses where existing conditions are investigated.

Children, homeless, and low-income populations were given special attention within the outcome measurement as these populations may be more sensitive to environmental and land use changes.

Regular Physical Activity •Unsafe streets •Public spaces for physical activity •Active transportation options

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Diet & Nutrition •Physical access to healthy food sources •Exposure, consumption of unhealthy foods

Environmental Pollutants

Social & Economic Stability

•Exposure to air pollution •Exposure to toxic pollutants

•Employment opportunties •Adequate, healthy housing •Crime rates

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t

BACKGROUND Fresno is located in the center of the San Joaquin Valley, in Central California, nearly equidistant to/from Los Angeles and San Francisco via Highway 99 (about 200 miles to both). Fresno is the 5 th largest city in the state and is the major metropolis of California’s most agriculturally-productive region. The top three agricultureproducing counties in the United State are in Fresno County. Fresno County is the top-producing county in California and generates nearly $5.6 billion of about 350 crops each year.7 Fresno’s rich historic significance in California’s large-scale agriculture industry dates back to the late 1880’s when the California railroad established a station in Fresno. After this major milestone, the City of Fresno experienced massive population growth with the railway station and then saw many changes to its neighborhoods during and after World War II. Inner city disinvestment, as with many metropolitan areas, clearly strained development and infrastructure maintenance in the downtown neighborhoods—a problem that persists today. Nevertheless, the downtown neighborhoods in the City retain many assets that can be used to leverage further growth, investment, and prosperity: more than two dozen buildings cataloged in the National Register of Historical places and a dozen more on the Local Registry; a classic grid-iron street pattern for easy mobility; a future high-speed rail station; and a strong, diverse population with vested interest in their city’s future. 8

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t WHO LIVES IN FRESNO? A diverse population lends Fresno a social landscape that is extraordinarily unique and nuanced. Health outcomes within and among the variety of ethnic and racial groups in Fresno are striking. This section provides an overview of demographics, social, and health characteristics and conditions in Fresno. Where possible, data was gathered at the most local level; however, the best available data was often at the City or County level.

Table 1. Racial Composition of Residents, 2000 & 2009

Hispanic White Asian Black Other

Fresno City 2000 2009 44.2% 49.3% 40.2% 34.6% 8.4% 8.7% 5.1% 5.0% 1.4% 1.5%

2000 30.8% 59.3% 11.5% 6.4% 1.6

California 2009 36.0% 61.9% 12.1% 5.8% 0.9%

Source: Census 2000, ACS 2009

The City of Fresno currently (2009) has a population of about 480,000 people spread out over 105 square miles, producing a density of 4,571 people per square mile. Of 166,000 units in Fresno, about 51% are renteroccupied, 8% are vacant, and 59% of renters spend more than 30% of their income on rent. Since 2000 population has increased in the city by about 12%. About 67% of households are family households, of which 26% are single female-headed. Nearly 30% of households are Spanish-speaking and compared to the State, Fresno’s population is more Latino/Hispanic and less White, Black, and Asian. More striking is the trend from 2000 to 2009, shown in Table 1, Racial Composition of Residents, 2000 & 2009. In Fresno, the Hispanic/Latino population has increased substantially while the other racial categories have not changed as substantially.

The map on the next page spatially demonstrates the stratified nature of the City’s residents.

In 2008, 26% of the population was in poverty, with a higher percentage of females with incomes below poverty level. As of May 2010, Fresno County had a 16% unemployment rate, significantly higher than the 12% State rate. Table 2, Select Characteristics of Residents, demonstrates once again that the City of Fresno is fairly similar to its neighboring cities of Merced and Stockton, however very different from California. Overall, Fresno is a very young city with a median age of nearly 29 years. Compared to California, more adults over age 25 in Fresno did not finish high school and of those working, more drive alone to their place of work and fewer take public transportation. Most noticeably different from State levels, nearly one-third of all Fresno families with children younger than five years old live below the federal poverty level (FLP). This level is consistent with nearby Merced, but much higher than Stockton—and over twice the level of California— indicating vast differences Table 2. Select Characteristics of Fresno Residents (2006-2008) in wealth within the San Fresno Merced Stockton California Joaquin Valley and City City City compared to the State.

Median age (years) 28.8 yrs 27.6 yrs 30.1 yrs 34.0 yrs No high school diploma

25.1%

31.4%

26.8%

19.8%

Commute to work Drove alone Public Transportation

77.0% 2.3%

71.3% 1.2%

73.8% 1.2%

72.9% 5.2%

Management

28.0%

27.2%

26.7%

35.5%

Fish/farm/forestry

2.9%

6.8%

3.7%

1.4%

29.7%

31.7%

14.0%

13%

Occupation

Poverty (below FPL) Families w/ children >5yr Source: ACS 2006-2008

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t POPULATION DISTRIBUTION IN THE CITY OF FRESNO

Source: ESRI projected 2005 Census Created by: Meredith Glaser, September 2010.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t

WHO LIVES IN THE DOWNTOWN NEIGHBORHOODS? The Community Plan area (Figure 3, Fresno’s Downtown Neighborhoods Community Plan Area) comprises of 7,300 acres including the central business district and its surrounding neighborhoods. Based on population growth, about 61,500 residents live within the Community Plan’s boundaries. The racial composition of the Downtown Neighborhoods is much more diverse than the City as a whole; Hispanic and Latino households dominate the area (44%), and Asian and African American populations are also concentrated here more so than in the City (14% and 13%, respectively). In 2000 unemployment in the DNC area was double the rate of the City at 23%; since then unemployment has increased from 11% to 16% for the City and although sufficient local data is not available, it is safe to assume that unemployment in the DNC area has also increased. Additionally, nearly 53% of households have incomes below the poverty level. Of 22,300 units in the Plan area, about 63% are renter-occupied even though the average cost of rent in the Downtown Neighborhoods is much lower than the rest of Fresno. Table 3, Synopsis of Selected Fresno Demographics, explores select demographic characteristics in Fresno and the San Joaquin Valley, with respect to racial and ethnic disparities.

Figure 3. Fresno’s Downtown Neighborhoods Community Plan Area

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t Table 3. Synopsis of Selected Fresno Demographics Demographic

Fresno

Population growth

The Central Valley is estimated to see the largest proportional population growth in California, from 1.15 million to 1.59 million residents, a 38.5% increase.9 The average age in Fresno is 29 years old, 6 years younger than the California average.10 The dominant ethnicity in Fresno is now Hispanic/Latino, with 49% of the population, compared to 36% average in the State.10 30% of Fresno households speak Spanish as the primary language and nearly one-quarter of those households experience linguistic isolation.10 The average African American/Black and Hispanic individual in the Fresno Metropolitan Area lives in a neighborhood where nearly 30% and 28%, respectively, of the population is in poverty; almost twice the rate for White individuals (15%).11 53% of African American/Black and 47% of Hispanic individuals would need to relocate to another neighborhood in order to be evenly distributed among the White neighborhoods.11 68% of Whites are homeowners, while 35% of African American/Blacks and 45% of Hispanics are homeowners.11 The average African American/Black and Hispanic individual in the Fresno Metropolitan Area lives in a neighborhood where the unemployment rate is 15% and 16%, respectively; almost twice the rate for White individuals.

(9%).11 32% of Fresno Metro Area adults do not hold a high school diploma—59% are Hispanic, 25% Black, 14% white. 57% of public elementary and secondary school children are Hispanic and 22% are White.11

Age profile Ethnicities Languages Income/poverty

Integration

Housing Unemployment

Education

VULNERABLE POPULATIONS Certain populations in Fresno are at increased risk of illness and disease. Migrant and seasonal farmworkers, homeless, Southeast Asian Refugees (Hmong), and of course children and elderly in any of these sensitive populations are even more vulnerable. Health and environmental issues for these specific populations include air quality, proximate industrial land uses, large-scale industrial agriculture and pesticide use.

Throughout the report’s assessment, we will focus on health impacts that may disproportionately affect these groups.

Farmworkers Estimates have documented 375,000 migrant and seasonal farmworkers in the San Joaquin Valley, representing 51% of the State’s farmworkers, and about 16% (60,000) reside in Fresno County.12 One study found that in their sample, 92% of farmworkers were immigrants.13 Out of the approximate 60,000 farmworkers estimated to reside in Fresno County, we can deduce that about 55,200 are immigrant farmworkers in Fresno County (7% of the population).

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t Little data exists about this population as they are not captured in the Census. One study, however, investigated health conditions of farmworkers in California, published in 2005. 14 Within the sample, the study demonstrated:     

18% suffered from two out of three risk factors for chronic disease 81% males and 76% females had unhealthy weight status (BMI) 28% males and 37% females were obese Iron deficiency anemia among male farmworkers was four times higher than US average 70% lack any sort of health insurance

Several studies have also explored socio-cultural and economic factors for migrant farmworkers. One study found that this population experiences elevated levels of acculturative stress and also high levels of anxiety and depression.15 Economic hardship, language difficulties, discrimination, and loss of social networks were cited as reasons for high stress levels. Other research has examined economic factors for farm and seasonal workers. One study found that the median annual income for their sample of farm and seasonal workers in 2000 to be $6250, and about 85% did not have medical insurance (compared to 37% of lower income adults) and 90% of their children were uninsured (compared to 22% of low income children). 14 Homeless Another population not captured in Census data is the homeless. Compared to low-income households, homeless families experience more spousal abuse, child abuse, drug use, mental health problems, weaker support networks, and depressed nutritional status.16 Homelessness was most cited as a result from economic pressures. The homeless population in Fresno also has not been thoroughly studied. The 2007 Housing Element estimates that there are at least 8,824 homeless in the City of Fresno. Research has shown that 40% of homeless individuals have some sort of chronic health problem, major anxiety, depression, or affective disorder, and homeless individuals make up 20-30% of all emergency room visits.16-19 Southeast Asian Refugees The Central Valley has one of the largest populations of Southeast Asian Refugees, particularly Hmong, and has remained a principle terminus for many families seeking peace and safety from the turmoil in their home countries. These residents represent a vulnerable population because they often do not speak English and thus have linguistic and cultural barriers to obtaining resources for health such as access to jobs, education, and medical care. Approximately one-third (27%) of all US Hmong refugees reside in Fresno County and about three-quarters (74%) of that population, or about 17,000 individuals, reside within the City of Fresno boundaries.10 Nearly half of all Fresno County Hmong (49%) do not speak English fluently. Between 20042007, nearly 4,400 refugees took up residence in Fresno County—this represents 38% of all Hmong refugees who came to California. Similar to farm worker individuals, refugees also suffer from depression, anxiety, and stress related to immigration and acculturation. Added stress places pressure on family and social networks, and may increase risk for heart disease.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t WHAT ARE THE CURRENT HEALTH CONDITIONS IN FRESNO? Those who live in the City of Fresno, Fresno County, and the San Joaquin Valley in general experience greater health burdens and worse health outcomes than the rest of California—and in some instances, the nation.

Moreover, disparities in health outcomes exist between populations and those of lower socioeconomic levels, communities of color, and other vulnerable populations are bearing the brunt of these health burdens.

Health disparities are a growing concern in the Fresno Metropolitan Area and represent a relevant discussion topic for the Downtown Neighborhoods Community Plan because it comprises of an area with increasingly sensitive populations and the most concentrated poverty in the County.

Poverty level indicates a household income for a family of four as $20,650 annually (2007). Poverty remains one of the strongest predictor of mortality20 and those who experience very low household incomes also suffer most from food insecurity,21 obesity,22 and cardiovascular disease.23 Areas with lower incomes and lower levels of educational attainment, as seen in Fresno, often experience higher levels of chronic conditions and encounter more challenges to accomplishing healthy behaviors than areas with higher incomes and higher levels of educational attainment.20,24,25 Whereas the existing conditions analysis within each determinant section examines concrete indicators, the purpose of this section is to provide a broad understanding of various health characteristics of the Fresno population. When available, the most local level data is presented and compared to City, County, or State levels.

LEADING CAUSES OF DEATH Compared to the State of California, Fresno County has a higher overall Table 4. All Causes of Death mortality rate with about 800 deaths per 100,000 people (compared to the (per 100,000) State rate of 666 per 100,000), a risk of dying equivalent to 1 death for Fresno County 800 every 125 people in the County (versus 1 death for every 161 persons in Merced County 754 the State). In Fresno County, cancer, heart disease, and stroke are by far San Joaquin County 802 the top three causes of death, followed by chronic lower respiratory California 666 disease, accidents/injuries, diabetes, Alzheimer’s, and Source: American Community Survey, 2009. influenza/pneumonia (Figure 4, Leading Causes of Death, per 100,000 population). Lung cancer was the primary form of cancer attributed to death, responsible for 25% of cancer mortality (40.4 deaths per 100,000). For every leading cause of death, Fresno County residents disproportionately suffer more from preventable chronic conditions than the rest of the State (see Table 4, Leading Causes of Death, per 100,000). Fresno County is not alone however; neighboring Merced and San Joaquin counties—both within the San Joaquin Valley—also have higher rates of death for most causes compared to the State. In

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t Figure 4. Leading Causes of Death in Fresno County, per 100,000 population (2010, age-adjusted)

Influenza/pneumonia

24 California

Alzheimer’s

29

Diabetes

Fresno County

32

Accidents

41

Chronic Lower Respiratory …

Stroke

43 54

Coronary Heart Disease

152

All cancers

161 0

100 rate per 100,000

200

Source: California Dept of Public Health: County Health Status Profiles, 2006-2008. Accessed at: http://www.cdph.ca.gov/pubsforms/Pubs/OHIRProfiles2010.pdf Compiled by: Raimi + Associates, July 2010.

Zip code data allows a closer look at the leading causes of death for those living within the boundaries of the Community Plan. The numbers do not represent rates, rather percentages of the total deaths, and the zip code boundaries are somewhat different than the Community Plan boundaries. Given those differences, Table 5, Leading Causes of Death, Downtown Neighborhoods (2008), tells a slightly different story: coronary heart disease (CHD) was the primary cause of death among the downtown residents, whereas cancers were the primary cause for the County. CHD and stroke fall under the umbrella of cardiovascular disease (CVD), and both involve dysfunction of the heart and surrounding blood vessels.

Table 5. Leading Causes of Death, Fresno Downtown Neighborhoods (2008) Cause of Death

% attributed

Coronary Heart Disease Cancers Stroke Chronic respiratory diseases Accidents Diabetes Alzheimer’s Total

24% 16% 7% 4% 6% 5% 2%

Total # deaths 197 132 56 34 48 42 20 529

Source: California Dept of Public Health: Deaths by Descendants Residence, 2008. Zip codes: 93701, 93702, 93706, 93721, 93728. Accessed at: http://www.cdph.ca.gov/data/statistics/Documents/DeathZip2008.pdf Compiled by: Raimi + Associates, July 2010.

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Other common measures of community health are infant mortality and the percentage of low birth weight or premature babies. Infant mortality represents the number of infant deaths (< 1 year old) per 1,000 live births.

Stratified by race in Figure 5, Infant Mortality by Race (2004-2006), the rate at which African American infants die is nearly double that of other races for Fresno County, the San Joaquin Valley (SJV), and the State. Also, in the Fresno Metropolitan Area, 5.7% of births are low birth weight. African American babies (12%) are born with low birth weight status at 2.7 times the rate of White infants (4.6%) and 2.3 times the rate of Hispanic infants (5.3%). A similar trend is found for preterm births in the Fresno Metro Area: 15.3% for African American infants, 11.5% for Hispanic, and 9.7% for White.26 One study on access to prenatal health care in the San Joaquin Valley showed that 24% of African Americans, compared to 18% of Whites, received inadequate prenatal care, defined by access or distance to a facility, language barriers experienced, and the provider’s short staffing.27 Disparities and inequalities of access to prenatal care, medical facilities, and other preventive healthcare resources in Fresno County and across the State contribute to these disparities.

Figure 5. Infant Mortality by Race in Fresno County (2004-2006 averages) 20

18

Infant Mortality Rate (deaths/1000 live births)

16

14

12

General 10

Black Hispanic

White

8

6 Healthy People 2010 Goal = 4.5

4

2

0 California

SJV

Fresno

Merced

San Joaquin

Source: As cited in Altshuler & Zuk (2008)

OBESITY & OVERWEIGHT Today more than half of American adults are overweight, and the prevalence has yet to plateau.28 Although heredity of obesity is significant and should not be neglected, genetics alone simply cannot explain the current US obesity prevalence of over 30%. Overweight and obese adults are at an elevated risk for numerous chronic diseases and conditions that deleteriously affect many aspects of daily living. 29 Obesity in childhood often carries into adulthood and represents a major risk factor for many chronic illnesses. 30 Studies have shown that risk of cancer, heart disease, stroke, diabetes, and Alzheimer’s (5 of the 8 leading causes of death in Fresno County) can be decreased by reducing the rates of obesity or overweight through lifestyle and behavior changes such as increased physical activity31 and reduced consumption of foods high in calories, Final Report – March 2011

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t sugar, and fat.32 Fresno County has a higher adult obesity prevalence that the San Joaquin Valley and the state of California. Figure 6, Adult Obesity and Overweight in Fresno County, 2007, demonstrates that although the prevalence of overweight and obesity combined in Fresno County is relatively similar to the Valley, but higher than California, obesity is most prevalent in Fresno with nearly 29% of all adults obese versus 23% in the State.

Figure 6. Adult Obesity and Overweight in Fresno County (2007)

Source: California Health Interview Survey. 2007. Compiled by: Raimi + Associates, July 2010.

Figure 7. Obesity prevalence by ethnicity and county, 2007

Source: California Health Interview Survey. 2007. Compiled by: Raimi + Associates, July 2010.

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Figure 8. Fresno County obesity prevalence by ethnicity, 2007

Source: California Health Interview Survey. 2007. Compiled by: Raimi + Associates, July 2010.

Figure 7, Obesity prevalence by ethnicity and county, 2007, indicates that Fresno County not only has the highest obesity rates among Fresno, Merced, San Joaquin Counties and the State, but also that disparities in obesity exist across all locales. Similarly, Figure 8, Fresno County obesity prevalence by ethnicity, 2007, shows that Latino and Black populations experience more overweight and obesity than White or Asian populations.

HEART-RELATED CONDITIONS Cardiovascular disease (CVD) is the leading cause of death and premature death in the US as well as Fresno.

Diabetes, high blood pressure, cholesterol, physical inactivity, obesity, and smoking are the most significant risk factors for developing CVD.33 According to the CHIS (2007), Fresno County has a diabetes prevalence of 10.5%, higher than the State level of 7.8%. The prevalence of high blood pressure in Fresno County is also higher than the State’s average—28.4% of the popualtion has been diagnosed with high blood pressure, compared to 26.1% for the State. Fresno’s elevated obesity levels coupled with higher levels of high blood pressure and diabetes position the County to also suffer more from CVD. Fresno County residents older than 45 experience higher rates of heart-attack related hopsitalizations than Merced and California (2006-2008).

Using zip code level data, it is clear Table 6. Heart attack related Hospitalization Rate (per 10,000 people, 2008) that the Downtown Neighborhoods Heart Attack-related experience even higher rates than Locale Hospitalizations non-Downtown Residents, the rest of Downtown zip codes median 74 Fresno County, and the State (see Fresno (93701, 93702, 93706, 93721, 93728) Table 6, Heart attack related Fresno non-Downtown zip codes 54 hospitalizations). The map on the Fresno County 55 next page spatially describes this California 43 discrepancy in heart attack-related Source: California Dept of Public Health: Heart Attack-related Hospitalizations, Age 45+ by Residence, 2008. Zip Accessed hospitalizations between zip codes. at: http://www.cdph.ca.gov/data/statistics/Documents/DeathZip2008.pdf; Compiled by: Raimi + Associates, July 2010.

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Cardiovascular disease-related hospitalizations in Fresno County

Source: California Dept of Public Health: Heart attack-related hospitalizations, Age 45+ by Residence, 2008. Zip Accessed at: http://www.cdph.ca.gov/data/statistics/Documents/DeathZip2008.pdf Created by: Meredith Glaser, September 2010.

PHYSICAL ACTIVITY The predominance and availability of sedentary activities—watching TV, playing computer games, driving, internet use, and even the proliferation of devices like remote controls, cell phones, and lawnmowers—are commonly cited reasons for the general downward trend of physical activity. However, this is not consistent across populations and especially ethnicities. Current academic research indicates that low-income, urban communities and communities of color disproportionately face challenges and barriers to leading active lifestyles.3,34-36 The high cost of land, safety concerns, lack of access to public transit, fewer pedestrian and cycling amenities and facilities, and relatively few parks or playgrounds available make it hard to envision a Final Report – March 2011

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t way to increase activity opportunities. Adult physical activity recommendations include a minimum of 30 minutes of moderate exercise per day to vigorous activity on at least three days per week. 37 In Fresno County, only 19% of Latino and 6% of Black adults claim to obtain vigorous physical activity levels (strenuous activity at least 3 times per week), compared to 21% of White and 24% of Asian populations (Figure 9, Fresno County levels of physical activity by ethnicity, 2007).

Figure 9. Fresno County levels of physical activity by ethnicity, 2007

Source: California Health Interview Survey. 2007. Compiled by: Raimi + Associates, July 2010.

ASTHMA & RESPIRATORY CONDITIONS Asthma, a chronic inflammatory disease of the lungs, and other respiratory conditions are becoming more prevalent across the nation and California. Individuals suffering from asthma experience a variety of symptoms including wheezing, shortness of breath, coughing, airflow obstruction, and at its worst, death.

Although there is a genetic component to the disease, a large body of literature has established the relationship between air pollution, especially fine particulate matter, and asthma. Emissions from combustion motors, heavy industry, environmental “The San Joaquin Valley has the highest rate of tobacco smoke, and other sources of pollution have childhood asthma in the State. Fresno County been linked to the disease and acute and/or chronic has the highest asthma prevalence of asthma in exposure to these sources exacerbate the symptoms. the Valley – over 19% of its population has been Stress also aggravates the condition. Planning diagnosed with asthma. Asthma prevalence in decisions around land use and transportation directly children ages 0-12 in the Valley is especially and indirectly impact individual and neighborhood high (21.4%) and children living in the Valley are exposure to asthma-inducing pollution. In California, 66% more likely to develop asthma than communities of color and lower income communities children living elsewhere. Furthermore, 1 in are disproportionately suffering from asthma and every 3 children in Fresno has been diagnosed chronic lung diseases, often a result of their with asthma.” (Zuk & Altshuler, 2008) community’s proximity to toxic land uses and sources of air pollution such as freeways, refineries, industrial agriculture, and pesticide use, among others. The San Joaquin Valley, and especially Fresno, is no exception.

Figure 10, Asthma prevalence by race, clearly demonstrates a straightforward trend that African Americans in several Central Valley counties experience higher rates of asthma that Latino or Whites.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t Figure 10. Asthma prevalence by race in Fresno County 35% Latino 30%

African American Whites

Asthma Prevalence

25%

20%

15%

10%

5%

0% California

San Joaquin Valley

Merced Co

San Joaquin Co

Fresno Co

Source: California Health Interview Survey. 2007. Compiled by Zuk & Altshuler, 2008.

Zip code level data also reveals these stark geographic discrepancies in asthma suffering. Compared to nonDowntown residents, Downtown residents had 37% more emergency room visits—and nearly 2.5 times higher than the State rate—and 30% more hospitalizations due to asthma, as shown in Table 7, Asthma hospitalizations and Emergency Room visits (2008) and the map on the following page.

In May 2006, the Air Quality Monitoring Study for Fremont Elementary School released a report on asthma in young children in Fresno. Fremont Elementary is located on the north end of Fresno, directly across Highway 99 from Jane Addams neighborhood. While selecting participants, the researchers found that 20% of children came from families with incomes below $15,000 and 40% were Hispanic, 42% White, and 16% African American. Within their sample, 28% had mild intermittent asthma, 48% had mild persistent asthma, and 24% had moderate or severe asthma; 73% of the children inhaled steroids to combat symptoms and 38% had used oral prednisone in the last 12 months. PM10 and NO2, respectively, most significantly impacted asthma symptoms in the study cohort over the 4 years of data gathering.

Table 7. Asthma Hospitalizations and ED visits (per 10,000 people, 2008) Locale

Asthma Hospitalizations

Asthma Emergency Room Visits

17.6 13.6 11.1 8.9

99.0 72.0 61.6 43.0

Fresno Downtown zip codes median (93701, 93702, 93706, 93721, 93728)

Fresno non-Downtown median Fresno County California

Source: California Dept of Public Health: Asthma-related Hospitalizations, Age 45+ by Residence, 2008. Zip Accessed at: http://www.cdph.ca.gov/data/statistics/Documents/DeathZip2008.pdf Compiled by: Raimi + Associates, July 2010.

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Asthma hospitalizations by zip code in Fresno County

Source: California Dept of Public Health: Asthma-related Hospitalizations, Age 45+ by Residence, 2008. Zip Accessed at: http://www.cdph.ca.gov/data/statistics/Documents/DeathZip2008.pdf Compiled by: Meredith Glaser, September 2010.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t SUMMARY OF HEALTH CONDITIONS Poverty. 43.5% of individuals in Fresno live in impoverished neighborhoods and 28% of families with young children live below the poverty level, impacting a variety of health factors such as available funds for healthy food, quality housing, and medical care.

Health Disparities. African Americans suffer disproportionately from obesity and asthma, and have higher rates of infant mortality than other racial groups in Fresno.

Higher rates of heart disease. Residents of the Plan area experienced 35% more heart-related hospitalizations than Fresno County and 75% more than the State.

Lower rates of physical activity. On a County level, 19% of Latino and 6% of Black adults claim to obtain vigorous physical activity levels, compared to 21% of White and 24% of Asian populations.

Asthma and respiratory health issues. 19%, and 1 out every 3 children in Fresno County, has been diagnosed with asthma. Emergency room visits and asthma hospitalizations are 37% and 30%, respectively, higher in the Downtown area than non-Downtown.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t WHAT IS THE DOWNTOWN NEIGHBORHOODS COMMUNITY PLAN? The DNC Plan covers a large area of about 7300 acres—the size of many small cities. The Plan’s boundaries contain seven neighborhoods: Jane Addams, Southwest, Lowell, Jefferson, Southeast, Downtown, and South Van Ness. The DNC Plan’s ultimate goal is to “regenerate the Downtown Neighborhoods of Fresno in a manner that brings lasting prosperity, social improvement, and physical consolidation.” Sustainability is at the heart of the plan, aiming to create an urban environment that “produce*s+ lasting social, physical, and economic benefits” for current and future residents. The Plan’s Values, Strategies, Plan Components, and Implementation Action Items are summarized below.

VALUES The Plan explicitly states the following six values that are the basis for the strategies and policy components.

These principles are carried throughout the Plan, are grounded in the Vision determined by the community and the City, and are primary elements chosen to indicate a higher quality of life.

Community Heritage Social Equity Livability & Health Walkability & Access Economic & Fiscal Health Sustainability

Preservation and maintenance of historic resources and patterns in the Downtown Neighborhoods.

Accommodate and attract all types of people, from all income levels, abilities, and life stages.

Achieve a high quality of life with a safe, pleasant environment that promotes social interaction.

Ensure easy access to a variety of goods, services, and employment that promote multiple transportation modes.

Provide essential and adequate services to local residents and businesses.

Invest in land use decisions that reduce energy and resource consumption.

STRATEGIES The six values from above guided the development of core strategies for achieving the goal. These strategies act as higher level activities that will usher more specific implementation actions. The following are the primary strategies for transforming the Downtown Neighborhoods: Downtown Redevelopment

Focus on adaptive reuse, new housing, and Transportation Demand Management strategies.

Preservation & Redevelopment of Neighborhoods

Incorporate adaptive reuse, market-rate housing, infill, distribute goods and services.

Improvements to the Public Realm

Increase public parking, improve streetscape, implement crimeprevention design techniques

Improvements to the Transportation Network

Expand multi-modal facilities, increase bicycle and pedestrian safety, capitalize on High Speed Rail station.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t Management & Promotion

Establish a system of neighborhood governance and promotion of Downtown marketing strategy

Employment

Establish jobs training programs, new businesses, and local-hiring.

Education

Introduce quality schools, after-school programs, and adult education.

Culture

Establish Downtown as a hub for art and culture, emphasizing Fresno’s rich agricultural history.

Social Services

Generate neighborhood-based childcare and services, while also decentralizing homeless services.

High Community Standards

Enforce building, zoning, and health codes and introduce a property and business improvement district.

PLAN COMPONENTS Based on the Plan’s values, the strategies are further articulated through ten interconnected plan components, summarized below, and are the chapters of the Plan. Each component has its own role and focus within the vision, yet all ten are necessary, interconnected, and support the physical growth, social development, and general transformation of the Plan Area. Table 8, Plan components and descriptions, catalogues the ten components.

Table 8. Plan components and descriptions Plan Component Urban Form and Land Use

Transportation

Parks, Open Space, and Streetscape Economic Development

Sustainable Infrastructure & Natural Resources

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Description

Revive the underlying structure of the Downtown Neighborhoods to create identifiable neighborhoods, districts, and corridors. The public realm of streets is fully integrated with a multi-modal transportation network that creates walkable neighborhoods.

Build on the existing grid-iron structure to efficiently accommodate all modes and create a safe, continuous, and clear means of reaching downtown.

Expand the open space and landscaping network with street tree and empty parcel infill, joint use agreements, community gardens, and underutilized alleyways.

Expand housing opportunities, access to quality amenities and infrastructure, including education and job training; establish a land use plan that ensures opportunities for economic growth and a high quality of life.

Utilize existing water resources, promote local renewable energy sources, minimize consumption, and enhance existing utility network. Integrate these important infrastructure components into the Plan area so residents can enjoy a system of well-maintained and well-dispersed utilities.

27

fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t Health & Well-being

Historic & Cultural Resources

Encourage positive lifestyle behaviors and choices that support health, prevent disease, and enhance longevity by improving access to healthy foods, safe places to recreate, health care facilities, and induce social activity. Address the needs of noise pollution, emergency vehicle routes, and safe evacuation routes.

Connect the Downtown Neighborhoods to their heritage and culture through a diverse network of preserved buildings and places compatible with the surrounding context and land uses.

GOALS & POLICY DIRECTIONS Within each of the categories above the Plan describes more specific goals and policy direction, along with corresponding key action items that support policy directions. These components in the first draft of the Community Plan represent the basis for analysis in this HIA. The Plan also defines policies and action items for each neighborhood. Although the policies addressed for each neighborhood are relevant and important, this HIA focuses on the Plan area as a whole and analyzing each individual neighborhood goes beyond the scope of this HIA.

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METHODS Since the consultant team is drafting the DNC Plan alongside the HIA, this HIA has great potential to influence the direction of the Plan in terms of health objectives. The DNC Plan HIA followed the best practices of the first four steps of the HIA process: screening, scoping, assessment, and communicate the results. Evaluation and monitoring are beyond the scope of this HIA and are not included. These steps were accomplished through: Interviews and meetings with stakeholders and decision makers including staff from the City of Fresnoâ&#x20AC;&#x2122;s Downtown & Community Revitalization Department, Fresno Metro Ministry, and Fresno County Department of Public Health, and the Local Government Commission in Sacramento.

On-going academic and professional guidance from UC Berkeley faculty and consultant team staff, and peerreviewed graduate student group Comprehensive literature review of the empirical evidence investigating the relationship between factors of the built environment and health.

Assessment of existing conditions pertaining to health, economic, environmental, and socioeconomic features in the City, County, and Downtown Neighborhoods.

Estimations of health impacts using qualitative and quantitative methods of the potential health impacts associated with the Plan.

Development of recommendations of revisions for the Plan based on the analyses from the literature review and the assessment.

Community input Local expert knoweldge

Academic guidance

METHODS METHODS Original data (CHIS, Census)

Professional guidance

Web-based tools (HDMT)

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Empirical literature & published studies 29

fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t INTERVIEWS & COMMUNITY MEETINGS Timeliness, value, and feasibility of this HIA came out in interviews and meetings throughout the various stages of the HIA. Because of the prospective nature of the HIA, we were able to coordinate research and data gathering, community engagement activities, and other strategies with the consultant team. Interviews and meetings with a variety of stakeholders demonstrated several factors that contribute to the timeliness and added value of this HIA, many of which will be discussed in later chapters:     

The City of Fresno’s need for a comprehensive existing health conditions report and an examination of the relationship between characteristics of the built environment and health The existing local and regional movement around planning, the built environment, and health issues Community support and involvement in numerous programs aiming to improve health in Fresno and the San Joaquin Valley Support and guidance from UC Berkeley and the Local Government Commission Well-documented elevated risks of obesity, asthma, and cardiovascular disease in the Downtown Neighborhoods

The HIA process underscores the importance of community input throughout the stages of the HIA and represents an iterative process in which community members gain insight into the challenges and opportunities facing their city or neighborhood and have a meaningful role in developing the desired outcomes and alternatives of the plan. This close collaboration enabled us to develop targeted strategies and vet policies and programs to ensure that they are appropriate, practical, and achievable. Throughout the assessment, community input from all interviews and meetings, as well as information garnered from local experts, were used as sources for prioritization. The following provides a summary of the meetings and interviews that took place in Fresno over the course of the HIA process.

DNC Plan Design Charette [5.17-5.21] In the beginning of the planning process, the lead consultant firm organized and directed a week-long design charrette. The process included several workshops in which community members identified key issues and challenges for the neighborhoods, prioritized the types of changes they would like to see take place in their community, and developed a clear vision for the future of downtown Fresno. On two separate evenings, about 40 residents came together to discuss the principle health issues of concern about each neighborhood. The charrette leaders supervised a prioritization process where each community member was allowed to choose five priority health issues of their choice out of a list of 25 issues. This process brought to light which issues are of primary concern from the standpoint of the residents. The topics assessed in the existing conditions analysis in this report originated from the priorities decided in the charrette process.

Stakeholder Interviews [6.28] The HIA team met with a variety of staff and stakeholders. Key City staff included Wilma Quan, Elaine Robles, Craig Scharton and these staff aided in further articulation of health priorities within the scope of the DNC Plan. Separately, staff from Fresno Metro Ministry (Reyna Villalobos) and Fresno County Public Health Department (Rosemarie Amaral) expressed support for the HIA of the DNC Plan and provided information about existing health programs in the Downtown Neighborhoods. Lastly, a meeting with Laura Podolsky, from the statewide nonprofit Local Government Commission, provided an opportunity to gain technical assistance insight and request further assistance for future collaborative community engagement meetings.

Downtown Design Charette [9.27-10.1] This week-long design charrette for the Specific Plan, lead by the primary consultants, allowed an opportunity for the HIA team to present initial findings and receive input Final Report – March 2011

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t from community members. The HIA team presented at the offices of The California Endowment to eleven community members plus staff from the County Department of Public Health (Rosemarie Amaral), and staff from the Local Government Commission (Paul Zykofsky and Laura Podolsky). Discussion topics included a workshop on the relationship between health and the built environment, prioritization of health issues, and a range of topics including displacement and brainstorming for policy or actions.

HIA Initial Findings Presentation & Community Meeting [11.2] Raimi + Associates, with help from The California Endowment, organized a follow-up community meeting from the October 1st meeting. The purpose of this meeting was to identify as many issues in the community—related to health or not—and brainstorm solutions, policies, programs, or other actions that could potentially be written into Plan. Over the course of four hours, the diverse group—who included four Hmong residents, four Spanish-speaking residents, and a number of others—was engaged and thoughtful throughout the process. Although some of the actions identified are already drafted in the Plan, a number of other issues and ideas were new and relevant. Overall, it was a very successful meeting where the consultants gained new information and new insight into the challenged faced by this complex, nuanced community.

ACADEMIC & PROFESSIONAL GUIDANCE This HIA was also regularly reviewed with academic and professional advice of several individuals. Edmund Seto, Ph.D., is a researcher and lecturer in the School of Public Health (Environmental Health Sciences division) and has a well-establish background in HIA, geographical information systems (GIS), and spatial epidemiology. Professor Jason Corburn, Ph.D., is an Associate Professor in the Department of City and Regional Planning and his research focuses on the links between environmental health and social justice in cities, notions of expertise in science-based policy making, and the role of local knowledge in addressing environmental and public health problems. Together and individually, they have conducted a number of HIAs, as well as numerous peer-reviewed academic contributions to the fields of HIA, public health, urban planning, and the connection between health and the environment. Dr. Seto and Professor Corburn offered their expert advice, resources, and general knowledge for this HIA. Lastly, this HIA was peer-reviewed for content, consistency, and robustness by a team of graduate students enrolled in the Masters in Public Health and/or Masters in City Planning programs and who have demonstrated experience in conducting Health Impact Assessments. Finally, Miriam Zuk, a PhD student in city planning, who has extensive experience with planning and public health principles and whose dissertation focuses on planning in Fresno, also reviewed and submitted comments on this paper.

This report also received guidance and was reviewed by several professionals in the field of planning and public health. Matt Raimi, AICP, Principal at Raimi + Associates, offered regular guidance and review for the project’s duration. Aaron Welch, LEED-AP and Senior Planner at Raimi + Associates, provided in-depth review of the report’s content. Finally, with funding from The California Endowment, Paul Zykofsky and Laura Podolsky, Associate Director and Project Manager at Local Government Commission (LGC) in Sacramento, offered regular communication, guidance, and review of the report. LGC also provided staff, resources, and technical assistance for community meetings, the design charrettes, and other community engagement strategies that greatly informed this HIA.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t LITERATURE REVIEW To inform and validate this HIA, data examining the relationship between features of the built environment and health outcomes was gathered from academic literature and existing published (non-academic) reports.

Included studies, peer-reviewed journal articles, and local published reports were chosen for criteria including: US-based studies, recently published in the last 10 years, and relevant to a built environment feature or health outcomes outlined in this report. Search engines included Google Scholar, PubMed, ScienceDirect, and Elsevier.

ASSESSMENT OF EXISTING CONDITIONS Web-based data gathering tools, existing reports and publications, and original analyses data was used to inform the findings of this HIA. On a macro level, San Francisco Department of Public Health’s Healthy Development Measurement Tool (HDMT) was used as a starting point to identify concrete health priorities that aligned to those discussed in the neighborhood design charrettes conducted by the consultant team with community members at the beginning of the planning phase (May, 2010). Myriad reports have been generated documenting existing health status, health outcomes, built environment and air quality conditions, and regional environmental issues.

Data from the California Health Interview Survey (CHIS), California Department of Public Health, and the US Census provided a macro lens for which to see demographic, socioecnomic, and health status or outcomes on the County or local scale. CHIS data lacks more localized information but can be interpolated to represent a local level. Whenever possible, data representing the Downtown Neighborhoods were used in order to portray the most accurate picture of the residents’ health. Demographic data was collected and analyzed from the Census Bureau. At this point in time, Census 2000 is the most recent demographic data available on the census-tract level. American Community Survey data from 2009 was used for city- and county-wide comparisons, interpolations, and trajectories.

Current relevant projects Numerous organizations are working on projects, programs, and policies dealing with health issues in the City and County of Fresno, as well as the San Joaquin Valley. These organizations are based in and outside of Fresno and are local, regional, or state-wide organizations and programs. It is important to recognize the work of the organizations below as it shows vested interest in improving the residents’ health and validates the need to consider and evaluate the health impacts of this long-range, comprehensive community plan.

The California Endowment’s Building Health Community Program Central California Regional Obesity Prevention Program Central Valley Health Network Central Valley Health Policy Institute The SJV Regional Equity Forum Central Valley Air Quality Coalition San Joaquin Valley’s Smart Valley Places Initiative Fresno West Coalition for Economic Development Fresno County Migrant Health Program Fresno Metro Ministries Fresno Works for Prevention Initiative West Fresno Health Care Coalition Concerned Citizens of West Fresno Final Report – March 2011

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ASSESSMENT OF KEY HEALTH ISSUES This section is organized by four major health determinants that were gathered through stakeholder interviews, community meetings, and information from previously published reports. Included are the following health determinants: (1) regular physical activity, (2) diet and nutrition, (3) environmental pollutants, and (4) social and economic stability. Within each of these determinants, an in-depth literature review provided a lens to analyze the most important 2-4 risk factors, which were identified and used to establish a variety of health indicators that could be investigated or measured and chronicled in the existing conditions profile. A summary of the health determinants analyzed is represented in the graphic below.

DETERMINANT 1: REGULAR PHYSICAL ACTIVITY As with many cities, auto-dependence created an urban development pattern that has yielded a less-defined and more scattered city with separated land uses. In suburban areas, the environment was built around automobile transportation; these areas are usually low-density, single-use neighborhoods that often isolate residents from work and other activities and lack efficient, reliable public transportation. Not only has this reinforced the primacy of automobile use above all others, but auto-dependence and segregated land uses have decreased physical activity levels and contributed to the obesity epidemic. One way to increase physical activity levels is improving an individual’s access to quality goods and services, enhancing transportation systems and infrastructure, and promoting an environment that is safe for walking and cycling.

Proximity to goods and services–the distance between home and other neighborhood amenities—is an important component for regular physical activity. Land uses, pedestrian facilities such as lighting and benches, commercial services, urban design, and residents’ perceptions of safety, distance, and relative need for goods and services are some indicators that may promote or impede the decision to walk or bike, rather than drive.38,39 Research on this topic is somewhat mixed. One study found that residents of higher-density, mixed-use areas make fewer vehicle trips and drive fewer miles than residents of lower-density, more singleuse areas,40 and when many destinations are near the home and there is a direct path to get there, people are more likely to engage in active transportation for at least 30 minutes on any given day.41 On the other hand, an especially industrial mix of land uses and transit-oriented development within close proximity to major freeways and arterials can increase individual exposure to sources of air pollution and increase risk of injury as a pedestrian or cyclist.42 Active transportation—using cycling or walking as a means of transportation—can help individuals obtain recommended levels of physical activity and save money on transportation costs. Some urban neighborhoods benefit from wide, well-maintained sidewalks, bicycle lanes and facilities, and proximal access to local parks and open space; however, most urban centers are grappling with the challenge of providing these amenities with limited resources. Unfortunately, certain neighborhoods are disproportionately burdened from a lack of pedestrian and bicycle infrastructure and park and open space investment. One study found that men who walked or biked to work were half as likely to be obese, had lower risk of CVD, and had overall higher fitness levels.43 Also, each additional mile of bike lane per square mile has been associated with an increase of approximately one percentage point in the share of workers regularly commuting by bicycle.44 Finally, public transit users (mostly to work) spend about 19 minutes walking per day and walked an average of one mile more than those who did not take transit.45 A working family of four making between $20,000 and $50,000 per year spends approximately 30% of their budget on transportation per year.46 The cost of transportation directly impacts disposable incomes of many Final Report – March 2011

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t families and increases in cost will disproportionally impact low-income families who already spend a larger proportion of their income on transportation.46,47 Active transportation and access to public transit can be a cost-saving measure for many families; studies have shown that those who rely more on transit, rather than driving, spend half as much of their income on transportation than those who rely on automobiles. 48 Injuries and fatalities are major concerns for pedestrians and cyclists. American pedestrians and cyclists are much more likely to be killed or injured than those in other countries, both on a per-trip and on a perkilometer basis.49 Vehicle collisions continue to kill about 45,000 people each year, with an average fatal injury rate for pedestrians and cyclists of 2.1 per 100,000. 49 In 2008, about 5,200 pedestrians and cyclists were fatally injured from vehicle collisions.50 Real or perceived safety influences when and how often residents will walk or cycle. Several environmental factors influence the rate of injuries and fatalities among pedestrians and cyclists: Pedestrian volume, vehicle speed, street type, and intersection design are among the most important variables.

Some evidence indicates that mixed-use and transit-oriented development can reduce traffic fatalities,51-53 and higher pedestrian volumes have been linked to lower rates of injuries and fatalities.54 Greater vehicle speeds directly correspond to injury severity and frequency,55 and higher traffic volumes correspond to a greater number of vehicle-pedestrian collisions.56 A study examining the impact of 16 education, enforcement, and engineering treatments implemented in the four most fatal (pedestrian deaths) Miami Dade County intersections demonstrated a reduction in pedestrian crashes by 8-13%.57 Traffic calming measures have also been shown to reduce pedestrian conflicts and collisions by 15%. 58 Park and open spaces can provide residents with spaces for physical activity and civic engagement.

Increasing access to and availability of parks and green space may be a tool for preventing chronic conditions by providing more opportunities to engage in physical activity. 59 Using GIS and activity monitors, one study found that a 1% increase in park and recreation area within a ½-mile radius of the participant’s home was associated with a statistically significant average of 1.3% increase in physical activity. 60 In another study, neighborhoods with only one additional physical activity-related facility (including parks) were associated with a 5% decrease in the odds of adolescent overweight and increased odds of engaging in 5+ bouts of moderate to vigorous physical activity per week.3 Parks also have the potential to economically revitalize park-poor urban neighborhoods, attract residents and businesses, and build assets for families and neighborhoods that otherwise would not occur. Park space has a direct association with nearby property values,61 as people generally desire to live in close proximity to a park and are thereby willing to pay more for the amenity.

Joint use of school recreation facilities is one way that school districts and cities can break down traditional boundaries to provide community members with greater access to available—often underutilized—facilities, which include gymnasiums, pools, field space, or basketball courts. Sharing these resources can alleviate financial pressure and can be a sustainable solution to enhance urban community life, use land more efficiently, and provide important gathering places for the members of a community.62 One study evaluating the effectiveness of opening and supervising an inner-city school playground on children’s physical activity levels found that the number of children who were physically active at the intervention playground was 84% higher than the unopened comparison.63 Scott et al (2007) found that schools represented 44% of potential neighborhood sites for physical activity as well as a significant association between locked school grounds and higher BMI among adolescent females.64

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t REGULAR PHYSICAL ACTIVITY | EXISTING CONDITIONS This section focuses on three indicators that determine regular physical activity levels in a population: (1) dedicated facilities for active transportation engagement, (2) spaces for physical and recreation activity such as parks and open space, and (3) the proximity of goods and services to those who seek them.

Lack of public spaces for physical activity

Unsafe Streets

Lack of access to active transportation options

Risk Factor PA.1: Unsafe streets PA.1.1. Indicator: Percent of automobile collis ions involving cyclists From 2000 to 2009, there have been 944 total bicycle collisions, 854 injuries, and 7 fatalities in the City of Fresno.65 Collisions are patterned on the highest volume streets in the downtown area: Divisadero Street, Belmont Avenue, Fresno Street, and Tulare Street. Although collisions are spread throughout the city, there is a concentration of collisions in the in the northeastern section of the downtown neighborhoods, including the neighborhoods Lowell, Jefferson, the northern portion of the Southeast neighborhood, and the central portion of the Southwest neighborhood. This data overlaps with the data presented in the Commuting to work section (below), where there is a higher mode share of cyclists in Lowell, Jefferson, and Southwest compared to the other neighborhoods. According to the reported data (see Table 9, City of Fresno SWITRS reported accident data, 2008-2009), the causes of the collisions were: auto right-of-way violation (26%), cyclist riding on the wrong side (16%), and the cyclist riding against the red light/running stop sign (16%).

Compared to other valley cities, Fresno has the highest overall Table 9. City of Fresno SWITRS reported accident data (2008-2009) number of bicycle fatalities and Accident Type 2008 2009 Totals injuries in 2008, but the lowest All Accidents 2351 1538 3889 rate per 1,000 residents. Figure Injuries 1049 716 1765 11, Distribution of Fatalities 27 19 46 bicycle/automobile collisions, 104 (4.5%) 71 (5%) 175 (5%) illustrates the locations of Bicycle involved Injuries 84 53 137 collisions (January 2000Fatalities 2 7 9 February 2009) and 152 (6.5%) 85 (5.5%) 237 (6%) demonstrates a large Pedestrian involved proportion of collisions Injuries 129 73 202 concentrating on the major Fatalities 10 3 13 corridors in the north and Total bicycle/pedestrian 256 (11%) 156 (10.5%) 412 (11%) northeast portion of the Injuries 213 126 339 Downtown Neighborhoods.

Fatalities 12 10 22 Source: Department of California State Highway Patrol. Collisions and Victims by Motor Vehicle (01/01/2008-12/31/2009), Jurisdiction: Fresno. Report generated: 08/10/2010.

PA.1.2. Indicator: Percent of automobile collisions involving pedestrians Out all automobile collisions from 2008-2009, 6% were pedestrian involved, resulting in 137 injuries and 9 fatalities.66 According to SWITRS 2009 data (see Table 9), 84 pedestrian-involved auto collisions occurred on local Fresno roads and 93% of the collisions resulted in injury or fatalities for the pedestrian, with a total of 86

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t injuries and 4 fatalities. In 2008, out of a total of 155 accidents, 90% of them resulted in 161 injuries and 10 fatalities.66 Figure 11. Distribution of bicycle/automobile collisions

Source: City of Fresno Bicycle, Pedestrian and Trails Master Plan, Fehr & Peers (2010)

PA.1.3. Indicator: Miles of bike lanes In the DNC Plan area there are no Class I paths or Class III routes. About 12.4 miles of Class II bicycle lanes exist in the 11.25 square miles of the Plan area. Table 10, Fresno City Bicycle Facilities (2010), below shows the existing bicycle facility mileage in the City of Fresno. There are 14 miles of class I bicycle paths. These paths are concentrated in the northern-most and southeastern-most edges of the city limits. The paths are, for the most part, disconnected and do not connect cyclists to the inner downtown core. There are 113 miles of class II bicycle lanes. Again, these facilities are concentrated in the northern-most edge of the city limits, are sparsely connected to each other or to other facilities, and rarely link cyclists to the downtown neighborhoods. Finally, there are Table 10. Fresno City Bicycle Facilities seven miles of class III bicycle DNC Plan area City of Fresno routes, signed with ‘sharrows.’ The Bicycle Facility Mileage Mileage 2010 Bicycle, Pedestrian, and Trails Class I (paths) 0 14 Master Plan (City of Fresno) cites the Class II (lanes) 12.4 113 following existing conditions and Class III (routes) 0 7 quality of the three bikeway Total 12.4 134 classifications: Source: Fehr & Peers. Downtown Neighborhoods Fulton Corridor: Existing Conditions Analysis. April 2010.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t Table 11. Existing bicycle infrastructure in the City of Fresno Bicycle Facility Class I Paths Class II Lanes and Class III Routes

Other facilities

Description  Several paths are unofficial, unpaved paths  Typically the paths are used for recreation purposes rather than for commuting  Class II lanes do not meet the current City Standard Specification (5-ft right of way) or CalTrans standards (3-ft right of way)  Proper markings are missing or inefficient  Lanes are discontinuous  Bicycle parking is insufficient and low quality  No City-owned long-term bicycle parking is available  Current policy does not require bicycle facilities or showers

Source: City of Fresno Bicycle, Pedestrian and Trails Master Plan, Fehr & Peers (2010)

Risk Factor PA.2: Lack of public spaces for physical activity PA.2.1. Indicator: Park and open space acres per 1,000 residents Currently 0.4 acres of parks per square mile exist in the City, 6.6 park acres per city square mile, and 3.1 acres per 1,000 residents. In the Downtown Neighborhoods, about 204 acres of park and open space exists, generating about 2.8 acres/1,000 residents (based on 2000 Census) in the DNC Plan area. This number nearly meets the requirements stated in the Master Parks Plan (3.0 acres/1,000 residents) but is 10% lower than the City rate. According to a Trust for Public Land publication, in FY 2008, the City of Fresno spent about 53$ per resident on park-related costs and maintenance, compared to the California average of $119. 67 Due to fiscal constraints, the City has cut funding for many recreation spaces such as pools and is considering reallocating Roeding Park’s Zoo acreage. As of 2008, the City of Fresno had 15 operating pools throughout the city that were open to the public; due to budget restraints, only two pools are available to city residents and they are not located in the Downtown Neighborhoods. Roeding Park, a large 146-acre park close to the Jane Addams Source: Google Earth, 2010. neighborhood, but inaccessible to most of its residents because of the Highway 99, houses the City’s zoo. Recently, the City notified residents that the zoo would expand, consuming 22 additional acres of the park. This reduction will drastically impact residents’ access to open space, especially those in or near the Jane Addams neighborhood.

Table 12. Existing open space acreage zoned by neighborhood Neighborhood Acres Acres/1,000 residents Jane Addams 146.7 24.7 Southwest 34.3 2.1 Lowell 2.3 0.3 Jefferson 2.3 0.2 Southeast 17.5 0.6 DNC 203.1 2.8 Fresno 3.1

PA.2.2. Indicator: Proximity to a community or neighborhood park Existing park space is unevenly distributed throughout the Downtown Neighborhoods and lack of access is a major concern (see Table 12, Existing open space acreage zoned by neighborhood). Jane Addams neighborhood is well-endowed with Roeding Park, however, due to its location, only the residents on the east side of Highway 99 have easy access to the park, excluding a large portion of the neighborhood population.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t PA.2.3. Indicator: Number of schools engaged in joint-use agreements for recreation spaces Burroughs Elementary school, in the Southeast neighborhood, has paved the way for future joint use agreements between the City and Fresno USD, and is now the first school to enter into such contract. In June of this year, the two partners came together and formally agreed to share the outdoor recreation space on the school grounds with the rest of the surrounding community. Instigated by a neighborhood parents’ group who conducted an assessment of the current conditions for where their children could play and presented the assessment to the school board as well as their petition: a joint use agreement that will allow them and their children to play on the school grounds after school, on the weekends, and on holidays. Burroughs is the first school to enter into a joint use agreement and despite some initial challenges with implementation and coordination, the transition has been relatively seamless and the grounds are well-used during non-school hours.

Risk Factor PA.3: Lack of access to active transportation options PA.3.1. Indicator: Commuting to work mode share The proportion of commute trips made by driving, cycling, and taking transit can be indicative of the how well-integrated a neighborhood’s built environment and transportation network is compared to other neighborhoods or to the City. The share of residents in the DNC Plan who drive alone is significantly lower than the City as a whole and the bus, bike, and walking share is much higher in the DNC area than the City (see Table 13, Commuting to work comparisons, 2000). Within the area, mode share vastly differs. Jane Addams residents drive alone more than the other neighborhoods, and as a consequence, they walk, cycle, or take transit far less than the others—corresponding well with the neighborhoods high vehicle ownership rates in the data presented above. Based on Census 2000, residents in the DNC Plan area walk (3.2%), cycle (1.1%), carpool (26.3%), and take transit (5.5%) much more frequently than the City. Jefferson neighborhood has the highest rates of carpooling and taking transit, while Lowell has the highest rates of cycling and walking to work and the lowest rates of driving alone. Nearly 10% of Lowell residents walk and cycle to work, triple the rate of the City, and corresponding to their low vehicle ownership rates.

Table 13. Commuting to work comparisons in the City of Fresno (2000) Mode Driving alone Carpooled Bus Bicycle Walking

Southwest Southeast 60.2% 60.0% 23.9% 27.1% 5.8% 4.6% 1.3% 0.8% 3.7% 2.3%

Jefferson 55.7% 28.8% 7.1% 1.0% 2.9%

Lowell 50.8% 27.5% 6.2% 2.5% 7.1%

Jane Addams 66.8% 20.3% 1.9% 0.7% 3.7%

DNC 58.6% 26.3% 5.5% 1.1% 3.2%

Fresno City 2000 74.7% 16.0% 2.4% 0.8% 2.1%

Fresno City 2008 77.0% 12.8% 2.3% 2.0%* 2.8%

Source: Census 2000. Table P30. Means of transportation to work for workers 16 years and older. Compiled by R+A, 2010 *Includes motorbikes, taxis

PA.3.2. Indicator: Bus ridership, operations & destinations (head way, routes, BRT) Fresno City is locally served by Fresno Area Express (FAX), regionally by Amtrak, and eventually state-wide by California High Speed Rail. FAX operates 18 routes on 114 vehicles, with an average of 30 minute headways. 68 FAX ridership was approximately 11.6 million in 2006 which equals about 25 rides per person per year, with an average of 38 passengers per hour.68 There is currently no Bus Rapid Transit (BRT) or Light Rail Transit (LRT) system in place in Fresno.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t REGULAR PHYSICAL ACTIVITY | COMMUNITY INPUT During the community health and neighborhood design workshops in the design charrette process, the neighborhood residents expressed strong interest in neighborhood-wide policies addressing improvement in the built environment and transportation networks. The following related policies were chosen as priorities for the residents and each of these priorities are represented in the draft DNC Plan this HIA is assessing.         

Develop land use patterns that encourage physical activity Transform corridors into thoroughfares that accommodate bicycles, pedestrians, autos, and transit Design buildings that provide “eyes on the street” and orient alleyways towards pedestrians Require design review to ensure buildings promote good neighborhood form Infill vacant land and subdivide large parcels into walkable blocks Create a bicycle and multi-use trail network so residents can walk safely and comfortably Enhance parks, trails, and open space Introduce joint-use agreements between Fresno Unified School District and the City in order to expand access to recreation and open space Transform alleyways intro clean, safe places or allow for their conversion to alternative uses such as community gardens, walking trails, or transferring them to adjacent property owners

REGULAR PHYSICAL ACTIVITY | SUPPORTED POLICIES & ACTIONS IN THE PLAN The Health and Wellness chapter explicitly describes action items that pertain to hazardous materials and includes goals and actions items such as minimizing exposure to criteria pollutants by avoiding locating new residential units near toxic or hazardous sites, creating buffers between industrial agriculture uses and sensitive uses, and monitor and enforcement of health standards.      

Prioritize bicycle and pedestrian improvements, especially around schools and commercial areas Implement transit improvements Utilize vacant land to increase parks within walking distance of local residences Promote compatible retail and services within walking or cycling distance of more residences Introduce Safe Routes to Schools Increase accessible sidewalks within neighborhoods where sidewalks are not present

REGULAR PHYSICAL ACTIVITY | PLAN ANALYSIS Over the next 15 years, population in the downtown area is expected to increase by about 13,000 residents, from 14,919 in 2000 to 27,764 in 2025. Accommodating this level of population growth in the design of the built environment and transportation network, and considering its impact on community health, will be crucial to downtown Fresno’s long-term success and a healthy, physically active population.

Land use, urban form and transportation In the Urban Form and Land Use chapter, connectivity of streets, grouping compatible land uses, increasing mixed uses, and restructuring the streetscape to accommodate cyclists and pedestrians are the key goals.

Improving the public realm of Downtown by enhancing the economic vitality and updating facilities are major components explained throughout the Plan. The Transportation section describes the concrete changes of Final Report – March 2011

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t the streetscape that will better accommodate pedestrians and bicyclists and provide a safer, efficient network of infrastructure—such as bicycle lanes, road diets, pedestrian amenities, street trees, and a scale of buildings that fits with the pedestrian perspective.

The regulating plan (also known as the “zoning code”) for the DNC Plan allows for a greater mix of land uses than is currently allowed, especially in the downtown core. The “City Center” is circumscribed by the “Valley Center,” which makes up the majority of the downtown triangle. These areas are characterized by increased allowances for density, building height, multi-family housing, and housing units per acre. These centers are the primary regional hubs for employment, government, and connection to regional transportation options.

Immediate outside this core, the “neighborhood general” designation is prominent residential descriptor for the other DNC Plan area neighborhoods and signifies restoration, preservation, and upgrades to existing residential units, establishing infill housing development projects when feasible. Revitalization of residential areas are concentrated in Jane Addams and Jefferson, with several pockets in the other neighborhoods. The main corridors in the neighborhoods are lined with local- and regional-serving commercial, retail, and light industrial (“corridor general”). Strategically placed in the “centers” of each neighborhood, in close proximity to the local school, the Plan designates these areas as “neighborhood centers” and, where appropriate, “community centers.” These two types of centers allows nearly all surrounding residents access to commercial, retail, and other goods and services within a ¼ to ½ mile walking distance from their residence.

The health impacts associated with a greater diversity of land uses resulting from this Plan are summarized over the next few pages.

Transit improvements The Transportation section also dedicates a goal to improving transit as a viable option for vehicle users, such as the implementation of Bus Rapid Transit and/or light rail. An efficient transit system could increase ridership and promote multimodal active transportation options. The DNC Plan prioritizes several corridors in the downtown areas as “Primary Transit Corridors” as well other “Secondary Transit Corridors.” The Primary Transit Corridors are to be managed in ways that minimize passenger delays and the City should invest in quality shelters and pedestrian amenities along these routes to improve ridership.  

Primary routes include: Fresno Street, Van Ness, B Street, Ventura, Blackstone, First Street, and Hazelwood.

Secondary routes include: Kearney, Trinity, Tulare, and Martin Luther King

The Plan also calls for several priority improvements to streets in the DNC area that should take place within the next five years. One of these improvements is a Bus Rapid Transit project. The Plan proposes two routes, on Kings Canyon and Blackstone/Abby corridors. These routes are similar to the ones implemented in Los Angeles, which increased ridership 27-42%. Based on these predictions, Fresno’s FAX ridership for the proposed BRT routes would also increase. Currently, the routes that traverse the downtown area (Routes 26 and 28) each had over 1.5 million annual boardings in 2000. Routes 30 and 38, also serving downtown Fresno, approached the 1.5 million mark in 2001 (the most recent ridership data generated by consultants hired by the City). With a 27-42% increase, it is reasonable to predict an additional 1.6 – 2.5 million passengers annually amongst the new BRT routes, or an extra 50 – 77 passengers per hour spread across the new BRT routes.

A few of DNC Plan neighborhoods would be impacted by the BRT. The two proposed routes traverse through the Southeast and Lowell/Jefferson neighborhoods, allowing these residents convenient access to the service. These neighborhoods also have the lowest overall vehicle ownership rates and therefore may be the Final Report – March 2011

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t neediest in terms of transit access. Lowell/Jefferson and Southeast neighborhood bus shares for commuters may increase more than other neighborhoods, by 1.2-1.9% for Southeast (5.8-6.5% total share) and 1.9-2.9% (9-10% total share). The DNC Plan area may see an increase in commuting by bus of 1.4-2.6%, bringing the bus to work share up from 5.5% to 6.9-8.1%. Jane Addams neighborhood has the lowest bus to work share with 1.9% and the highest driving alone rate at 67%; unfortunately the plan does not include public transportation improvements in this neighborhood. Jane Addams residents may not benefit from increased mobility, which can improve health through enhanced opportunities for physical activity and access to goods and services. A lack of transit improvements may also isolate this community from the rest of the Downtown Neighborhoods.

Collisions and safety Automobiles, cyclists, and pedestrian collisions are addressed throughout the Plan, particularly in the Transportation and Community Health and Wellbeing chapters. The Plan calls for installation of traffic calming facilities that should take place within the next five years. These include: narrowing traffic lanes, installing cycling lanes, widening sidewalks, and installing bulb-outs. The goal of installing traffic calming devices is so slow the speed of traffic—a well-documented indicator for reduced accidents, traffic injuries, and fatalities. As previously discussed, traffic calming facilities have been shown to reduce pedestrian conflicts and collisions by up to 15%.58 Disaggregating SWITRS data of pedestrian injuries and fatalities from the city level to the neighborhood level was not available, however, it can be assumed that cyclist accidents might follow a similar trend in terms of location and frequency of accidents as pedestrian-related accidents— concentrating on the highest vehicle volume, highest vehicle speed roads, several of which are in or pass through the downtown neighborhoods. As described in the existing conditions analysis, a concentration of bicycle/automobile collisions occur in the Lowell/Jefferson neighborhoods. The current draft of the Plan outlines the major thoroughfares in these neighborhoods as “priority” corridors for improvements, especially through road diets. Narrowing the automobile right-of-way will slow traffic, dedicate space to bicyclists, and create a safer environment for all modes of travel.

Cycling infrastructure Improvements for cyclists are a core Table 14. Bicycle lane mileage changes component in the Transportation +1.1 miles of lanes per square mile chapter of the Plan. Opportunities for Change safe cycling increase levels of physical activity, which improves health Existing .76 miles of lanes per square mile outcomes. One of the major near-term implementation priorities for the DNC 1.87 miles of lanes per square mile Plan area streetscape is the installation Plan of bicycle lanes. The Plan prioritizes about 8.6 added miles of bicycle lanes in the 11.25 mi2 DNC Plan area, bringing total mileage up to 21 miles of Class II lanes. According to research, the additional 8.6 miles may increase the share of workers regularly commuting by bicycle by up to 1.1%.44 An additional 1.1% in the share of cycling commuters in the DNC Plan area would increase the rate from 1.1% to 2.2%. Although the hope is to get commuters out of their automobiles and on bicycles, this mode shift may not occur. Those who walk or take transit to work may shift to cycling as well as those who drive alone or carpool. The total, raw number of accidents may also increase due to the increase in cyclists on the road, though this increase may not reflect an accident rate increase.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t Pedestrian improvements A major area of improvement in the DNC Plan is the pedestrian realm. The Plan calls for major streetscape improvements, both in the short-term (within 5 years) and the long-term (20 years). Street trees, benches, wider sidewalks, bulbouts, and other facilities have been shown to enhance the pedestrian environment, encourage walking, and improve pedestrian safety.

Opportunities for safe walking may increase levels of physical activity, which improves health outcomes. With a potential 27-42% increase in ridership with a BRT system, individuals shifting modes from driving to transit will likely walk more. As research demonstrated those who take transit walk on average 19 minutes more and an extra mile more per day than those who do not take transit.45 For an average 200-lb person, a 19-minute walk translates into 125kcals burned, which, over the course of a year of commuting to work (about 240 days), may result in a 10-lb weight loss. Especially for individuals suffering from hypertension, diabetes, obesity and CVD—and those at high-risk for these conditions—a small weight loss of 10 pounds can significantly improve health status and reduce mortality.

The DNC Plan also addresses the need for Safe Routes to School in the Jane Addams neighborhood by prioritizing 3.5 miles of the neighborhood for pedestrian upgrades, including off-street paths and corner striped crossings. Without other traffic calming facilities, vehicle volume and speed may not be altered.

Without slowing the traffic, children and other sensitive populations may be negatively impacted and injuries/fatalities may remain constant or increase with more children present.

Parks and open space Policy alternatives that prioritize urban green space may provide an avenue for increasing social welfare by more fairly distributing parks and open space. On a neighborhood-level, the DNC Plan calls for expanding access to open space by creating new parks, preserving and enhancing existing parks, and pursuing joint-use agreements between the City and the school district. Vacant land parcels and brownfields in Fresno represent underutilized land and are often considered “blighted” and “undesireable” by both businesses and homeowners. These types of land parcels not only threaten the surrounding community by offering space for illicit activities but they can also bruise the community’s reputation. Nevertheless, these lots are ripe with opportunity for community gardens or small neighborhood parks. Using acreage as a proxy for engagement in physical activity can be problematic; opening a park or a school playground doesn’t mean that kids will play there. Nevertheless, in significantly park-deficit neighborhoods, such as those in the DNC Plan area, are very likely to benefit from an increased access to parks, open space, and other safe places to play. As explained in the literature summary, increasing access to parks has the potential to increase physical activity and places for social interaction.

Joint use agreements are a key component to increasing local access to parks and open space. Joint use agreements involve partnership and collaboration between local government and school district officials to share cost, use, and responsibility of the available facilities or spaces. Schools are perfect places to combine these resources, not only for financial reasons but also because schools already have facilities (such as basketball courts and baseball fields) and trained staff. Partnering with schools and local universities for student interns is a viable option for increasing recreational opportunities. Table 15, DNC Plan impacts on park acreage per 1,000 residents by neighborhood, shows the added park acreage with new parks as well as those created by joint use agreements between the school district and City. Research has shown a positive relationship between an increase in neighborhood parks and recreation spaces and physical activity.

Programming, monitoring, and evaluation are key components for a successful joint use relationship. Some Final Report – March 2011

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t communities have expressed concern that opening schools to the community may ignite criminal or antisocial behavior, however this has not been the case for most entities that enter into joint use agreements. In fact, many case studies highlight the fact that real and perceived crime actually decreased once a joint use agreement was in place.1 The Plan particularly pays the most attention to Lowell and Southeast neighborhoods, which are two of the most park-poor areas in the Downtown Neighborhoods. The only joint use agreement in the City thus far is located in the Southeast neighborhood; if this relationship remains steady and utilitarian, as it is now, it could act as a role model for other schools to follow.

Table 15. DNC Plan impacts on park acreage per 1,000 residents by neighborhood Existing Zoning DNC Plan Acres/ Acres/ Neighborhood Acres 1,000 residents Acres 1,000 residents % change Jane Addams 146.7 24.7 166.1 27.9 113% Southwest 34.3 2.1 70.5 4.3 206% Lowell 2.3 0.3 4.5 0.7 196% Jefferson 2.3 0.2 22.5 1.8 978% Southeast 17.5 0.6 122.5 4.1 700% DNC 203.1 2.8 386.1 5.1 179% Source: Google Earth, 2010.

REGULAR PHYSICAL ACTIVITY | RECOMMENDED REVISIONS FOR THE PLAN Based on the results of the Literature Findings and Plan Analysis the following recommendations are provided in order to be incorporated into the Final Draft Plan. Many of the goals and policy directions within the Draft Plan are supported by this HIA. The following revisions are recommended with specific regard to improving health outcomes associated with physical activity: 1. Ensure vulnerable populations are not disproportionately impacted by any of the goals, policies, or key actions.

2. Include recommended actions for programming associated with the establishment of joint use agreements between the City and Fresno USD. 3. Do not eliminate or reduce any existing park space in the Downtown Neighborhoods.

4. Where feasibly, redirect funding to maintain and introduce recreation spaces including parks and pools.

5. Continue support and programming of recreation programs.

6. Use community benefits agreements to incentivize developers to locate parks and open space in their development areas.

7. Promote bicycle and pedestrian safety courses in schools and workplaces.

8. Ensure funding for parks is maintained or increased.

1

The Center for Cities and Schools has a multitude of examples of this. Please visit: www.citiesandschools.berkeley.edu

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DETERMINANT 2: DIET & NUTRITION Access to safe, affordable, nutritious food is a basic individual need, however, more and more urban communities are faced with challenges in their food environment. The “food environment” is comprised of all sources where individuals acquire food. More than ever before, Americans are purchasing and consuming food away from home.69,70 Food from restaurants, fast food outlets, and convenience stores are often highly processed and high in calories, sugar, saturated fat, cholesterol and sodium71-73—nutrients that, when consumed in high amounts, may increase one’s risk for the development of obesity, diabetes, hypertension, and cardiovascular disease.23,74

Grocery stores have been correlated with increased fruit and vegetable intake. The mere presence of one full-service grocery store has been associated with higher fruit and vegetable intake, as well as a reduced prevalence of overweight individuals and obesity.75 Neighbourhoods with one full-service grocery store is also associated with a 9% reduction in overweight and 12% reduction in CVD risk factors 32 In low-income neighbourhoods, one study found that for every single additional grocery store increases the likelihood of meeting nutritional guidelines by one-third.76 Full service, large chain grocery stores, compared to corner stores or convenience stores, offer a wider variety of foods, more fresh produce, and are generally less expensive. It is also well-established that fruit and vegetable consumption is one of the best predictors for chronic disease and obesity,74 and establishing a diet that incorporates these ingredients at a young age is a protective strategy for combating the onset of illness, disease, and especially obesity. 77 A study analyzing food store availability in Minneapolis-St. Paul showed that large chains are more likely to locate in lowpoverty, suburban areas than are small or non-chain stores—89% of the large chain grocery stores were located in areas with less than 10% poverty rates.78 Prices for goods also varied greatly with suburban largechains 10-40% cheaper. Additionally, fresh produce was 50% less likely to be found in inner-city stores than suburban stores.78 Farmers markets, farm-to-school programs, community or urban gardens, and community supported agriculture benefit community members by providing the opportunity for residents to grow or purchase fresh, local produce at affordable prices. Local procurement of goods and produce strengthens the local economy, supports small family farms, reduces transportation of food to plate, and some argue that the produce tastes better without the pesticides and other pollutants that come with the long-distance traveling of food. Neighbourhood and school gardens also provide a new and unique space for social interaction and learning; however, implementation and programming for neighbourhood and school gardens are constant challenges since cities and school districts frequently experience shortages of funding, time, and personnel.

Additionally, empirical evidence documenting the nutritional or educational benefits of school gardens comprises of a few, inconclusive quasi-experimental studies.

Food insecurity, the inability to acquire the adequate amount of food for proper health, is disproportionately high in lower income communities and communities of color. Although low-income households experience higher rates of food insecurity, they also spend disproportionately more of their income on food, creating a deficit of funds for health insurance, medical care, transportation, rent, utilities, and extracurricular activities.

For example, a family of four with an annual income of $10,000-14,999, spends about 37% of monthly income (~$413) on food whereas a family earning over $70,000 annually, spends about 9% of income on food.79 Some research has quantified the impact of income on obesity, concluding that for each increase of $1,000 in median household income, obesity risk decreased by 0.1%. 80 Additionally, while low-income communities already spend a higher percentage of their income on food, they also have the highest obesity

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t and mortality rates.79,81 This occurrence may be mediated, in part, by the low cost of calorie-dense foods. The inverse relationship between the calorie-density of foods and its associated energy cost means that diets based on refined grains, added sugars, and added fats are more affordable than the recommended diets based on lean meats, fish, fresh vegetables, and fruit.

Fast food outlets are a cause of concern for residents in lower income areas. In one study, participants with incomes below the Federal Poverty level had twice the amount of fast food outlets in their neighbourhood, were more likely to consume fast food more than once per week, and eat it in their neighborhood compared to higher income groups.73 On a typical day, 30% of American children and teens eat fast food.82 The same study found that these kids consumed more calories, fat, carbohydrates, soda, and less fiber, fruits and vegetables, and milk compared to those who did not eat fast food. When fast food outlets, convenience chains, and liquor stores are the only options for food retail in these communities, lower income residents and especially food stamp participants who can only use their vouchers at participating grocery stores, experience extra hardship accessing healthy food sources. Research demonstrates that, compared with higher income neighborhoods, convenience stores and fast food chains are more prevalent and large chain grocery stores are less prevalent in lower income areas and communities of color.83 Our current environment, overwhelmed with fast food, prudent marketing of high fat, high calorie foods, and increasing rates of sedentary leisure activities, does not encourage health-promoting lifestyles, especially for the most vulnerable of populations: those from lower-income, lower-resource communities.70

DIET & NUTRITION | EXISTING CONDITIONS The DNC Plan area has a variety of food stores, restaurants, and fast food outlets. Since Fresno has generally lower incomes and higher rates of poverty than County or State levels, residents faces food access challenges that are faced by other cities â&#x20AC;&#x201C; such as a lack of grocery stores, poor quality produce, and the proliferation of liquor and convenience stores as well as fast food outlets. Overconsumption of high-calorie, low-nutrient foods, combined with an activity-deficient lifestyle are primary risk factors for the three leading causes of death in Fresno downtown neighborhoods (CVD, cancer, and stroke).

Lack of physical access to healthy food sources

Exposure and consumption of unhealthy foods

Risk Factor DN.1: Lack of physical access to healthy food sources DN.1.1. Indicator: Number and distribution of grocery stores or produce markets A total of five full-service grocery stores and one neighborhood-serving supermarket serve the DNC Plan area.

Figure 12, Locations and trade areas of full-service grocery stores in the DNC Plan area, demonstrates the uneven distribution of full-service grocery stores in the area. Jane Addams, Lowell, Jefferson, and parts of Southwest and Southeast neighborhoods have limited or no access. Figure 13, Comparisons of food retail in the DNC Plan, indicates vast differences in the types and distribution of food retail between the neighborhoods and several conclusions can be drawn. These conclusions are summarized below:

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t  

 

Restaurants are more prevalent than food stores by 2.6 times.

A majority of the food stores are convenience, corner, or liquor stores since only 5 full-service grocery stores serve the neighborhoods. These food stores rarely provide fresh fruit and vegetables, and when they do, customers pay a premium.

Southwest has significantly more restaurants and food stores than any other neighborhood.

Jane Addams has the fewest food stores and highest ratio of restaurants to food stores (7:1).

Source: State Board of Equalization, 2008; Strategic Economics, 2010.

Total Number

DN.1.2. Indicator: Retail Food Environment Index (RFEI) Figure 13. Comparisons of food retail in the DNC In 2007, the California Center for Public Health Plan Advocacy calculated Fresno’s Retail Food 94 100 Environment Index, a common measure of an Food stores 90 area’s food environment that divides the 80 Restaurants 70 number of fast food and convenience 60 40 44 50 establishments by the number of 29 40 27 supermarkets, produce markets, and farmers 30 10 9 12 20 markets.84 They calculated a RFEI of 6.23, 7 4 10 compared to 4.13 for California as a whole— 0 meaning that Fresno has 6.23 times the amount of fast food and convenience stores than supermarkets, produce markets, and farmers markets. Given the lack of grocery stores in the DNC area and the high Neighborhood prevalence of fast food and convenience stores, it is safe to assume that the DNC area Source: State Board of Equalization, 2008; Strategic Economics, 2010. may have a substantially higher RFEI than the rest of the City.

DN.1.3. Indicator: Number and distribution of farmers markets One farmer’s market serves the Downtown Neighborhoods, located near the Fulton Mall and adjacent to City Hall on O Street between Fresno and Tulare Streets. “Market on the Mall”—the only certified farmers market in the downtown area—is open year-round on Mondays and Fridays from 10am – 2pm. The market accepts Electronic Benefits Tranfers (EBT) for SNAP (formerly Food Stamps) as well as WIC/Seniors food vouchers.

Four other farmers markets serve the greater Fresno area, but they are located 5-10 miles north of downtown and thus inaccessible and impractical for Downtown Neighborhood residents to patronize.

Additionally, there seems to be little promoting or providing of information about all the farmers markets in the area. Information was difficult to find and was obtained from several different online sources. A huge barrier to organizing farmers markets is the paperwork and fee associated with obtaining a Conditional Use Permit, which is required by the City.

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Figure 12. Locations and trade areas of full-service grocery stores in the DNC Plan area

DN.1.4. Indicator: Number and distribution of community gardens There are currently twelve community and school gardens in the City, but only four serve the Downtown Neighborhoods and the others are located far from the downtown. Fresno Metro Ministry, a local organization dedicated to improving community health in Fresno, has helped establish a number of community garden projects in the City. Programming for community gardens is an essential component for a successful community garden. Fresno Metro Ministry (FMM) has a community garden program that has successfully established several of the existing community gardens, both in the private and public sphere.

Reyna Villalobos, FMM’s Central California Regional Obesity Prevention Program director and Tom Matott, Parks & Community Gardens Manager, shared their community garden information with the consultant team. The Southwest neighbourhood has no community garden, while two gardens are on the fringe of Southeast, one in Downtown, and one more on the outskirts of Lowell/Jefferson. FMM’s garden programming has faced numerous challenges; the main challenge is “keeping active interest” by participants.

Mr. Matott commented on participants’ weariness of heavy commitment: Once folks figure out that they need to get to the garden every other day, they tend to fall away. This may be due to location as well. The farther someone has to go to garden, the fewer the weekly visits are, and the lower the participation rate. This could be fixed with more small neighborhood gardens.

In addition to increasing small neighbourhood gardens, education and organization were cited as the “next two biggest needs.” These are two assets for successful community garden implementation. A few other challenges faced by FMM and City officials are land acquisition, indemnity insurance, and steady participation.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t DN.1.5. Indicator: Number of schools with farm -to-school programs Currently there are no farm-to-school programs. In addition to the thousands of acres of large-scale agricultural land surround the City of Fresno, about 8 small, organic farms are located just outside of the Downtown Neighborhoods Plan area. In October 2005, a 10-week pilot program with Fresno USD introduced elementary students to nutrition and agriculture-based learning with local produce. Produce and harvesting was learned about in the classroom and then purchased from local growers and served each Wednesday in the cafeteria.

Risk Factor DN.2: Exposure and consumption of unhealthy foods DN.2.1. Indicator: Public school proximity to fast food outlets Fast food has a strong presence in Fresno and a great majority of public schools are located within ¼ mile of these establishments—especially in the Southeast and downtown core neighborhoods. In fact, 65% of Fresno public schools are within ½ mile of a fast food establishment. When schools and fast food restaurants are located near each other, students have easier access to fast food and may be able to walk there before, during, or after school. Figure 14, Public school proximity to fast food establishment, describe the relationship of fast food establishment proximity to public schools in Fresno, Merced, and Stockton.

DN.2.2. Indicator: Resident proximity to convenience stores, fast food outlets, & grocery stores Zuk and Altshuler (2008) reported that the City of Fresno has the highest ratio in the San Joaquin Valley of fast food establishments to population: 7.19 fast food outlets per 10,000 people. According to GIS data, approximately 5% of the DNC population resides within ¼-mile of a fast food outlet, 6% within ¼-mile of a convenience/liquor store, and only 2% resident within ½-mile of a grocery store.

DN.2.3. Indicator: Percent of children, teens & adults who eat fast food 3+ times per week On the County level, CHIS 2007 demonstrated that 24% of Fresno County children, teens, and adults ate fast food 3 or more times in the past week, compared to 19% of California. Access to fast food is becoming easier not only in our cities, but now on school campuses as well. According to a Public Health Institute report released in 2000, 90% of California high schools sell chips, candy, and other “competitive foods” in vending machines and 72% permit advertising of brand-name fast foods and beverages on campus.85 DN.2.4. Indicator: Percent of children & teens who drink 2+ glasses of soda per day Nearly one-third (26%) of Fresno County children and teens drink two or more glasses of soda or other sweetened beverage per day, compared to 15% for California. Discretionary calories, such as soda, contribute to overweight and obesity and having easy access to establishments that sell these items can increase the likelihood of consuming them.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t Figure 14. Public school proximity to fast food establishment in Fresno County

Source: Altshuler & Zuk (2008)

DIET & NUTRITION | COMMUNITY INPUT During the community health and neighborhood design workshops in the design charrette process, the neighborhood residents expressed interest in neighborhood-wide policies that address improvement in access to sources of safe, affordable, nutritious foods. The following related policies were priorities of the residents:   

Facilitate safe, convenient access to healthy foods Provide opportunities for community gardens and local food production Enable urban agriculture on a permanent and interim basis

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t DIET & NUTRITION | SUPPORTED POLICIES & ACTIONS IN THE PLAN The Plan outlines the following policies that will likely improve residents’ access to healthy food source as well as discourage access to unhealthy food sources:       

Strive for all residents to live within ¼ mile of food retail that provides healthy foods, preferable fullservice grocery stores or farmers markets Encourage additional full-service grocery stores Promote the development of new farmers markets in the Downtown area Encourage residents to grow food in their yards Prohibit new drive-through restaurants in the majority of the Downtown Neighborhoods area Prohibit new fast food restaurants and large chain restaurants in the area Prohibit concentrations of liquor stores

DIET & NUTRITION | PLAN ANALYSIS Supermarkets, produce stands, farmers markets, and other food retail are vital assets of any community and their presence increase fruit and vegetable intake, promotes physical activity, and builds a local economy.

The DNC Plan at its current draft state includes myriad strategies and key actions that support healthy eating habits with specific regard to the distribution of food retail in the Downtown Neighborhoods.

Healthy food retail At this stage, it is difficult to estimate how many new full-service grocery stores, fruit/vegetable markets, and farmers markets will open and where they will open—and thus how that infrastructure would impact health in the community. Nevertheless, several components of the Plan favor healthy food retail, even if it is not explicit. Increasing density, identifying neighborhood commercial centers, and planning for compact development will encourage the Plan’s goal to strive for all residents to be within ¼ mile of healthy food retail. Several of the ‘Key Actions’ address the need for more full-service grocery stores, farmers markets, and fruit/vegetable markets, laced throughout the Urban Form and Land Use, Community Health and Wellbeing, and the Economic Development chapters. The Plan also establishes policies and action items articulating the need for more community gardens and the ability for residents to engage in urban agriculture. Although urban agriculture does not usually produce significant amount of food and requires programming, these activities enhance social interaction and neighborhood capital.

The implementation of the policies above is likely to positively impact residents’ health and wellbeing and may improve health directly by increasing fruit and vegetable intake or physical activity, and indirectly by enhancing social networks and building community trust and cohesion. Improving the food retail environment cannot occur in a siloed manner; in other words, opening an additional grocery store in Jane Addams neighborhood will not automatically create a healthier, nutritious environment. The store must be desired by the community, its products used by the residents, and its facilities accessible to those who need it most. Similarly, a community garden cannot grow and harvest food on its own; policy and programming must support its success. Public outreach, community involvement, and other topics discussed in this report— transportation, housing location, land use, education, and employment, among others—all play a role in improving the food environment.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t Unhealthy food retail The policy directions and action items drafted in the Plan at this point deter the proliferation of most unhealthy food retail in the DNC Plan area. Prohibiting new drive-through restaurants, fast food and large chain restaurants may allow for the opening of local businesses, deterring formula fast food chains and encouraging a pleasant pedestrian environment. Non-fast food restaurants do not necessarily serve healthier food items or smaller portion sizes. Establishment of a program to guide restaurateurs serving decisions could be appropriate. Prohibiting concentrations of liquor stores is also likely to improve the health and safety of nearby residents, if grocery stores or other healthy food retail are within a walkable, convenient, and safe distance away. If there are no replacements or alternatives to corner, liquor, or convenience stores, health and safety may not improve in the short or long term. This also goes for fast foodâ&#x20AC;&#x201D;if there is no replacement or alternative, or if the price-point of the new restaurants are too high, residents will retain their consumption levels of fast food and health will likely remain the same.

The preliminary policies and goals associated with food access drafted in the DNC Plan are a major first step in the right direction and represent cutting edge objectives for a comprehensive, long-term planning document. Acknowledging the role of planning policy in community nutrition and nutritional status legitimizes the importance and immediacy of the issue. Continued support and programming of local alternative sources to nutritious foods and community programs for local hiring and quality and cost control is also vital.

DIET & NUTRITION | RECOMMENDED REVISIONS FOR THE PLAN Based on the results of the literature findings and Plan Analysis this HIA provides the following recommendations to be incorporated into the Final Draft Plan. Food and nutrition are essential, basic human needs and much of our current food environments do not support healthy decisions around eating. Many of the goals and policy directions within the Draft Plan are supported by this HIA. The following revisions are recommended with specific regard to improving health outcomes associated with diet and nutrition: 1. Include recommended actions for programming associated with the establishment of community gardens, urban agriculture policy and programming must support its success 2. Continued support and programming of local alternative sources to nutritious foods and community programs for local hiring and quality and cost control.

3. Remove or reduce the burdens for acquiring a Conditional Use Permit for farmers markets.

4. Incentivize large supermarkets to locate in the Plan area.

5. Develop a marketing campaign for the Fresno farmers markets.

6. Leverage local large agriculture companies for community benefits agreements with fruits and vegetable production.

7. Prohibit the opening of any new fast food, convenience store, or liquor store within a 1/2-mile radius of any public school.

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DETERMINANT 3: ENVIRONMENTAL POLLUTANTS The County of Fresno has been ranked the single worst county in California in terms of air quality and there are many contributors to this status. Transportation systems and land use are tightly correlated with a community’s indoor and outdoor air quality, noise levels, and general environmental health. Studies have implicated traffic sources of air pollutants such as NO2 and PM as potential sources of acute and chronic health effects.86,87 It is well-established that exposure to traffic-related air pollution can have negative effects on health and health impacts associated with traffic-related air pollution.88,89 Furthermore, poor quality of housing and housing location can lead to numerous health problems. This section will focus on other sources of environmental hazards and air pollution, besides those related to transportation.

Outdoor air pollution is a principle environmental and social concern that has broad health impacts. It is well-established that increased exposure to air pollution has a direct effect on acute and chronic respiratory illnesses (such as asthma), but it is also associated with cardiovascular disease, hypertension, cancers, and allergic reactions. It’s estimated that 6% of annual deaths are due to outdoor air pollution. 90 Particulate Matter (especially PM2.5 and PM10) is extremely harmful to human health as it can be inhaled into the deepest part of the lungs, and ultra-fine particles may even pass into the blood stream. PM2.5 health impacts may include decreased lung function, aggravated asthma, and nonfatal heart attacks.91 Exposure to green-house gases, especially NOX and Particulate Matter, is associated with higher rates of hospitalizations for asthma, especially in children, and CVD events.92,93 Long-term occupational exposure to diesel exhaust has been associated with 40% increase in the relative risk of lung cancer.94 Substandard housing conditions and a poor quality indoor environment impair residents’ health and development, especially for vulnerable populations such as children and the elderly. Average US children spend 80-90% of their time indoors and a healthy indoor home environment is essential for children’s normal development.95 Unfortunately, in low-income Californian households, substandard housing conditions exist where various indoor contaminants pose a risk to child health. 95,96 Stark racial disparities in quality of housing exist and the resulting health disparities in the US have been constant over the past few decades. 2,96 Research has demonstrated that poor housing conditions have an impact on health of the residents who reside there. For example, deteriorating housing conditions, such as leaks, holes in the walls, floors, and ceilings, and the presence of dust, cockroaches, and other allergen-emitting pests are significantly associated with asthma symptoms, especially in lower-income households.97 Also, in the US, more than 17% of lowincome children have blood lead levels above the allowable limit and children with higher blood lead concentrations score significantly lower in arithmetic and reading scores compared to children with blood lead concentrations.98 Inadequate home insulation, warmth, and cooling can impair the health of household inhabitants by increasing mold and humidity-related allergen sensitizers as well as impair immune response and the ability to fight illness during cold winter months. 96 Finally, without adequate ventilation air pollutants, especially total volatile organic compounds (TVOC), formaldehyde (HCHO), and biological contaminants, have the opportunity to coagulate in a single space and have been shown to increase allergic reactions and asthma espisodes.99 Proximity to polluting land uses can impact an individual’s or household’s exposure to environmental toxicants. Infected dirt, dust, and water can be ingested, inhaled, or absorbed into the skin. Heat, wind, rain and other natural occurrences, combined with exposure, impact the severity of health effects. For example, those living near noxious land uses (less than ½ mile) are up to 66% more likely to be hospitalized for asthma, 30% more likely to be lower-income, and 13% more likely to be a minority than those outside the tested

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t boundaries.100 Also, children living within ¼ mile from a major freeway were nearly 4 times as likely to have asthma and children living in close proximity to a major road (more than 29,000 ADT) were 2.5 times likely to have asthma.86 In one study, personal exposures to nitrogen dioxide for those residing near major roads and freeways were: 36.0 μg/m3 for children living and going to school near a motorway with an average flow of 170,000 vehicles a day; 29.7 μg/m3 for children near a motorway with 126,000 vehicles a day; and 25.1 μg/m3 for those near a road with 45,000 vehicles a day.101 Toxic pollutants, such as pesticides, insecticides, and fertilizers, have been strongly associated with cancers and heart disease. Fresno County is among the top three agriculture-producing counties in the United States, the top county in California, and generates nearly $5.6 billion of goods each year.7 In 2006, over 1.6 million acres of farm land existed on 6,081 farms in the county. 102 Dairy operations and organic matter from animal feed and dried manure contain toxic Particulate Matter. The Environmental Protection Agency has listed the following contaminants as especially harmful to human health when ingested through tainted water supplies or soil/dust exposure:103     

Industrial or man-made concentrations of naturally-occurring substances, such as nitrate and ammonia associated with livestock manure from agricultural operations, have been identified as possibly carcinogens Bacteria and nitrates are commonly found near animal waste; nitrate contamination in infants can disrupt oxygen flow in the blood Concentrated Animal Feeding Operations (CAFOs) often produce high levels of salt and nitrates that can pollute groundwater Mining and construction releases large amount of heavy metals, especially arsenic, into ground water sources Fertilizers and pesticides contain nitrogen that breaks down into nitrates and collects in ground water

Pesticide exposure and pesticide drift poses a risk to human health. Large amount of synthetic pesticides, insecticides, herbicides, and other chemical operations have been used for protecting crops and preventing loss since the 1940s. Pesticide drift is the movement of pesticides through the air away from where they are applied. A great breadth of literature has indicated that their use indicate a dose-response relationship and significant association with the development of non-Hodgkin lymphoma and leukemia, tumors, and brain and prostate cancer.104,105 Children are at an elevated risk for exposure to toxic pollutants. Because of their size, their rapidly growing bodies, and the special ways they interact with their environment (such as playing on the ground and putting their hands in their mouths), means that they are susceptible to contaminants and their indoor and outdoor environments should be safe and promote healthy, optimum physical, mental, and biological development.

Children who live near lead-contaminated soil or dust may unknowingly ingest, inhale or absorb up to contaminated soil or dust and consume up to 160 mg/day of any given soil or dust contaminant (toddlers), 30 mg/day for a school-aged child, and 66 mg/day for an adult.106 Chronic exposure to lead, mercury, and other metals in soil or water can impact neurological development and IQ. 107 One study found that children ingested up to 10mg of lead per day.106 More acute impacts include other effects such as headache, nausea, fatigue, eye irritation and skin rash for the above cited and other chemicals. Furthermore, children have a larger lung surface area per kilogram of body weight than adults and breathe 50% more air per kilogram of body weight than adults, and exposure to particulate matter has been shown to worsen asthma and lung function in children.108-110 Improvements in air quality will benefit children’s respiratory health. In a study examining hospital admissions of children in the Utah valley during 3 consecutive winter—before, during, and

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t after a strike that closed a steel mill in the valley that was the largest source of air pollution—showed a greater than 50% drop in admissions of children for asthma.108 ENVIRONMENTAL POLLUTANTS | EXISTING CONDITIONS Air pollution and soil and water contaminants do not respect boundaries and are often carried to other locales by natural events such as wind, rain, and human manipulation. The DNC Plan neighborhoods are located not only adjacent to one the busiest freeways in the State, but some of the DNC Plan neighborhoods, especially Southwest and Jane Addams, are adjacent to farm land as well. The neighborhoods that are both near freeways and farmland may be at even higher risk to considerable exposure to airborne particulate matter, chemicals, pesticides, and other environmental toxicants associated with industrial agricultural and heavy transportation.

Exposure to air pollution

Exposure to toxic pollutants

Risk Factor EP.1: Exposure to outdoor air pollution EP.1.1. Indicator: Number of days exceeding State standards for criteria air pollutants Particulate levels for the South Coast Air Basin and the Central Valley in California have the highest recorded levels of Particulate Matter in the country, exceeding the national ambient air-quality standards for each season of the year.111 Those who live and work in the San Joaquin Valley are disproportionately exposed to particulate matter mostly from Table 16. San Joaquin Valley Emissions Inventory (% of total emissions) farming practices, including the ROG CO NOX SOX PM10 PM2.5 tilling of dry soil, agricultural Source 12.8% 2.9% 16.2% 68.3% 7.2% 12.2% burning, crop harvesting, Stationary Area 24.0% 14.6% 2.7% 3.5% 74.3% 49.1% diesel-powered water pumping, 24.9% 63.5% 79.5% 17.6% 8.0% 16.8% and the idling of diesel trucks Mobile 38.2% 18.9% 1.6% 10.6% 10.5% 21.8% who are transporting goods all Natural over the country (see Table 16, Source: CARB, California Emissions Inventory Data (2007) as cited in Zuk & Altshuler (2008) San Joaquin Valley Emissions Inventory, 2006). Fresno recorded the highest emissions of all criteria pollutants in the San Joaquin Valley counties, Table 17, Fresno County Emissions Inventory, 2007, describes each pollutant’s average concentration in the County, the total emissions for the pollutant (when available), California’s air quality standard, and the number of days air quality in Fresno County exceeded the State standard (when available).

Table 17. Fresno County Emissions Inventory (2007) Pollutant Fresno Total emissions (Averaging time) Concentration (tons/day, 2005) Ozone (8 hr) 0.112 ppm n/a PM10 (24 hr) 111 µg/m3 82 tons PM2.5 (24 hr) 104 µg/m3 29 tons CO (8 hr) 3.2 ppm 388 tons NO2 (1 hr) 0.086 ppm 117 tons

State Standard 0.070 ppm 50 µg/m3 35 µg/m3 9.0 ppm 0.18 ppm

Days above State standard in 2007 74 days 63 days n/a 0 days n/a

Source: CARB, California Emissions Inventory Data, 2007

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t EP.1.2. Indicator: Proximity to freeways, truck routes, and congestion According to the most recent Highway Congestion Monitoring Program, released Figure 15. Congestion at Peak Hours in Fresno (2008)

by CalTrans (2008), Fresno’s daily vehiclehours of delay on the local highways have increased 4-fold since 1998; however, data indicates a recent decline by 56% since 2006.112 Table 18, Excess Fuel Consumption, Travel Cost, and Emissions due to Congestion in Fresno, describes the relationship of vehicle-hours of delay to excess fuel consumption, cost, and emissions. In 2008, congestion in Fresno caused 693 daily person-hours of delay, an extra 1083 gallons of fuel consumed, added $13,883 in costs per day, and contributed an extra 0.3 tons of emissions per day.112 Congestion maps, in the same report, indicate morning and evening peak congestion occurs primarily on south-bound directions for Highways 99 and 41 just north of the Fresno Downtown triangle, but that the evening congestion causes almost twice the amount of delay than the morning (Figure 15, Congestion at Peak Hours in Fresno).

Source: CalTrans, HICOM (2008)

Table 18, Excess Fuel Consumption, Travel Cost, and Emissions due to Congestion in Fresno, describes the relationship of vehicle-hours of delay to excess fuel consumption, cost, and emissions. In 2008, congestion in Fresno caused 693 daily person-hours of delay, an extra 1083 gallons of fuel consumed, added $13,883 in costs per day, and contributed an extra 0.3 tons of emissions per day.112 Table 18. Excess Fuel Consumption, Travel Cost, and Emissions due to Congestion in Fresno (2008) Total Daily Delay (vehicle hours) 630 hours Average vehicle occupancy 1.1 persons Estimated daily person-hours of delay 693 hours Excess fuel consumption per day 1083 gallons Total user cost per day $13,883 Total emissions per day .3 tons Source: Highway Congestion Monitoring Program. CalTrans, 2008.

Risk Factor EP.2: Exposure to toxic pollutants EP.2.1. Indicator: Proximity to heavy industry ARB’s Toxic Release Inventory list allows public knowledge of sources of environmental hazards and air pollution in their region. In the greater downtown area, 52 toxic facilities report to the EPA. The facilities

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t cluster in the southern and southwestern portion of the downtown neighborhoods. The largest Air Toxic Hot Spots facilities that are high emission producers in Fresno are located near downtown, in or near the Southeast and Southwest neighborhoods:113 Earthgrains, Tinkler Mission Chapel, PPG Industries, SC Johnson Home Storage Inc, and California Dairies, Inc. Figure 16. Known TRI sites in Greater Fresno (2010)

EP.2.3. Indicator: Vehicle ownership by tenure and neighborhood Overall, vehicle ownership is very high in Fresno City, County, and in the DNC Plan neighborhoods. Table 19, Vehicle ownership by tenure and neighborhood (2000), shows across all locales the percentage of renteroccupied households with no vehicle available is significantly higher than owner-occupied households. Nearly 60% of all households (renter- and owner-occupied) in Lowell and Southwest have no vehicle, compared to 48% in the Plan area and 25% in the County as a whole. Jane Addams has significantly higher vehicle ownership rates, with almost 80% of renter-occupied and 84% of owner-occupied households owning 1-2 vehicles. Higher ownership rates may indicate increased vehicle miles traveled and thus higher total emissions.

EP.2.5. Indicator: Pesticide drift In nearly 233,500 applications, over 27.5 million pounds of pesticides were used throughout the County in 2008.114 Although farmland has decreased by 15% since 2002, cultivated land still represents over one-third (31%) of the total land in Fresno County and is directly adjacent to the urban realm of the City of Fresno, especially in the west and southwest portion. Since industrial agriculture surrounds the City, pesticide drift into the Downtown Neighborhoods is highly plausible and of particular concern in terms of exposure to toxic chemicals, especially for the farmworkers who are applying the chemicals and for vulnerable populations sensitive to toxic pollutants. Pesticides have been shown to drift up to one mile from their application site and not only pollute the air, but also soil and water.115

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Table 19. Vehicle ownership by tenure and neighborhood in Fresno (2000) Southwest

Southeast

Jefferson

Lowell

Jane Addams

37% 41% 16% 3% 2%

29% 43% 21% 6% 2%

38% 45% 14% 2% 1%

50% 38% 9% 2% 1%

19% 45% 33% 3% 1%

34% 43% 18% 4% 2%

22% 48% 24% 5% 1%

20% 47% 26% 5% 1%

No vehicle 1 vehicle 2 vehicles 3 vehicles

22% 40% 23% 11%

12% 36% 39% 10%

10% 36% 40% 11%

7% 46% 29% 15%

10% 49% 35% 4%

14% 39% 35% 10%

5% 31% 46% 14%

5% 27% 46% 17%

4+ vehicles

5%

3%

4%

3%

2%

3%

4%

7%

Household type

DNC

Fresno City

Fresno County

Renter-occupied No vehicle 1 vehicle 2 vehicles 3 vehicles 4+ vehicles Owner-occupied

Source: US Census, 2000; Compiled by R+A, 2010

ENVIRONMENTAL POLLUTANTS | COMMUNITY INPUT During the community health and neighborhood design workshops in the design charrette process, the neighborhood residents expressed interest in neighborhood-wide policies that both directly and indirectly address environmental hazards and improvements in air quality. Many of the policies in preceding sections address air quality indirectly through built environment, land use, and transportation policy goals and strategies. The only policy that was prioritized by the residents that directly related to air quality was to “reduce air pollution throughout the city.”

ENVIRONMENTAL POLLUTANTS | SUPPORTED POLICIES & ACTIONS IN THE PLAN The DNC Plan includes a variety of goals, policy directions, and key action items that consider air quality, especially in terms of transportation, land use, and proximity to hazardous elements. A few key actions that embody air quality, environmental hazards, and toxic pollutants and are supported by this HIA include:      

Create appropriate buffers between industrial or agricultural uses and residential areas, schools, or other sensitive uses.

Continually assess existing soil and water contaminant monitors and install new monitors where necessary Avoid locating new residential uses on or near toxic sites without proper mitigation or within 500’ of freeways or major roads Create policies that minimize the use of pesticides Do not locate truck routes on residential streets Conduct proactive code enforcement activities for housing

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t ENVIRONMENTAL POLLUTANTS | PLAN ANALYSIS The DNC Plan heavily focuses on improving public transportation, walkable and bikable neighborhoods, connectivity, and reducing dependence on the auto. However, the auto is not the only source of environmental pollutants or even GHG emissions in the Downtown Neighborhoods. Industrial sources, largescale agriculture, and the routing of diesel trucks also play a significant role. Employing evidence-based and best practices land use and transportation strategies may result in decreased air pollution and improved health status, particularly with asthma and chronic respiratory diseases.

Air pollution A focus throughout the DNC Plan is reducing the impact of air pollution through land use and transportation decisions that lower VMT, promote compact development, and advocate a good mix of land uses while also encouraging sustainable development and energy and natural resource conservation. Exact increases in densities are unknown at this point, so precise impacts on VMT cannot be precisely calculated. Nevertheless, while increasing density can positively impact sustainability, economic vitality, and enhance physical activity opportunities—it can also increase individual exposure to air pollutants if development and population increase occurs faster than transit and economic development (or improvements in air quality).

Long terms changes in public transit, such as implementation of Bus Rapid Transit or Light Rail and improved system efficiency, combined with improvements to land uses and other transportation changes, could decrease vehicle use, increase active transportation, and overall decrease negative health outcomes pertaining to air quality. PM10, PM2.5, ozone, and NO2 most significantly impact asthma symptoms. Recalling from the existing conditions analysis (Table 17, Fresno County Emissions Inventory, 2007), many of these pollutants’ concentrations were above the state standard. A recent study specifically looked at air pollution in the San Joaquin Valley and quantified the health impacts associated with improving air quality throughout the Valley. Although the study was regionally based, rather than neighborhood-specific, it allows us to make educated assumptions about the Plan area with regards to ozone and PM2.5 reduction.

Ozone reduction could significantly improve health outcomes, especially for those with preexisting asthma or respiratory illnesses and conditions. A recent study116 found that complying with the Federal 8-hr ozone standard (a reduction of 0.052 ppm) in the entire San Joaquin Valley would result in significant health benefits to the population. By interpolating the San Joaquin Valley population to proportionately match the population of the City of Fresno, each year of compliance with the ozone standards would result in:2    

75 fewer hospitalizations for respiratory causes 3,362 fewer asthma attacks 27,127 fewer days of school missed by children $4.6 million dollars saved per year

PM2.5 reduction could also significantly improve health outcomes. The same study found that complying with the Federal PM2.5 standards—a reduction of 65 micrograms/m3—would result in even greater benefits for the

2

2008 San Joaquin Valley population = 3,326,552; original data: 520 fewer hospitalizations for respiratory causes; 23,300 fewer asthma attacks; 188,000 fewer days of school missed by children; $32 million dollars saved per year

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t entire San Joaquin Valley than that of ozone compliance. Again, by interpolating original data 116 with proportional population calculations, reducing PM2.5 could result in:3     

432 fewer children would suffer from acute bronchitis 432 fewer days of missed work for adults 2,353 children would not suffer from upper respiratory symptoms 66 people would avoid premature death each year $4.3 million dollars saved per year

Cars, trucks, and agricultural equipment are major sources for these two criteria pollutants. The DNC Plan aims to reduce the use of one of these sources (cars). For the health benefits of reducing both ozone and PM2.5 it is safe to assume that these benefits may be concentrated in the Downtown Neighborhoods, as the existing conditions and plan analyses have discussed the industrial, agricultural, and automobile dominant development patterns in this area.

Housing quality Housing is an important element laced throughout the entire Plan’s policy actions, and the focus on expanding housing options, contextual design, code enforcement, and quality control will likely improve the health of those who live in the Downtown Neighborhoods. Other important strategies are ensuring the use of high quality construction and materials, property maintenance, and upgrading. Within the individual sub-area plans, “enabling proactive code enforcement” is mentioned as a key strategy in Jefferson, Lowell, Southwest, and Jane Addams neighborhoods. Improving the quality of housing has the potential of reducing individual Toxic pollutants The Health and Wellbeing chapter in the DNC Plan is the only place where exposure to toxic pollutants is addressed. Health outcomes are explicitly mentioned especially asthma and respiratory conditions. Three different goals in this section pertain to toxic pollutants, with the intent of reducing health burdens and improving health outcomes associated with toxic environments. Emphasis on improving housing quality by code enforcement activities, property maintenance ordinance, and monitoring will likely produce positive health effects in the long term. Avoiding locating housing near industrial agriculture, creating buffers between incompatible land uses such as toxic waste plants, monitoring soil and water contaminants, and enforcing standards will direct health towards positive outcomes.

Unfortunately, since pesticides will still be most likely used at the current rate, the health of those in close proximity to such land uses will remain impacted. The health of the workers who are applying pesticides, who are often migrant and seasonal farmworkers, will also remain unchanged and they will not benefit from policies in the Plan. Policies directed at industrial agriculture is beyond the geographic boundaries of the DNC Plan, and thus this HIA, however, it’s important to consider for the upcoming General Plan Update.

3

2008 San Joaquin Valley population = 3,326,552; original data: 3,000 fewer children would suffer from acute bronchitis; 3,000 fewer days of missed work for adults; 16,310 children would not suffer from upper respiratory symptoms; 460 people would avoid premature death each year; $3 billion dollars saved per year

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t Housing location The new regulating plan allows the Valley and City Center to have unlimited and 15 stories, respectively, increasing density considerably. Noise and air pollution from nearby roads and transportation hubs may impact the health of the high density of residents living there in the future. The Valley Center is directly adjacent to the proposed High Speed Rail station and ¼ mile from the Amtrak Station. Amtrak and the HSR trains traverse the City Center and several Downtown Neighborhoods. Literature has demonstrated a direct relationship between proximity to major freeways, roads, and noxious land uses with asthma 93,109,117 and CVD events88,118,119 as well as sleep disruption.120 A high concentration of residential use in these areas, without proper mitigation, could increase asthma, CVD, and sleep disruption of the residents. Improving housing quality in the Downtown Neighborhoods is driving force for improving population health.

Increasing density and housing units in the Downtown neighborhoods combined with enhanced economic development may improve access to goods and services in the area. Although some research has shown that compact cities with higher densities have more convenient access to goods, services, and other amenities, other research has shown that those residents may experience higher levels of exposures to potentially harmful pollutants. According to the Regulating Plan, the “Valley” and “City Centers” may need to incorporate certain measures to mitigate negative health impacts associated with living in close proximity to major roads and freeways as well as regional transportation systems, such as the High Speed Rail.

ENVIRONMENTAL POLLUTANTS | RECOMMENDED REVISIONS FOR THE PLAN Based on the results of the Literature Findings and Plan Analysis the following recommendations are provided in order to be incorporated into the Final Draft Plan. Air quality and exposure to toxic pollutants is a major concern in Fresno and the rest of the San Joaquin Valley. Many of the goals and policy directions within the Draft Plan are supported by this HIA. The following revisions are recommended with specific regard to improving health outcomes associated with respiratory illnesses, CVD & cancer: 1. Ensure vulnerable populations are not disproportionately impacted by any of the goals, policies, or key actions.

2. Develop better dialogue between local public agencies and industry to better consider local residents’ concerns over air pollution risks from area sources.

3. Avoid routing trucks on roads adjacent to parks, schools, gardens, health clinics, or other uses that may hold sensitive populations.

4. Avoid locating new park and recreation areas, community gardens, schools, or other uses that may hold sensitive populations near freeways or busy roads.

5. Increase the frequency of shuttle and bus services from communities who would use regional transit.

6. Establish workplace and retail fees for parking, unbundle cost of parking from housing units, and reduce parking requirements for new developments.

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DETERMINANT 4: SOCIAL AND ECONOMIC STABILITY Employment, income, and educational attainment are critical economic indicators of a successful city or neighborhood. Jobs that provide employees with a safe environment, a living wage, health insurance, and access to training opportunities takes investment and can have significant impacts on mental health, chronic diseases, and mortality. Employees who are provided with health insurance, paid leave, and a safe workplace tend to experience greater health and more productivity. A vibrant local economy can retain skilled workers and locating housing, jobs, and recreation in close proximity of one another may benefit social networks, reduce dependence on the vehicle, and create more sustainable environment. Furthermore, affordability, quality, location, comfort, and safety of housing are important factors that impact health outcomes of residents and the proportion of income spent on housing and home energy and utilities can impact a household’s ability to pay for other expenses such as nutritious food, health care, and transportation. This section examines these topics as they relate to health.

Employment often indicates a consistent level of access to financial stability that can provide means for obtaining nutritious foods, health care and medication, education, transportation to work, and overall life satisfaction. In a longitudinal study, researchers found those unemployed who had a pre-existing illness or disability had mortality rates over three times higher than the average and those who were unemployed but not ill at time of research showed a 37% increased mortality over the next 10 years. 121 Unemployment has also been found to have an adverse effect on psychological function, indicating increased rates of anxiety, depression, lower self-esteem, and concern for bodily function (and not associated with pre-existing conditions).122 Another study showed that those who experienced any occurrence of unemployment were twice as likely to develop a chronic illness later in life.123 Income and health are tightly related. Poverty level indicates a household income for a family of four as $20,650 annually (2007). Poverty remains one of the strongest predictor of mortality 20 and those who experience very low household incomes also suffer most from food insecurity,21 obesity,22 and cardiovascular disease.23 Income has been found to positively correlate with cholesterol in men and women, a risk factor of CVD,25 while low-income women have also been found to have higher rates of obesity and CVD. 23 Also, a 1994 study demonstrated that a $2100 per month increase in salary would reduce depressive symptoms by 4 per week and reduce sick days by 3 per year.124 Educational attainment often corresponds with income level and is a constant predictor of health outcomes.

Lower levels of educational attainment correlate with high smoking rates, blood pressure, and cholesterol levels.25 Employment rates are higher for those with high school diplomas than those who do not, and even higher among those with college degrees. 125 A mother’s educational attainment is also highly predictive of the child’s likelihood of graduating high school.126 Areas with lower incomes and lower levels of educational attainment, as seen in Fresno, often experience higher levels of chronic conditions and encounter more challenges to accomplishing healthy behaviors than areas with higher incomes and higher levels of educational attainment.20,24,25 Employer-based health care coverage can allow an individual or a family access to timely medical care, preventive medicine, medication, health education, and personal time with medical and health professionals.

Since a majority of chronic illnesses in this country are preventable, health insurance represents a vital resource and premature mortality is associated with a lack of access to health care. Unfortunately, many jobs lack employer-sponsored health care. In fact, 41% and 46% of Blacks and Hispanics, respectively, had

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t employer-sponsored health insurance in 2003, compared to 70% of Whites, most likely due to low-paying or part-time jobs.127 Employee sick leave is an important component for recovery and recuperation, yet only half of all Americans have paid sick leave.128 Based on the 2002 National Survey of America's Families indicated that employed parents with family income less than the FPL, 54.2% had no paid leave compared to 16.4% for employed parents with family income double the FPL.129 Furthermore, only 29.7% of children in fair or poor health had a parent with access to paid sick leave compared with 36.9% of children in good, very good, or excellent health.129 Loss of productivity from “presenteeism”—coming to work when sick—accounts for more than productivity lost from sick leave.128 Housing instability, and the absence of housing, is common among financially struggling households. Direct housing costs (rent, utilities) have a large impact on household budgets, but extraneous costs of living, such as nutritious food, medication and medical bills, transportation to/from jobs, and adequate clothing have a significant impact as well. Households who earn lower incomes have less money available for basic living needs are often forced to reconcile between one need or another. The lack of housing all together also threatens population health, especially for migrant and immigrant workers. Depressed residential stability, measured by number of times moved, is also associated with reduced quality of housing and reduced health outcomes.97 Real and perceived crime has a large impact on residents’ social and physical environment, and their health.

Numerous variables have been found in the literature to influence crime rates, the perception or fear of crime, and then of course individual health effects of crime. The direct health effects of crime, such as injury and death, are an absolute public health and medical care issue particularly for the victims and their families, as well as for those who witness or hear about the acts of violence. Youth are at particular risk for detrimental psychosocial effects of real and perceived crime. Among adolescents, for each unit increase in cumulative exposure to violence, the risk of self-rated ‘poor health’ increased by 38%.130 Other research has found that “exposure to violence reduces perceived control.” A study of Black urban youth found that depression and hopelessness were significantly associated with the reported frequency of exposure to, or victimization by, violence in their lifetime.131 Exposure to high rates of community violence causes stress in residents and has been correlated with low birth weight, infant mortality, and other physical health effects.132 Certain built elements within our cities attract or detract crime. Windows and porches that face the street are classically recognized as a crime prevention strategy. Street lighting, trees, and benches also act as deterrents for anti-social behavior. Parks provide space for neighborhood members to congregate, socialize, and build trust with one another—also called ‘social capital.’ Research has demonstrated that communities with high rates of civic engagement in neighborhood parks and open space, in turn, have lower crime rates and lower incidence of chronic conditions. Social participation has also been found to be one of the strongest predictor of physical activity levels.133 Research suggest that measures to improve social capital, and reduce crime, in certain communities might be important in lowering the prevalence of lifestyle-related diseases and condition, such as obesity and cardiovascular disease. One such measure is providing open space for neighbors to network and build report with one another.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t SOCIAL & ECONOMIC STABILITY | EXISTING CONDITIONS The Downtown Neighborhoods have been suffering from disinvestment for decades. This has resulted in a depressed economy with high unemployment rates and a lack of opportunities for high quality jobs and educational opportunities. The residents of these neighborhoods cannot afford to purchase homes or spend more money on higher quality housing. Landlords have little interest in maintaining their properties and slumlords have aggravated the renting market and are not held responsible for the maintenance of their properties resulting in substandard housing conditions. For these reasons and more, the Downtown Neighborhoods experience extraordinarily high rates of crime, contributing to poor health outcomes and the cyclical nature of disinvestment in the area.

Lack of high quality employment opportunities

Lack of adequate and healthy housing

High crime rates

Risk Factor SE.1: Lack of high quality employment opportunities SE.1.1. Indicator: Percent unemployed As of June, 2010, Fresno County unemployment rate was 16.9%, compared to 12% in California. 134,135 Unemployment has increased drastically since the 2000 Census, when it was at almost 12%. The 2000 Census revealed that the DNC Plan neighborhoods had much higher rates of unemploymentâ&#x20AC;&#x201D;two to three times that of the City and County. Based on historical trends, we can estimate that the DNC Plan neighborhood employment rates have followed a similar path and increased with the recent economic recession.

Table 20. Labor force and median income summary in Fresno (2000) Neighborhood Labor force Unemployed % Unemployed Median income Southwest 5,250 1,250 23.8% $18,197 Southeast 11,653 2,294 19.7% $22,593 Jefferson 3,722 838 22.5% $17,970 Lowell 2,252 788 35.0% $12,085 Jane Addams 2141 524 24.5% $23,768 DNC 25,018 5,694 22.8% $18,922 Fresno City 180,070 20,100 11.2% $32,236 Fresno County 341944 40,334 11.8% $34,725 Source: US Census, 2000; Compiled by R+A, 2010

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t SE.1.2. Indicator: Jobs providing a living wage A living wage denotes that the salary is sufficient for an individual to support their family, especially if they are the sole provider and are working full-time. In Fresno County, a living wage for a family of one adult and one child is $18.54/hour and for two adults and two children, $30.54/hour.4 For males in the DNC area, manufacturing, construction, and agriculture employment industries dominate the labor force (16%) are the primary employing industries in the DNC Plan neighborhoods while for females, educational, health and social services, and health care assistance (31%). Primary occupations in the DNC Plan area and their corresponding median wage (Fresno County) are presented in the table (below).

The top five occupations projected to have the most job openings in Fresno County from 2006-2016 are presented below. All of these occupations do not provide adequate salaries to be deemed a living wage.  Farmworkers and Laborers, Crop, Nursery, and Greenhouse (10,020 openings)  Retail Salespersons (4,630)  Cashiers (3,640)  Waiters and Waitresses (3,480)  Personal and Home Care Aides (3,380)

FRESNO AVERAGE WAGES Construction $15/hr (Apprentice) $12/hr Agriculture $13/hr Health care $15/hr Health educators $21/hr Retail $9/hr

SE.1.3. Indicator: Jobs providing medical care/paid sick leave Since a majority of chronic illnesses in this country are preventable, health insurance represents a vital resource. Unfortunately, many jobs lack employer-sponsored health care. Table 21, Percent of workers with employer-provided medical care and paid sick leave (2009), shows the distribution of medical care access across the primary occupations in the United States.136 The disparity in employer-sponsored health care is apparent and unevenly allocates medical care resources and overburdens lower-income populations who already have fewer resources to cope with the consequences of illness, injury, and disease.

The table indicates several important conclusions: (1) management and professional occupations have the highest access to paid sick days and employer-based medical care access; (2) service and sales, including retail, construction, and transportation occupations have the lowest access to paid sick days and employersponsored medical care access; and (3) less than one-third of part-time employees have access to paid sick leave, compared to 79% of full-time employees and less than one-quarter of part-time employees have employer-sponsored medical care, compared to 88% of full-time employees. The majority of occupations in the DNC area are part-time and represent occupations with the lowest access to medical care and paid sick leave.

Table 21. Percent of workers with employer-provided medical care and paid sick leave (2009) Occupation Management, Professional Health care/social assistance Construction Sales Service industries Full-time Part-time

Medical care access 94% 76% 72% 64% 50% 88% 24%

Paid sick leave 87% 79% 42% 56% 48% 79% 28%

Source: US Bureau of Labor Statistics, 2010; Compiled by R+A, 2010.

4

Calculated by: http://www.livingwage.geog.psu.edu/places/0601927000

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t SE.1.4. Indicator: High school graduation rates for DNC schools For the most part, educational attainment in the DNC Plan neighborhoods is lower than the City or the County. Using 2000 Census data, the figure below shows the education attainment of residents over the age of 25. The Downtown Neighborhoods are severely less educated that the City and County of Fresno, with twice as many residents having less than a high school diploma. For the City and County, about 50% of residents have at least some college, Associate Degree, or Bachelor’s Degree, compared to only 20% of the Downtown Neighborhood residents. For a vital local economy, there is a great incentive to provide access to high quality schools especially for lower-income communities, such as the Downtown Neighbourhoods.

Figure 17. Educational attainment of Fresno residents, 2008

SE.1.5. Indicator: Percent of households experiencing linguistic isolation Linguistic isolation can impact a resident’s ability to find opportunities for employment and education, and can limit ones abilities to access general resources that other English-speaking residents would not need to worry about. In 2009, a quarter (24%) of all Spanish- and Asian-language speaking individuals endured linguistic isolation in the City of Fresno. On a more local level, using Census 2000 tract-level data, 15% of all DNC Plan area households were linguistically isolated, a majority of them Spanish speaking (73%). In the northern portion of the City where only 11% of households were Spanish-speaking, only 3% of all households were linguistically isolated. As a whole, in 2000, 9% of households were linguistically isolated and 73% were Spanish-speaking.

Risk Factor SE.2: Lack of adequate and healthy housing SE.2.1. Indicator: Renter-occupied housing units Although renting households are more prevalent than owner-occupied households, single-family housing units have increased, while multi-family units have remained constant. Table 22, Tenure and Household Summary, provides a summary of the Census 2000 data pertaining to the DNC Plan neighborhoods. The Final Report – March 2011

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t majority of DNC Plan neighborhood households are over 50% renter-occupied and have larger household sizes, especially for renter-occupied households than the City as a whole. Lowell and Jefferson neighborhood have the highest percentage of renter-occupied households (88% and 77%), while Southeast neighborhood has the largest household size (4.5 per renting household size, 3.7 per owning).

Table 22. Tenure and Household Summary Area Southwest Southeast Jefferson Lowell Jane Addams DNC Fresno City

Total Households 4,354 8,350 3,219 1,868 1,804 20301 139,951

Renter % 60.6% 56.5% 76.7% 86.9% 50.8% 62.7% 49.3%

Average renting household size 3.9 4.5 3.9 3.4 3.8 3.9 3.0

Average owning household size 3.3 3.7 3.0 3.1 2.6 3.1 3.0

Source: US Census, 2000; Compiled by R+A, 2010.

SE.2.2. Indicator: Percent of households living in overcrowded units Household size in Fresno City has been steadily increasing, from 2.59 in 1980, 2.84 in 1990, 2.99 in 2000, and 3.1 in 2006.10 According to the 2007 Housing Element Update in the City of Fresno General Plan, 14% of households experience overcrowding conditions in the City, and 11.5% renter-occupied housing units are overcrowded. More than one person per room (including living rooms) signify overcrowding. Since the Downtown Neighborhoods have a higher percentage of renters than the rest of the City (63% versus 49% for the City), it’s safe to assume that at least 11.5% of the households (1,464 households) are overcrowded.

SE.2.3. Indicator: Median rent & population spending more than 30% of income on housing Currently, median rent in the City is $806/month (2008). In the 2000 Census, the DNC Plan neighborhoods had overall lower median rent values than the City—as low as $379/month in Lowell, compared to $538/month for the City—and certainly lower than the State average of $747/month (Table 23, Median Rent Comparisons).

Table 23. Median Rent Comparisons (2000) Area Rent ($) DNC Plan area 480 Fresno City 538 Fresno County 534 California 747 Source: US Census, 2000; Compiled by R+A, 2010.

“Housing burden” is considered Table 24. Percent of renters experiencing housing burden (2009) spending over 30% of one’s income % of population % of population on housing and associated costs (ie., spending >30% of spending >50% of utilities). Nearly 50% of renting Area income on rent income on rent households in the DNC Plan area Fresno City 60% 31% spend 30% or more of their income Fresno County 52% 27% on rent and related expenses.

California 55% 28% Renters in Lowell and Jefferson spend Source: US Census, 2000; Compiled by R+A, 2010. the highest proportion of income on rent. Downtown residents experience much more hardship compared to the City, County, and State levels.

Table 25, Percent of renters experiencing housing burden (2009), reveals the vast changes in the housing landscape in the last decade.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t SE.2.4. Indicator: Households under the Federal Poverty Level The 2007 City of Fresno Housing Element Table 25. Income and poverty by neighborhoods (2000) indicates, as of 2006, that 12% of the Median income % households under FPL households in Fresno City are lower income, Area $18,197 53.8% 13% very low income, and 19% extremely low Southwest $22,593 Southeast 45.5% income. The DNC Plan neighborhoods had $17,970 significantly lower household incomes than Jefferson 54.4% the City of Fresno. Also, 44% of households in Lowell $12,085 65.9% the plan area need housing assistance, where Jane Addams $23,768 44.2% only 28% of the County households need $18,922 DNC 52.7% housing assistance. Additionally, 33% of the $32,236 31.0% DNC Plan are female-headed living under the Fresno City federal poverty level, which is comparable to the City’s 33%.

Source: US Census, 2000; Compiled by R+A, 2010.

SE.2.5. Indicator: Number of low, very low & moderate housing units needed by year 2015 According to the Housing Element, nearly 3,000 housing units for extremely low-income households are needed in the City of Fresno and these households can typically afford a maximum of $404/month on rent.

Furthermore, housing for the homeless and farmworker populations are severely substandard and lacking.

SE.2.6. Indicator: Percent of housing stock in need of repair According to the survey completed in October 2007 for the Housing Quality portion of the Housing Element, about 6% of the 2000 housing stock is in need of repair—meaning that they need minor, moderate, or substantial repair. That number for the DNC Plan area was more than double: between 9% and 21% of units surveyed needed repair. The neighborhood in need of the most housing repair was the Southeast and Lowell neighborhoods, corresponding to other data of poverty and percentage of renter-occupied households. In 2007, it was estimated that 15% of the housing stock in the DNC area need minor, moderate, or substantial repair—compared to only 6% of the City. Some neighborhoods are in more need than others; 21% of Southeast neighborhood units need repair, the highest amount in all the DNC area. Health impacts associated with unsafe housing materials and slack code enforcement include asthma, injuries, lead poisoning, CVD, and cancers.

Mold, dust, roaches, lead Table 26. Summary of DNC Plan neighborhoods housing repair needs (2007) paint, and general Area Units in survey Units needing work Percent (%) substandard housing Southwest 1921 175 9% problems are pervasive in Southeast 1057 217 21% the City, and especially in 1023 133 13% the downtown Jefferson 1224 227 19% neighborhoods.

In the Lowell Jane Addams 197 37 19% County, according to CHIS 2003, about 26% of Fresno DNC 5422 789 15% County adults saw Fresno City 27353 1761 6% cockroaches in their places Source: US Census, 2000; Compiled by R+A, 2010. of residences (compared to only 16% in the State). Furthermore, differences between ethnicities were stark: 36% of Latino households, 14% of White, 42% of Asian households saw cockroaches in their residences.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t SE.2.7. Indicator: Homelessness and housing displacement According to the survey completed in October 2007 for the Housing Quality portion of the Housing Element, about 8,824 homeless individuals reside in the City of Fresno. The 2010 Fresno Madera Continuum of Care Report documented 3,762 homeless individuals, most of whom are seasonal agriculture workers, victims of domestic violence, severely mentally ill, and veterans. Some of these individuals were also victims of the economic downturn and recently lost their home due to financial constraints of unemployment. Children and elderly minorities suffer most from displacement as social ties are lost, distance to school and other activities change. Since shelters and programs for the homeless are concentrated in the Downtown Neighborhoods, it is safe to assume that the majority of these individuals may be living in or near these shelters or programs. In fact, illegal encampments of homeless individuals and families have been sited in Southwest and lower Van Ness neighborhoods, both within a half-mile from central Downtown. Prostitution, drug use, and violence are major public health issues faced by these individuals.

Risk Factor SE.3: High crime rates SE.4.1. Indicator: Violent crime rate The violent crime rate in the City of Fresno is 766 incidents per 100,000 people; property crime rates amount to 5,772 incidents per 100,000 people. Using live data from the Fresno Police Department, Fresno Bee’s Crime Map demonstrates that within the last year there were 37 homicides and 59 rapes by force. Maps from the website show the concentration of homicides in the Downtown Neighborhoods while there is no clear pattern for forced rapes.

SE.4.2. Indicator: Percent of people who feel safe in their neighborhood at night According to CHIS 2007, nearly 39% of Fresno County residents ‘disagree’ or ‘strongly disagree’ that their neighborhood park is safe at night. Stakeholder interviews and community members often brought up the issue of perceived crime in their neighborhoods and that the fear of violence was a major barrier to accomplishing everyday activities.

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Figure 18. FresnoBee Crime Data: Homicide (October 2009-October 2010)

Source: Accessed at: http://data.fresnobeehive.com/crime. November 25, 2010.

Figure 19. FresnoBee Crime Data: Forced Rape (October 2009-October 2010)

Source: Accessed at: http://data.fresnobeehive.com/crime. November 25, 2010.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t SOCIAL & ECONOMIC STABILITY | COMMUNITY INPUT During the community health and neighborhood design workshops in the design charrette process, the neighborhood residents expressed strong interest in neighborhood-wide policies addressing improvement in employment, education outcomes, and the local economy. This topic was a very high priority for the community members. The following related policies were priorities for the Downtown residents, in order of importance:          

Provide training opportunities in the trades and encourage the public and private sector to hire locally Smaller schools and better staffing Promote and enable economic development Design buildings that provide “eyes on the street” and orient alleyways towards pedestrians Introduce neighborhood serving retail, banks, and services in order to keep resources within the neighborhoods Outreach to banks and businesses to promote investment in the area Enable proactive code enforcement Distribute homeless and housing services throughout the entire City of Fresno and surrounding region Promote a greater proportion of owner-occupied dwellings, including using Neighborhood Stabilization Program grants to purchase housing Hold slumlords accountable for maintenance and up-keep

SOCIAL & ECONOMIC STABILITY | SUPPORTED POLICIES & ACTIONS IN THE PLAN Currently, the Downtown Neighborhoods are experiencing a weakened real estate market due to a history of disinvestment, incompatible patterns of development, a lack of quality retail, and significant infrastructure needs. The DNC Plan provides a unique opportunity for decision makers and their collaborators to strategize the future growth and direction of the economy, employment, and housing sectors that dominate the DNC Plan area and support the residents of the Downtown Neighborhoods as well as those in the greater Fresno region.

The current draft of the DNC Plan calls for increasing density and changing the mix of land uses, particularly in the Valley and City Centers as well as particular neighborhood centers throughout the Plan Area. This HIA supports the following key actions in the current draft of the Community Plan due to their relevancy to health outcomes:        

Promote economic development that is compatible with intended character of the neighborhood Introduce neighborhood centers at or near important intersections Develop an incentive program to redevelop blighted multi-family properties Promote homeownership by current residents Identify funds to support job creation, retention, and training in the neighborhoods Avoid concentrations of social services Support existing and new health care services Encourage employer-based health care and sick leave

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t SOCIAL & ECONOMIC STABILITY | PLAN ANALYSIS The current DNC Plan draft demonstrates drastic changes in land uses allowed and calls for focused investment in the Downtown Neighborhoods. These changes will correspond most with changes in employment and education opportunities, housing affordability, displacement, and crime.

Employment According to employment projections detailed in the existing conditions section, the top five industries that are projected to generate the most employment opportunities include farmworkers and laborers (including crop, nursery, and greenhouse), retail salespersons, cashiers, waiters and waitresses, health center and clinic workers. The DNC Plan may provide a variety of employment options, including those above. Many of these occupations require little training or skill and only some provide a living wage, health insurance, job security, or upward mobility for the employee. Health impacts are associated with the number and the type of employment opportunities, as well as the wages and benefits those opportunities provide. The key health related characteristics of the above projected employment growth are described in the Table 27, Key healthrelated characteristics of impacted industries at full-time status. Oftentimes, these positions are only available for part-time employment; in this case, the percent of employees with access to health insurance and paid sick leave dramatically reduces.

Table 27. Key health-related characteristics of impacted industries at full-time status Living % access to % provided Nonfatal injury rate* Occupation wage** health insurance* paid sick leave* (per 100 employees) n/a 5 Farmworkers Rarely 8% Manufacturing Rarely 50% 48% 8 Restaurant waitpersons Sometimes 50% 48% 5 56% 5 Retail/Cashiers Sometimes 64% Construction Sometimes 72% 42% 5 Personal home care aides Often 76% 79% 5 Part-time

24%

28%

*Source: US Bureau of Labor Statistics, 2010; Compiled by R+A, 2010 ** Calculated by: http://www.livingwage.geog.psu.edu/places/0601927000

Overall, the increase in job opportunities will likely reduce unemployment for Fresno and the Downtown Neighborhoods, especially if employers are obligated to follow local hiring and recruitment requirements.

There is also the possibility of retaining the residents who currently leave Fresno for employment, which would reduce VMT and preserve the local economy. Many of the industries projected to increase (above) require some skill and training. In order to successfully decrease and maintain a lower unemployment rate, training programs will be crucial. Those who remain unemployed will likely suffer higher rates of psychological dysfunction, chronic disease, and overall mortality. Given the negative health impacts associated with those who are unemployed, it will be increasingly important to implement and monitor policies and programs related to local hiring and job training programs.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t Education Education, income, and health status are directly related. The Plan calls for smaller, neighborhood schools with high quality instruction and after school programs. In the long term, health may improve though implementation and coordination will be essential. Education is not a stand-alone issue as many facets of access to quality education and challenges of individual learning are important to consider on the student, teacher, school-wide, and district level. Diet and nutrition, parent involvement, youth violence, and instruction quality all impact learning and performance and in order to see long-term health improvements, these social and familial aspects must be addressed on a comprehensive level.

Housing affordability One strategy for transforming Downtown is introducing new housing in the Downtown core in order to activate the area. Without a specified proportion of affordable housing units, however, the Plan may not address the needs of low and very low income residents. Moreover, the Plan also suggests introducing market-rate housing in the surrounding neighborhoods. Though market-rate housing may attract buyers of higher socioeconomic status and generates more income and diversity for the area, lower income households in the DNC Plan are cannot afford it. Potential health impacts of this trend may include a widening of the gap of health disparities between those who can and cannot afford higher quality housing. Such conditions may include increases in asthma and other respiratory diseases, CVD, overweight and obesity, and socially-driven conditions such as isolation, crime, depression, and displacement.

Displacement As the neighborhoods within the DNC Plan Area undergo change as a result of new retail, commercial, and updated housing developments and a renewed interest in Downtown, area incomes and housing costs may increase. Though literature on the topic is mixed, individuals experiencing increased rent costs without increased incomes may no longer be able to afford higher rents and may be displaced. 137 Many of those most likely to be displaced â&#x20AC;&#x201D; often low income minoritiesâ&#x20AC;&#x201D;already have fewer resources to cope with the social, physiological, and psychological impacts associated with moving. Displacement disrupts social networks and can move people farther from work or school. Potential indirect health impacts of displacement include depression, academic delay in children, emotional and behavioral problems, unemployment, loss of health protective social networks, and reduced self-rated health. Those most likely to be displaced in the future are the households living in close proximity of the districts where development is likely to occur.

Crime The Downtown Neighborhoods Community Plan addresses various facets of crime prevention by incorporating policies and action items that identify specific avenues to reduce crime and enhance perceptions of safety. Revitalizing the alleyways and promoting the design of buildings to face towards the street are likely to enhance safety in the long term. Prohibiting the concentration of liquor stores is another key action item that will likely increase safety in the community. Liquor stores are often venues for crime and antisocial, unsolicited behaviour, and prohibiting concentrations of them in certain neighbourhoods will likely dissuade related activities or relocate activities to other areas. All of these strategies may reduce violent and property crime in the Downtown Neighborhoods. Reducing poverty and improving opportunities for jobs and education are also key strategies in the Plan for decreasing crime rates and must not be ignored.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t SOCIAL & ECONOMIC STABILITY | RECOMMENDED REVISIONS FOR THE PLAN Based on the results of the Literature Findings and Plan Analysis this HIA provides the following recommendations to be incorporated into the Final Plan. Land use, urban form, and transportation are key components of the Plan. Although design is an important aspect of land use and urban form, the Plan may rely too heavily on design and neglect real community needs. Moreover, the uses of land must meet the needs of the community, must be culturally appropriate, and must seamlessly meld with the surrounding transportation network as well as the commercial, retail activity, and public services that may support residents without owning a vehicle. The following revisions are recommended with specific regard to health outcomes associated with social and economic stability: 1. Ensure vulnerable populations are not disproportionately impacted by redevelopment or gentrification of their neighborhoods.

2. Ensure at least 30% of new housing is dedicated as affordable housing for very low and extremely low-income households.

3. Ensure employees working in short-term construction jobs and long-term jobs in commercial, retail, and manufacturing will be provided a living wage, health insurance, and paid sick days.

4. Assess and prevent potential business displacement, taking steps to maintain property affordability for current vulnerable businesses or supporting re-location in the project area.

5. Assess and prevent potential residential displacement, especially for low-income households.

6. Where feasible, prioritize local recruitment and hiring for all employment.

7. Ensure that retail is reflective of the communityâ&#x20AC;&#x2122;s wants and needs.

8. Encourage childcare facilities placed in office parks, commercial areas, and multi-family housing developments.

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RECOMMENDATIONS This section provides a summary of the health impacts that are fully described in the previous assessment chapter. One of the main goals of this HIA is to judge how the Downtown Neighborhoods Community Plan will potentially impact the health effects on a population, and the distribution of those effects within the population. Fresno’s diverse population carries many sensitive individuals and households, especially minority, extremely low-income or homeless, youth, elderly, and seasonal or migrant farmworkers. The majority of these households live well below the poverty line and represent vulnerable populations that currently often endure more significant health challenges. The decisions made in this Community Plan will affect those populations and those effects should be considered when drafting this Plan in its final stages.

Based on the existing conditions analyses, plan analyses, and impact findings, the following section formulated to confirm the most important recommended revisions that emerged from this HIA.

SUMMARY OF IMPACTS & RECOMMENDATIONS SOCIAL & ECONOMIC STABILITY Summary of Impacts Affordability. The Plan recommends introducing market-rate housing in the Downtown Neighborhoods in order to activate and diversify the area. Residents in the Downtown Neighborhoods experience housing burden, spending over 30% of their income on housing compared to 20% for the City overall. Market-rate housing will not be an affordable solution to Downtown residents and may displace some residents, especially those close to the potential investment areas.

Displacement. Gentrification of the Downtown Neighborhoods will likely result in permanent or temporary displacement, due to demolition/construction and increased costs of new housing. Displacement often negatively impacts health by increasing stress, depression, loss of social networks, homelessness, unemployment, and academic delay in children.

Housing quality. The Plan’s emphasis on expanding housing options, contextual design, code enforcement, and quality control will likely improve the health of those who live in the Downtown Neighborhoods, especially in Lowell where housing repairs are most dire.

Jobs. Employment generated from the Plan include a variety of occupations, most of which may not provide a living wage, require few skills or little training. Since most of these occupations are low-paying and often part-time, most employees do not have access to medical insurance and paid leave. Employees who do not have access to these benefits experience reduced productivity and have poorer self-rated health than those with benefits.

Unemployment. With the Plan’s recommendations for local hiring policies and downtown redevelopment, local unemployment is likely to decrease. Higher household incomes in general correlate with better health outcomes.

Schools. Education, income, and health status are directly related. Since the Plan calls for smaller, neighborhood schools with high quality instruction and after school programs, health will likely improve in long term. Implementation and coordination will be essential.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t Neighborhood-serving retail. The Planâ&#x20AC;&#x2122;s emphasis on strategic development and investment on specific corridors and nodes will likely improve the local economy and household access to higher quality goods and services.

Recommended Revisions 1. Ensure vulnerable populations are not disproportionately impacted by redevelopment or gentrification of their neighborhoods.

2. Ensure at least 30% of new housing is dedicated as affordable housing for very low and extremely low-income households.

3. Ensure employees working in short-term construction jobs and long-term jobs in commercial, retail, and manufacturing will be provided a living wage, health insurance, and paid sick days.

4. Assess and prevent potential business displacement, taking steps to maintain property affordability for current vulnerable businesses or supporting re-location in the project area.

5. Assess and prevent potential residential displacement, especially for low-income households.

6. Where feasible, prioritize local recruitment and hiring for all employment.

7. Ensure that retail is reflective of the communityâ&#x20AC;&#x2122;s wants and needs.

8. Encourage childcare facilities placed in office parks, commercial areas, and multi-family housing developments.

9. Incentivize employers to encourage volunteering and voting.

DIET & NUTRITION Summary of Impacts Grocery stores. Increasing access to and availability of grocery stores is a central piece of the policy recommendations in the Plan and will likely increase the health of the residents in the Downtown Neighborhoods. The existing distribution of full-service grocery stores in the Downtown Neighborhoods is uneven and concentrated in the northern and eastern parts of the City. Full-service grocery stores have been shown to offer a wider variety of foods, especially fresh produce, that is more affordable than convenience stores. People who live closer to grocery stores are more likely to fulfill recommendations for fruit and vegetable intake, thus decreasing their risk of overweight, obesity, diabetes, and other chronic conditions.

Fast food restaurants. The Plan recommends authorizing a moratorium on new fast food and formula restaurants in the Downtown Neighborhoods. Although this policy does not impact existing restaurants nor consumption of fast food, implementation of this recommendation will allow expand opportunities for local merchants to use the space and reduce any potential increased access to high fat, high calorie foods.

Urban agriculture and farmers markets. The Plan encourages community gardens and for residents to grow produce in their yards, which improve local resources of nutritious foods and can be incorporated into educational programs for all ages. A steady source of funding for management and coordination is necessary for successful urban gardening programs, which the Plan does not explicitly recommend.

Recommended Revisions 1. Ensure vulnerable populations are not disproportionately impacted by any of the goals, policies, or key actions.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t 3. Continued support and programming of local alternative sources to nutritious foods and community programs for local hiring and quality and cost control.

4. Remove or reduce the burdens for acquiring a Conditional Use Permit for farmers markets.

5. Incentivize large supermarkets to locate in the Plan area.

6. Develop a marketing campaign for the Fresno farmers markets.

7. Leverage local large agriculture companies for community benefits agreements with fruits and vegetable production.

8. Prohibit the opening of any new fast food, convenience store, or liquor store within a 1/2-mile radius of any public school.

ENVIRONMENTAL POLLUTANTS Summary of Impacts Land use. Many of the Downtown Neighborhoods are surrounded by heavy industrial agriculture and processing/manufacturing facilities that produce environmentally toxic pollutants in nearby air, water, and soil. Studies show that residents who live near such land uses are at increased risk of exposure to acute and chronic health-damaging elements. At this point, the Community Plan currently does not address this issue.

Environmental health risks from agriculture-related sources are likely to continue, especially impacting lowerincome, minority residents who reside there. Childhood asthma rates may also continue to rise and disproportionately impact children of color.

Criteria pollutants. The Downtown Neighborhoods’ location—in between two major highways and surrounded by industrial agricultural uses—create precarious conditions for regulating harmful air pollutants.

Although the Plan emphasizes reduction of automobile dependence, the Plan does not have capacity to influence external stationary or mobile sources of emissions. As such, respiratory conditions highly related to motor-vehicle emissions are likely to continue.

Housing location. The Plan’s long-term focus on increasing density along main corridors strategically places housing in close proximity to transit, jobs, and community amenities. Although this could improve health through increased use of transit and active transportation, increasing physical activity and revitalizing the local economy; however living near major roads has been shown to increase respiratory conditions especially for children.

Recommended Revisions 1. Ensure vulnerable populations are not disproportionately impacted by any of the goals, policies, or key actions.

2. Develop better dialogue between local public agencies and industry to better consider local residents’ concerns over air pollution risks from area sources.

3. Avoid routing trucks on roads adjacent to parks, schools, gardens, health clinics, or other uses that may hold sensitive populations.

4. Avoid locating new park and recreation areas, community gardens, schools, or other uses that may hold sensitive populations near freeways or busy roads.

5. Increase the frequency of shuttle and bus services from communities who would use regional transit.

6. Establish workplace and retail fees for parking, unbundle cost of parking from housing units, and reduce parking requirements for new developments.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t REGULAR PHYSICAL ACTIVITY Summary of Impacts Transit improvements. The Plan calls for increased density and strategic investment in neighborhood and city centers and improvements in access to FAX bus routes. This will likely increase use of public transportation.

People who live near bus stops are more likely to use it, and those who use public transportation are more likely to meet or exceed recommendations for physical activity and experience less social isolation, contributing to better physical and emotional health. Increased use of public transit has also shown to decrease air and noise pollution, resulting in improved respiratory and cardiovascular health, especially for vulnerable population such as children.

Auto use. The Planâ&#x20AC;&#x2122;s direction for increased density and transit improvements in the Downtown neighborhoods in the long-term may decrease automobile use in these neighborhoods as destinations will be in closer proximity to each other. Transportation Demand Management and other parking strategies used in Downtown will likely decrease use of vehicles for those traveling into the Downtown area. Jobs, however, must be concentrated within close proximity to residential uses in order for vehicle use to decrease or local and regional transit must be viable options for commuters to switch from driving. If job locations are not proximate and transit is not improved enough, auto use for commuters may not change.

Collisions and traffic safety. Streetscape improvements laid out in the Plan will likely decrease automobile accidents, especially collisions with cyclists and pedestrians. Traffic calming devices have been shown to slow the speed of traffic and reduce pedestrian collisions. A safer pedestrian and cyclist environment may encourage people to walk and cycle more, improving physical activity and community interaction. Focusing improvements in areas with high collision rates will be essential.

Active transportation. Increased bicycle lanes and an enhanced pedestrian environment will likely result in more cyclists and people walking. Amenities such as wider sidewalks, benches, and street trees not only slow traffic, but also are inviting to pedestrians. Improving cycling and pedestrian infrastructure will encourage active, sustainable, and safe transportation. Focusing improvements in areas with lacking infrastructure will be essential.

Recommended Revisions 1. Ensure vulnerable populations are not disproportionately impacted by any of the goals, policies, or key actions.

2. Include recommended actions for programming associated with the establishment of joint use agreements between the City and Fresno USD. 3. Do not eliminate or reduce any existing park space in the Downtown Neighborhoods.

4. Where feasible, redirect funding to maintain and introduce recreation spaces including parks and pools.

5. Continue support and programming of existing and new recreation programs.

6. Use community benefits agreements to incentivize developers to locate parks and open space in their development areas.

7. Promote bicycle and pedestrian safety courses in schools and workplaces.

8. Ensuring funding for parks is maintained or increased.

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fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t NEXT STEPS The creation of this report satisfies the 4th step of the HIA process, sharing the findings and recommendations from the assessment to inform and influence the decision-making around the final draft of the Downtown Neighborhoods Community Plan. This report has documented the HIA findings, which has included a great breadth of details about background academic literature, an existing conditions profile, a list of supported policy directions in the current Plan Draft, and finally specific recommendations for revisions of this Draft.

Further communication of the HIA findings will be presented to the lead consultant and relevant community partners. The final stage of the HIA process is monitoring and evaluation, perhaps one of the most challenging and disputed steps in the process. This HIA has not included a plan for monitoring and evaluation of long-term impacts on health. The team of consultants is currently drafting the final DNC Plan. The prospective nature of this HIA allows for the incorporation of the recommendations put forth in this HIA into the final Plan.

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REFERENCES 1. Ogden C. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006;295(13):1549-55.

2. Kawachi I, Daniels N, Robinson DE. Health Disparities By Race And Class: Why Both Matter. Health Aff. 2005;24(2):343-352.

3. Gordon-Larsen P, Nelson MC, Page P, Popkin BM. Inequality in the built environment underlies key health disparities in physical activity and obesity. Pediatrics. 2006;117:417-424.

4. WHO European Centre for Health Policy, ed. Health Impact Assessment: Main concepts and suggested approach. Gothenburg Consensus Paper. Copenhagen: WHO Regional Office for Europe; 1999.

5. Quigley R, den Broeder L, Furu P. Health Impact Assessment International Best Practice Principles. Special Publication Series No. 5.

2006.

6. City of Fresno: Downtown Specific and Community Plans. Project Information: Overview. http://fresnodowntownplans.com/. Updated 2010. Accessed August 5, 2010.

7. California Farm Bureau Federation. Fresno County Farm Bureau Information. http://www.cfbf.com/counties/?id=10. Updated 2009.

Accessed August 3, 2010.

8. Mccreedy M, Leslie JG. Get Active Orlando: Changing the Built Environment to Increase Physical Activity. Am J Prev Med. 2009;37(6, Supplement 2):S395-S402.

9. California Department of Finance. 2009 Demographic Summary City of Fresno. Updated 2009 Demographic Summary - City of Fresno.

Accessed Sept 25, 2010.

10. Census 2009. American Community Survey. Updated 2009.

Accessed Sept 25, 2010.

11. Harvard School of Public Health. Diversity Data: City of Fresno Profile. http://diversitydata.sph.harvard.edu/Data/Profiles/Show.aspx?loc=5 36. Updated 2010. Accessed Sept 25, 2010.

12. Larson A. Migrant and Seasonal Farmworker Enumeration Profile Study: California. . September 2000.

13. Emmi KE, Jurkowski JM, Codru N, Bell EM, Kacica MA, Carter TP. Assessing the health of migrant and seasonal farmworkers in New York State: statewide data 2003-2005. J Health Care Poor Underserved. 2010;21(2):448-63.

14. Rosenbaum S, Shin P. Migrant and Seasonal Farmworkers: Health Insurance Coverage and Access to Care. Kaiser Commission on Medicaid and the Uninsured. April 2005.

15. Hovey JD, Magana C. Acculturative Stress, Anxiety, and Depression among Mexican Immigrant Farmworkers in the Midwest United States. Journal of Immigrant Health. 2000;2(3):119-131.

16. Wood D, Valdez RB, Hayashi T, Shen A. Homeless and housed families in Los Angeles: a study comparing demographic, economic, and family function characteristics. Am J Public Health.

1990;80(9):1049-1052.

17. Schanzer B, Dominguez B, Shrout PE, Caton CLM. Homelessness, Health Status, and Health Care Use. Am J Public Health.

2007;97(3):464-469.

18. Rosenheck R, Seibyl CL. Homelessness: Health Service Use and Related Costs. Med Care. 1998;36(8):1256-1264. http://www.jstor.org/stable/3766891.

19. Gelberg L, Linn LS. Assessing the Physical Health of Homeless Adults. JAMA. 1989;262(14):1973-1979.

20. Fiscella K, Franks P. Poverty or income inequality as predictor of mortality: longitudinal cohort study. BMJ. 1997;314(1724).

21. Casey PH, Szeto K, Lensing S, Bogle M, Weber J. Children in FoodInsufficient, Low-Income Families: Prevalence, Health, and Nutrition Status. Arch Pediatr Adolesc Med. 2001;155(4):508-514.

22. Wang Y, Zhang Q. Are American children and adolescents of low socioeconomic status at increased risk of obesity? Changes in the

Final Report â&#x20AC;&#x201C; March 2011

association between overweight and family income between 1971 and 2002. Am J Clin Nutr. 2006;84(4):707-716.

23. Mobley LR, Root ED, Finkelstein EA, Khavjou O, Farris RP, Will JC. Environment, obesity, and cardiovascular disease risk in low-income women. Am J Prev Med. 2006;30:327-332.

24. Pickett KE, Pearl M. Multilevel analyses of neighborhood socioeconomic context and health outcomes: a critical review.

Journal of Epidemiology and Community Health. 2001;55:111-122.

25. Winkleby MA, Jatulis DE, Frank E, Fortmann SP. Socioeconomic status and health: how education, income, and occupation contribute to risk factors for cardiovascular disease. Am J Public Health.

1992;82(6):816-820.

26. California Health Interview Survey. CHIS 2007 Adult, Teen, Child Public Use Files. http://www.chis.ucla.edu/. Updated January 2007.

Accessed September, 2010.

27. Bengiamin MI, Capitman JA, Ruwe MB. Disparities in Initiation and Adherence to Prenatal Care: Impact of Insurance, Race-Ethnicity and Nativity. Maternal and Child Health;14(5):618-624.

28. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of Overweight and Obesity in the United States, 1999-2004. JAMA. 2006;295(13):1549-1555.

29. Whitaker R. Predicting obesity in young adulthood from childhood and parental obesity. New England Journal of Medicine, The. 1997;337(13):869-73.

30. Powell LM, Slater S, Chaloupka FJ. Relationship between community physical activity setting and race, ethnicity, and socioeconomic status. Evidence-Based Preventive Medicine.

2004;1(2):135-144.

31. Giles-Corti B, Donovan RJ. The relative influence of individual, social and physical environment determinants of physical activity. Soc Sci Med. 2002;54(12):1793-1812.

32. Morland K, Roux A, Wing S. Supermarkets, other food stores, and obesity: The Atherosclerosis Risk in Communities Study. American Journal of Preventive Medicine. 2006;30(4):333-339.

33. Gregg EW, Cheng YJ, Cadwell BL, et al. Secular Trends in Cardiovascular Disease Risk Factors According to Body Mass Index in US Adults. JAMA. 2005;293(15):1868-1874.

34. Gordon-Larsen P, McMurray RG, Popkin BM. Determinants of Adolescent Physical Activity and Inactivity Patterns. Pediatrics.

2000;105(e83).

35. Kipke MD, Iverson E, Moore D, et al. Food and park environments: neighborhood-level risks for childhood obesity in Eeast Los Angeles.

Journal of Adolescent Health. 2007;40(4):325-333.

36. Powell LM, Slater S, Chaloupka FJ, Harper D. Availability of Physical Activity-Related Facilities and Neighborhood Demographic and socioeconomic Characteristics: A National Study. American Journal of Public Health. 2006;96(9):1676-1680.

37. Haskell W, Lee IM, Pate RR, et al. Physical activity and public health : Updated recommendation for adults from the American College of Sports Medicine and the American Heart Association.

Medicine and science in sports and exercise. 2007;39(8):1423-1434.

38. Borst HC, Miedema HME, de Vries SI, Graham JMA, van Dongen JEF. Relationships between street characteristics and perceived attractiveness for walking reported by elderly people. J Environ Psychol. 2008;28(4):353-361.

39. Borst HC, de Vries SI, Graham JMA, van Dongen JEF, Bakker I, Miedema HME. Influence of environmental street characteristics on walking route choice of elderly people. J Environ Psychol.

2009;29(4):477-484.

40. Crane R. The Influence of Urban Form on Travel: An Interpretive Review. Journal of Planning Literature;15(1):3-23.

41. Frank LD, Schmid TL, Sallis JF, Chapman J, Saelens BE. Linking objectively measured physical activity with objectively measured

79

fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t urban form: Findings from SMARTRAQ. Am J Prev Med. 2005;28(2, Supplement 2):117-125.

42. Angotti T, Hanhardt E. Problems and Prospects for Healthy Mixeduse Communities in New York City. . 2001;16(2):154. http://www.informaworld.com/10.1080/02697450120077352.

43. Gordon-Larsen P, Boone-Heinonen J, Sidney S, Sternfeld B, Jacobs DR,Jr, Lewis CE. Active Commuting and Cardiovascular Disease Risk: The CARDIA Study. Arch Intern Med. 2009;169(13):1216-1223.

44. Pucher J, Dill J, Handy S. Infrastructure, programs, and policies to increase bicycling: An international review. Prev Med. 2010;50(Supplement 1):S106-S125.

45. Besser LM, Dannenberg AL. Walking to Public Transit: Steps to Help Meet Physical Activity Recommendations. Am J Prev Med. 2005;29(4):273-280.

46. Lipman B. A heavy load: The combined housing and transportation burdens of working families. Washington, DC: Center for Housing Policy. 2006.

47. Cooper MN. Rising Energy Prices Strain Household Budgets and the Economy, For Most Americans. Consumer Federation of America: Consumers Union. September 2004:www.consumersunion.org/pub/0929%20price%20report.pdf.

48. Haas P, Makarewicz C, Benedict A, Bernstein S. Estimating Transportation Costs by Characteristics of Neighborhood and Household. . 2008;2077(-1):70. http://dx.doi.org/10.3141/2077-09.

49. Pucher J, Dijkstra L. Promoting Safe Walking and Cycling to Improve Public Health: Lessons From The Netherlands and Germany.

Am J Public Health. 2003;93(9):1509-1516.

50. National Highway Traffic Safety Administration. Fatality Analysis Reporting System, National Statistics. http://wwwfars.nhtsa.dot.gov/Main/index.aspx. Updated 2008.

51. Cervero R. Mixed land-uses and commuting: Evidence from the American Housing Survey. Transportation Research Part A: Policy and Practice. 1996;30(5):361-377.

52. Frank LD, Sallis JF, Conway TL, Chapman JE, Saelens BE, Bachman W. Many Pathways from Land Use to Health: Associations between Neighborhood Walkability and Active Transportation, Body Mass Index, and Air Quality. 2006;72(1):87. http://www.informaworld.com/10.1080/01944360608976725.

53. Ewing R, Pendall P, Chen D. Measuring Sprawl and Its Transportation Impacts. Transportation Research Record: Journal of the Transportation Research Board. 2003;1831:175-183.

54. Jacobsen PL. Safety in numbers: more walkers and bicyclists, safer walking and bicycling. Injury Prevention. 2003;9(3):205-209.

55. Wier M, Weintraub J, Humphreys EH, Seto E, Bhatia R. An arealevel model of vehicle-pedestrian injury collisions with implications for land use and transportation planning. Accident Analysis & Prevention. 2009;41(1):137-145.

56. Loukaitou-Sideris A, Liggett R, Sung H. Death on the Crosswalk.

Journal of Planning Education and Research. ;26(3):338-351.

57. Zegeer C, Blomberg R, Henderson D, et al. Evaluation of MiamiDade Pedestrian Safety Demonstration Project. Transportation Research Board of the National Academies. 2008;2073.

58. Morrison DS, Petticrew M, Thomson H. What Are the Most Effective Ways of Improving Population Health through Transport Interventions? Evidence from Systematic Reviews. Journal of Epidemiology and Community Health (1979). 2003;57(5):327-333. http://www.jstor.org/stable/25570002.

59. Giles-Corti B, Broomhall MH, Knuiman M, et al. Increasing Walking: How important is distance to, attractiveness, and size of public open space? American Journal of Preventive Medicine.

2005;28(2S2):169-176.

60. Roemmich JN, Epstein LH, Raja S, Yin L, Robinson J, Winiewicz D. Association of access to parks and recreational facilities with the physical activity of young children. Prev Med. 2006;43(6):437-441.

61. Crompton J. The Impact of Parks on Property Values: Empirical Evidence from the Past Two Decades in the US. Managing Leisure.

October 2005(10):203-218.

Final Report â&#x20AC;&#x201C; March 2011

62. Cooper T, Vincent JM. Joint Use School Partnerships in California: Strategies to Enhance Schools and Communities. August 2008.

63. Farley T. Safe play spaces to promote physical activity in inner-city children: results from a pilot study of an environmental intervention.

American journal of public health (1971). 2007;97(9):1625-31.

64. Scott M. Weekend schoolyard accessibility, physical activity, and obesity: the Trial of Activity in Adolescent Girls (TAAG) study. Prev Med. 2007;44(5):398-403.

65. Fehr & Peers I. Downtown Neighborhoods Fulton Corridor: Existing Conditions Analysis. . April 2010.

66. Department of California Highway Patrol. Collisions and Victims

by Motor Vehicle (01/01/2008-12/31/2009), Jurisdiction: Fresno. .

Report generated: 8/10/2010.

67. The Trust for Public Land. Park-related Total Expenditure per Resident by City. . http://www.tpl.org/content_documents/citypark_facts/ccpe_Spendi ng_Reports_2010.pdf. Updated FY 2008. Accessed September, 2010.

68. Nelson\Nygaard. MEMORANDUM: Background Parking and Public Transportation Conditions in the Fresno Fulton Corridor. April 2010.

69. Story MS, et al. Individual and Environmental Influences on Adolescent Eating Behaviors. J Am Diet Assoc. 2002;102(3):S23-S29.

70. French SA, Story M, Jeffery RW. Environmental influences on eating and physical activity. Annual Review of Public Health.

2001;22:309-335.

71. Powell LM, Chaloupka FJ, Bao Y. The Availability of Fast-Food and Full-Service Restaurants in the United States: Associations with Neighborhood Characteristics. Am J Prev Med. 2007;33(4S):S240S245.

72. Nielsen SJ, Popkin BM. Patterns and Trends in Food Portion Sizes, 1977-1998. JAMA. 2003;289(4):450-453.

73. Moore LV, Diez Roux AV, Nettleton JA, Jacobs DR, Franco M. FastFood Consumption, Diet Quality, and Neighborhood Exposure to Fast Food: The Multi-Ethnic Study of Atherosclerosis. Am J Epidemiol.

2009;170(1):29-36.

74. Epstein LH, Gordy CC, Raynor HA, Beddome M, Kilanowski CK, Paluch R. Increasing fruit and vegetable intake and decreasing fat and sugar intake in families at risk for childhood obesity. Obesity Research. March 2001;9(3):171-178.

75. Inagami S, Cohen DA, Finch BK, Asch SM. You Are Where You Shop: Grocery Store Locations, Weight, and Neighborhoods.

American Journal of Preventive Medicine. July 2006;31(1):10-17.

76. Morland K, Wing S, Diez Roux A. The contextual effect of the local food environment on residentsâ&#x20AC;&#x2122; diets: the atherosclerosis risk in communities study. Am J Public Health. 2002;92:1761-1767.

77. Bazzano LA, He J, Ogden LG, et al. Fruit and vegetable intake and risk of cardiovascular disease in US adults: the first National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. Am J Clin Nutr. 2002;76(1):93-99.

78. Chung C, Myers SL. Do the Poor Pay More for Food? An Analysis of Grocery Store Availability and Food Price Disparities. Journal of Consumer Affairs. 1999;33(2):276-297.

79. Frazao E, Andrews M, Smallwood D, Prell M. Food Spending Patterns of Low-Income Households. Economic Information Bulletin;29(4).

80. Moore LV, Diez Roux AV. Associations of Neighborhood Characteristics With the Location and Type of Food Stores. Am J Public Health. 2006;96(2):325-331.

81. Drewnowski A. Obesity and the food environment: Dietary energy density and diet costs. American Journal of Preventative Medicine. ;27(3):154-162.

82. Bowman SA, Gortmaker SL, Ebbeling CB, Pereira MA, Ludwig DS. Effects of Fast-Food Consumption on Energy Intake and Diet Quality Among Children in a National Household Survey. Pediatrics.

2004;113(1):112-118.

83. Powell LM, Slater S, Mirtcheva D, Bao Y, Chaloupka FJ. Food store availability and neighborhood characteristics in the United States.

Prev Med. 2007;44(3):189-195.

80

fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t 84. California Center for Public Health Advocacy. Searching for Healthy Food: The Food Landscape of California's Cities and Counties. . http://www.publichealthadvocacy.org/searchingforhealthyfood.html.

Updated January 2007. Accessed July 11, 2010.

85. Samuels & Associates, prepared for Public Health Institute. 2000 CALIFORNIA HIGH SCHOOL FAST FOOD SURVEY: Findings and Recommendations. . Feb 2000.

86. Kim JJ, Huen K, Adams S, Smorodinsky S, Hoats A, et al.

Residential Traffic and Children’s Respiratory Health. Environ Health Perspect. 2008;116(9).

87. Gauderman WJ, Vora H, McConnell R, et al. Effect of exposure to traffic on lung development from 10 to 18 years of age: A cohort study. The Lancet. 2007;369:571-577.

88. Tonne C, Melly S, Mittleman M, Coull B, Goldberg R, Schwartz J. A case-control analysis of exposure to traffic and acute myocardial infarction. Environ Health Perspect. 2007;115:53-57.

89. Lipfert FW, Wyzga RE, Baty JD, Miller JP. Traffic density as a surrogate measure of environmental exposures in studies of air pollution health effects: Long-term mortality in a cohort of US veterans. Atmos Environ. 2006;40:154-169.

90. Kunzli N, Kaiser R, Medina S, et al. Public-health impact of outdoor and traffic-related air pollution: a European assessment. The Lancet. 2000;356(9232):801. http://www.sciencedirect.com/science/article/B6T1B-43P3TK19/2/34bf5f8445b3fe79b07c1ed83270d7c7.

91. United States Environmental Protection Agency (USEPA).

Particulate Matter: Health and Environment. http://epa.gov/particles/health.html. Updated 2004. Accessed July 20, 2010.

92. Brauer M, Hoek G, Smit HA, et al. Air pollution and development of asthma, allergy and infections in a birth cohort. European Respiratory Journal. 2007;29:879-888.

93. Delfino RJ, Chang J, Wu J, et al. Repeated hospital encounters for asthma in children and exposure to traffic-related air pollution near the home. Annals of Allergy, Asthma & Immunology.

2009;102(2):138-144.

94. California Air Resources Board (CARB). Health Effects of Diesel Exhaust Particulate Matter. . 2006. Available at: http://www.arb.ca.gov/research/diesel/dpm_draft_3-01-06.pdf.

95. Breysse P, Farr N, Galke W, Lanphear B, Morley R, Bergofsky L. The Relationship between Housing and Health: Children at Risk.

Environ Health Perspect. 2004 November;112(15):1583–1588.

96. Jacobs DE, Wilson J, Dixon SL, Smith J, Evens A. The Relationship of Housing and Population Health: A 30-Year Retrospective Analysis.

Environ Health Perspect. 2009;117(4):597-604. http://www.jstor.org/stable/25478164.

97. Rauh VA, Chew GR, Garfinkel RS. Deteriorated housing contributes to high cockroach allergen levels in inner-city households.

Environ Health Perspect. 2002 April;110(Suppl 2):323–327.

98. Bellinger DC, Needleman HL. Intellectual Impairment and Blood Lead Levels. N Engl J Med. 2003;349(5):500-502. http://dx.doi.org/10.1056/NEJM200307313490515.

99. Daisey JM, Angell WJ, Apte MG. Indoor air quality, ventilation and health symptoms in schools: an analysis of existing information.

Indoor Air. 2003;13(1):53-64. http://dx.doi.org/10.1034/j.16000668.2003.00153.x.

100. Maantay J. Asthma and air pollution in the Bronx: Methodological and data considerations in using GIS for environmental justice and health research. Health Place.

2007;13(1):32-56.

101. Brugge D, Durant J, Rioux C. Near-highway pollutants in motor vehicle exhaust: A review of epidemiologic evidence of cardiac and pulmonary health risks. Environ Health. 2007;6(1):23. http://www.ehjournal.net/content/6/1/23.

102. US Department of Agriculture. 2007 Census of Agriculture: Fresno County Profile. . 2007.

Final Report – March 2011

http://www.agcensus.usda.gov/Publications/2007/Online_Highlights /County_Profiles/California/cp06019.pdf.

103. US Environmental Protection Agency. Private Drinking Water Wells and Human Health. . http://www.epa.gov/privatewells/health.html. Updated 2006.

Accessed August 3, 2010.

104. Alavanja M, Hoppin J, Kamel F. Health Effects of Chronic Pesticide Exposure: Cancer and Neurotoxicity. Annual Review of Public Health. 2004;25:155-197.

105. Bassil KL, Vakil C, Sanborn M, Cole DC, Kaur JS, Kerr KJ. Cancer health effects of pesticides: Systematic review. Can Fam Physician.

2007;53(10):1704-1711.

106. Hawley JK. Assessment of Health Risk from Exposure to Contaminated Soil. Risk Analysis. 1985;5(4):289-302. http://dx.doi.org/10.1111/j.1539-6924.1985.tb00185.x.

107. Debes F, Budtz-Jørgensen E, Weihe P, White RF, Grandjean P. Impact of prenatal methylmercury exposure on neurobehavioral function at age 14 years. Neurotoxicol Teratol. 2006;28(3):363-375.

108. Schwartz J. Air Pollution and Children's Health. Pediatrics.

2004;113(4):1037-1043.

109. Gauderman WJ, Avol E, Lurmann F, et al. Childhood asthma and exposure to traffic and nitrogen dioxide. Epidemiology. 2005;16:737743.

110. Hwang BF, Lee YL, Lin YC, Jaakkola JJ, Guo YL. Traffic related air pollution as a determinant of asthma among Taiwanese school children. Thorax. 2005;60:467-473.

111. Ngo M, Pinkerton K, Freeland Sea. Airborne particles in the San Joaquin Valley may affect human health. Cal Ag. 2010;64(1):12-16.

112. CalTrans. 2008 State Highway Congestion Monitoring Program (HICOMP) Annual Data Compilation. . September 2009.

113. San Joaquin Valley Air Pollution Control District. 2007 Annual Report on the District’s Air Toxics Program. . 2007. http://www.valleyair.org/busind/pto/Tox_Resources/annual%20repo rt%202007.pdf.

114. Department of Pesticide Regulation. 2008 Annual Pesticide Use Report: Fresno County. . http://www.cdpr.ca.gov/docs/pur/pur08rep/08_pur.htm. Updated 2009. Accessed September, 2010.

115. Nuckols JR, Gunier RB, Riggs P, Miller R, Reynolds P, Ward M. Linkage of the California Pesticide Use Reporting Database with Spatial Land Use Data for Exposure Assessment. Environmental Health Perspectives. 2007;115(5):684-689.

116. Hall JV, Brajer V, Lurmann FW. Measuring the gains from improved air quality in the San Joaquin Valley. J Environ Manage.

2008;88(4):1003-1015.

117. Ryan PH, LeMasters , Biswas P, et al. A comparison of proximity and land use regression traffic exposure models and wheezing in infants. Environ Health Perspect. 2007;115:278-284.

118. Adar SD, Gold DR, Coull BA, Schwartz J, Stone P, Suh H. Focused exposures to airborne traffic particles and heart rate variability in the elderly. Epidemiology. 2007;18:95-103.

119. Hoffmann B, Moebus S, Stang A, et al. Residence close to high traffic and prevalence of coronary heart disease. Eur Heart J. 2006;27:2696-2702.

120. Vallet M, Gagneux J-, Blanchet V, Favre B, Labiale G. Long term sleep disturbance due to traffic noise. J Sound Vibrat. 1983;90(2):173191.

121. Moser K, Goldblatt P, Fox J, Jones D. Longitudinal study: mortality and social organisation. In: Goldblatt P, editor. Longitudinal study: mortality and social organisation. London: OPCS, 1990. 1990.

122. Linn MW, Sandifer R, Stein S. Effects of unemployment on mental and physical health. Am J Public Health. 1985;75(5):502-506.

123. Bartley M, Plewis I. Accumulated labour market disadvantage and limiting long-term illness: data from the 1971-1991 Office for National Statistics' Longitudinal Study. Int J Epidemiol.

2002;31(2):336-341.

81

fresno downtown neighborhoods | h e a l t h i m p a c t a s s e s s m e n t 124. Ettner SL. New evidence on the relationship between income and health. J Health Econ. 1996;15(1):67-85.

125. Tenenbaum HR, Porche MV, Snow CE, Tabors P, Ross S. Maternal and child predictors of low-income children's educational attainment.

Journal of Applied Developmental Psychology. 2007;28(3):227-238.

126. Haveman R, Wolfe B. The Determinants of Children's Attainments: A Review of Methods and Findings. Journal of Economic Literature. 1995;33(4):1829-1878. http://www.jstor.org/stable/2729315.

127. Lillie-Blanton M, Hoffman C. The Role Of Health Insurance Coverage In Reducing Racial/Ethnic Disparities In Health Care. Health Aff. 2005;24(2):398-408.

128. Levin-Epstein J. Presenteeism and Paid Sick Days. . Feb 2005.

129. Clemans-Cope L, Perry CD, Kenney GM, Pelletier JE, Pantell MS. Access to and Use of Paid Sick Leave Among Low-Income Families With Children. Pediatrics. 2008;122(2):e480-486.

130. Boynton-Jarrett R, Ryan LM, Berkman LF, Wright RJ. Cumulative violence exposure and self-rated health: longitudinal study of adolescents in the United States. Pediatrics. ;122:961-970.

131. Kawachi I, Berkman LF. Neighborhoods and Health. New York, NY: Oxford University Press; 2003.

Final Report â&#x20AC;&#x201C; March 2011

132. Wright R. Health effects of socially toxic neighborhoods: the violence and urban asthma paradigm. Clinics in Chest Medicine.

2006;27:413-421.

133. Lindstrom M, Hanson BS, Ostergren PO. Socioeconomic differences in leisure-time physical activity: the role of social participation and social capital in shaping health related behaviour.

Social Science and Medicine. 2001;52(3):441-451.

134. California Employment Development Department. Fresno County Profile. . http://www.labormarketinfo.edd.ca.gov/cgi/databrowsing/localArea ProfileQSResults.asp?selectedarea=Fresno+County&selectedindex=1 0&menuChoice=localAreaPro&state=true&geogArea=0604000019.

Updated 2010. Accessed June 22, 2010.

135. California Employment Development Department. State Detailed Overview. . http://www.labormarketinfo.edd.ca.gov/.

Updated 2010. Accessed August 3, 2010.

136. US Bureau of Labor Statistics. Employee Benefits in the United States. http://www.bls.gov/ncs/ebs/sp/ebnr0016.pdf. Updated March 2010. Accessed August 5, 2010.

137. McKinnish T, Walsh R, Kirk White T. Who gentrifies low-income neighborhoods? J Urban Econ. 2010;67(2):180-193.

82