# Development of a

# Health Impact Assessment (HIA) Protocol

# For Polk County, Florida

# 2005-2006

# 

# 

# Environmental Public Health Leadership Institute Fellow:

# Timothy G. Mayer; B.S., R.S., M.P.H.

*Environmental Administrator;* Polk County Health Department

2090 East Clower Street

Bartow, Florida 33830-6741

\(863\) 519-8330 ext 1201

<timothy_mayer@doh.state.fl.us>

# Mentor:

# Sarah B. Kotchian; Ed.M., M.P.H., Ph.D.

*Research Assistant Professor;* Department of Family and Community
Medicine and Associate Director for Planning, Institute for Public
Health, University of New Mexico

# Acknowledgement:

# Daniel O. Haight; M.D.

*Director;* Polk County Health Department and

*Associate Professor*, University of South Florida

# EXECUTIVE SUMMARY:

Polk County is one of the fastest growing counties in Florida, a rapidly
growing state. Development and residential construction continue to
increase and expand, outpacing infrastructure and services. Concurrent
with this expanding development, chronic disease status indicators for
the county lag behind both state averages and Healthy People 2010 goals.
Research has shown a connection between health status and the built
environment.

A Health Impact Assessment (HIA) protocol is under development for
construction projects and developments in Polk County. This tool will be
derived from existing HIAs and customized for the unique characteristics
of Polk County. The HIA will include review of proposed developments and
construction for components designed to increase physical activity of
the residents, such as adequate sidewalks, lighting, proximity to retail
and accessibility by transportation other than private motor vehicle.
The HIA process will be incorporated into the existing development
review process without additional review time or impact on the current
county procedures.

Industry education and support are essential for the success of an HIA
in this area. Incentives to encourage participation by the construction
and development industry include fast track permitting for properties
within a development which have undergone an HIA and have incorporated
preferred design elements, as well as designation by the Polk County
Health Department as a "Healthy Design" community or development. Such a
designation can be used as a marketing tool to attract potential new
homeowners.

The resultant improved community design will, over time, facilitate an
increased level of physical activity in community members and,
ultimately, an improvement in community health status.

# INTRODUCTION/BACKGROUND:

####### ***Problem Statement:***

Polk County is a fast growing county with an overall population increase
of 12% in the last five years, with some municipalities growing by more
than 20% (Table 1) (1, 2). Polk County is growing faster than
demographers expected and has already passed estimates for 2010.
Building permits in 2005 for the county rose 36% over the number issued
in 2004 (3), indicating an expansion of this trend in the future (Table
2). This trend has been in the forefront of issues facing the county,
but mainly in regards to the lack of infrastructure such as adequate
roads, water and sewage utilities, and schools. Several areas of the
county have had building moratoriums in effect due the lack of promised
services. Since the demand is for even more construction, resistance
exists for anything which may be perceived as an obstacle or delay in a
fast and simple development review and permitting process.

Polk County's Chronic Disease Profile (Table 3) illustrates how the
county lags behind the statewide figures as well as US Healthy People
2010 Goals (4, 5,6). Motor Vehicle Death Rates (Table 4) are also far
above the statewide rate and the disparity is growing (4,5). As the
county continues to grow and the population increases, these rates will
continue to increase unless measures to address them are put into
practice. The health status of the county has become an issue of
interest due to the lack of preventative health care for indigent and
low-income residents. As the health status of this segment of the
population decreases, the demand on county health care resources has
increased. A recent referendum for implementation of a health care tax
passed. It will improve the ability to address individual health status
issues in the short-term; it will not address many of the causes in the
long term. While the specific programs also may not directly benefit the
entire population, it demonstrates an awareness of health status as an
issue in the county and a willingness to make an effort to improve it.
The health status of this population can be extrapolated to the county
population as a whole.

When comparing this tremendous increase in population and development
activity with health status indicators, an inverse relationship is
evident. This relationship has been well documented (7), but not widely
shared in Polk County, so few, if any, shareholders are aware of the
long term health impact of the built environment and how it can be
addressed by improved planning and development practices. In the 2003
report "Measuring the Health Effects of Sprawl" from Smart Growth
America, Polk County was one of the 448 counties nationwide that was
indexed as to its sprawl (9). It scored 105.24, a little less "sprawled"
than the average of 100 (an inverse scoring system). The study also
indicates an expected Body Mass Index (BMI) of 26.08. The data used for
this study was from 2000. The Behavioral Risk Factor Surveillance System
survey from 2003 indicates \>35% of Polk County's population was
overweight (BMI\>25) and 27% was obese (BMI\>30). It would be
interesting to recalculate Polk County's sprawl index, in light of the
recent explosive population and building growth. Education of the
benefits of healthy designed communities and developments is the key to
a successful project. The Health Impact Assessment (HIA) tool which will
be developed will be used in two ways; (1) to evaluate the design of a
proposed development or project before construction and encourage
improvements or modifications that can reduce the negative health
effects of that community construction design, and (2) by using the
Protocol for Assessing Community Excellence in Environmental Health
(PACE-EH) process, to assist community leaders, homeowners associations,
etc. address existing developments or subdivisions and develop ways to
retrofit those communities to provide improvements that will reduce
negative health effects.

![](media/image1.jpeg){width="2.2472222222222222in" height="3.625in"}

Table 1: This picture is from The Ledger and compiled from The Bureau of
Economic and Business Research, University of Florida, 2005 estimates
and the U.S. Census Bureau\'s 2000 census.

![](media/image2.jpeg){width="1.8131944444444446in"
height="3.1256944444444446in"}

Table 2: This picture if from The Ledger research of January 19, 2006
and compiled from county and municipal building statistics.

####### ![](media/image3.wmf){width="5.875in" height="3.9208333333333334in"}**CHRONIC DISEASE PROFILE**

**Table 3: This picture is compiled from date found at
http://www.floridacharts.com/charts/brfss.aspx**

####### **Motor Vehicle Death Rate**

![](media/image4.png){width="5.375694444444444in"
height="3.2083333333333335in"}

Table 4: This picture is from
<http://www.floridacharts.com/charts/report.aspx?domain=04&IndNumber=0110>
and provided by the Florida Department of Health, Office of Planning,
Evaluation, and Data Analysis.

Data Source: Florida Department of Health, Office of Vital Statistics

***Behavior Over Time Graph:***

Development Growth

V Negative Health Effects

A

R

I

A HD/Medical Community

B Awareness

L

E Public Awareness

S Impetus for Change

Physical Activity

TIME

The Behavior Over Time graph (above) illustrates the current trends.
Growth increases at an almost exponential rate, leaving infrastructure
far behind. The resultant sprawl requires greater motor vehicular travel
which reduces physical activity by the general population. This leads to
a subsequent increase in negative health effects. The medical community
is aware of these health effects and becomes more concerned as they
increase. The public is slowly becoming aware of this issue, which
results in an opportunity for change. The current overall awareness of
the issue makes the timing right for an effort such as providing design
alternatives via a HIA. After the HIA process has been implemented, the
trends on the graph will change in that public awareness will rise even
more, physical activity will increase, and negative health effects will
begin to decrease. Development growth can continue to increase, but will
do so with changes in design that encourage healthy activities such as
increased walking.

***Causal Loop Diagram:***

![](media/image5.wmf){width="6.499305555555556in"
height="4.563194444444444in"}

In this particular case, this archetype may be better titled as
Intentional Adversaries. The development industry and regulators (HD)
have an inherent adversarial relationship by their very nature. With
separate and distinct priorities, it is difficult to develop a mutually
beneficial relationship. The two small loops describe each entity's main
goals and actions when utilizing HIAs, which for the HD is an
improvement in the health status of a community and for the development
industry is profitable development. The central connecting arrows
indicate the original perceived effects of implementing an HIA process.
The outside loop illustrates the process that provides the solution to
the adversarial relationship.

***10 Essential Environmental Health Services:***

![](media/image6.png){width="3.75in" height="3.8125in"}

1.  ***Figure 3:*** Adopted: Fall 1994, The Public Health Functions
    Project. Public Health Functions Steering Committee, Office of
    Disease Prevention and Health Promotion, Office of Public Health
    Science, Office of the Secretary United States Department of Health
    and Human Services.

This project seeks to fulfill the following aspects of the 10 Essential
Services of Environmental Health (8):

[Monitor Health]{.underline} -- The health profile indicators such as
the chronic disease profile, motor vehicle death statistics, and the
Behavioral Risk Factor Surveillance Survey (BRFSS) are used to
illustrate certain characteristics and behaviors of the community that
are linked to development and the existing built environment. The
PACE-EH process will be used in existing communities to assess the
health status and Environmental Health issues of that community.

[Inform, Educate, Empower]{.underline} - Once the facts and data are
gathered into a cohesive presentation, the shareholders can be educated
about the benefits of healthy community design. The PACE-EH process is
not only an effective assessment tool; it is a tremendous opportunity to
educate a specific community about those benefits as well.

[Mobilize Community Partnerships]{.underline} -- The HD will have an
improved relationship with many partners, including planners, the
construction industry, homeowners' associations, and the general public.
We have already had preliminary meetings with the construction industry
and planners, both with very positive results. As the HIA tool is
further developed, input and support from both of these groups will be
critical to the ultimate effectiveness of the tool.

[Develop Policies]{.underline} -- While the implementation of the HIA
review process is, by itself, the development of a policy, Polk County
is in the very early stages of rewriting the Land Development Code. In
the years since its initial promulgation, many amendments and changes
have made it difficult to understand and interpret. The rewrite is
expected to take between 9 to 12 months to complete and HD will be
involved in every stage of this rewrite and will be able to incorporate
healthy design components into the LDC.

***National Goals Supported:***

This project seeks to support CDC's Health Protection Goal of "Healthy
People in Healthy Places" and more specifically in regards to Healthy
Communities. By improving the design of communities to encourage greater
physical activity, chronic diseases such as coronary heart disease,
stroke, obesity, diabetes and high blood pressure can be reduced.
Improving the safety of communities by reducing unnecessary or
extraneous motor vehicle trips can help reduce the number of traffic
fatalities. Reducing unneeded motor vehicle trips can also help reduce
emissions and improve air quality which can reduce the number of medical
events associated with asthma and chronic lower respiratory disease.

This project also seeks to support many of the Healthy People 2010
Objectives. Under Focus Area 7 -- Educational and Community-Based
Programs, Community Setting and Select Populations, specifically
Objective 7-10 "Increase the proportion of Tribal and local health
service areas or jurisdictions that have established a community health
promotion program that addresses multiple Healthy People 2010 focus
areas". This project will support this through implementation of the
PACE-EH process. Polk County has been using PACE-EH for over three years
and has been successful in getting built environment issues such as
sidewalks and lighting addressed in at least one of its communities.
PACE-EH will continue to be used to address these issues and needs of
each specific community. Each community is unique as to their particular
EH needs, whether they are traditional issues like aging septic tank
systems or non-traditional issues such as sidewalks. Design issues of
the existing built environment will be emphasized and shown as having
significant impacts on a community's health.

Focus Area 8 -- Environmental Health has six areas that are supported by
this project. Primarily in the Outdoor Air Quality section, this project
will support reducing Harmful Air Pollutants (Objectives 8-1, 8-2, and
8-4) by striving to reduce the number of unneeded motor vehicle trips
taken in a community. The HIA will provide feedback needed to
incorporate community designs or modifications that allow safe walking,
cycling, or public transportation as alternatives to individual motor
vehicle use. There is also the potential to use the HIA tool in
evaluating proposed power generation facilities. There are three to four
such facilities proposed for the Polk County area in the near future.
Input provided through the use of an HIA would be able to address
concerns about power generation emissions. In the Water Quality section,
specifically Objective 8-5 Safe Drinking Water will be addressed during
the HIA review process. Many rules and policies exist, both locally and
statewide, regarding the provision of municipal water supplies to new
developments and projects in the county. Through the HIA review process,
recommendations for provision of water supply based on health benefit
will be offered. In the Healthy Homes and Healthy Communities section,
there are two objectives that will be supported by this project.
Objectives 8-18 and 8-19 will be addressed by this project. In existing
communities by using the PACE-EH process and as a part of the HIA for
new proposed developments. Polk County has a radiological health section
which currently tests 350-400 homes each year. The PACE-EH process will
allow us to get into existing residences and increase the number of
homes tested for radon. The HIA will include a recommendation that new
construction be radon-resistant. Many of the remaining undeveloped areas
in Polk County are reclaimed phosphate mines, which is a major source of
radon gas.

Focus Area 15 -- Injury and Violence Prevention. In the section on
Unintentional Injury Prevention, Objectives 15-15, 15-16, 15-17, and
15-18 will all be supported by this project. As the HIA process helps to
promote a reduction in unneeded motor vehicle trips, traffic will be
reduced with a corresponding reduction in motor vehicle injuries and
deaths. As the HIA promotes safe walkable communities, pedestrian
injuries and deaths will also be reduced.

Focus Area 22 -- Physical Activity and Fitness. There are two closely
related areas in this section; Physical Activity in Adults which
involves Objective 22-1 and 22-2 and Access which involves Objectives
22-14 and 22-15. As the HIA review tool to be developed by this project
encourages community design, facilities for safe walking and bicycling
in communities will be increased. The presence of these facilities will
encourage community members to become more physically active. This focus
area will probably be the most improved by the recommendations of the
proposed HIA process.

This project also supports several activities, objectives and goals of
the National Strategy to Revitalize Environmental Public Health
Services. Activity I-B-3: Promote institutional and strategic changes to
foster ongoing coordinated efforts with strategic partners and other
stakeholders to implement and evaluate environmental interventions to
improve health and well-being for urban and rural residents. The HIA
process will be a major change to how developments are reviewed in Polk
County. By becoming a partner in the development review process with
planners and developers, fundamental changes to community design can be
made which can improve the health of the community. Activity IV-A-3:
Support the development and use of guidance documents to promote
effective environmental public health services, such as PACE-EH. The
Polk County Health Department has been very successful in its PACE-EH
efforts over the past three years. As noted above, the PACE-EH process
will be used to do an HIA in existing communities to assist in healthy
community revitalizations. Activity VI-AI-1: Identify all stakeholders
that influence all components of the environment (built and natural)
that have an impact on environmental public health services. This is one
of the essential and primary tasks of this project to develop and
implement an HIA review process. Activity VI-AI-3: Develop mechanisms
for regular communication and coordination among stakeholders. The
development review process has long been established, but through this
project, the HD will be able to take a place at the table. The
development review process in Polk County is currently undergoing an
extensive revision, as are the development rules and building codes. The
HD is actively providing input into this revision.

***Project Logic Model:***

Health Impact Assessment Protocol for Polk County, Florida

  ------------ ---------------- ------------- ---------------- ------------- -------------- -----------
  **Inputs**   **Activities**   **Outputs**   **Components**   **Impacts**   **Outcomes**   **Health
                                                                                            Effects**

  ------------ ---------------- ------------- ---------------- ------------- -------------- -----------

# PROJECT OBJECTIVES/DESCRIPTIONS/DELIVERABLES:

####### ***Program Goal:***

Develop a Health Impact Assessment (HIA) review process and tool for use
in Polk County regarding Land Use Planning and Development. This tool
will be used to provide input demonstrating alternatives to existing
growth strategies that currently lack consideration of environmental and
health impacts.

####### ***Health Problems:***

1)  Chronic Disease and Behavioral Risk Factor Indicators for Polk
    County exceed statewide rates and Healthy People 2010 rates for
    coronary heart disease, obesity, hypertension, and physical
    activity.

2)  Motor vehicle deaths in Polk County exceed the statewide rates.

3)  Land development and building construction is increasing at almost
    exponential rates and beyond the capacity of existing
    infrastructure, resulting in sprawl.

4)  The county population is growing beyond predicted rates.

####### ***Outcome Objectives:***

1)  Develop and implement a Health Impact Assessment in the Polk County
    Land Development review process.

2)  Implement community design changes with health impacts in mind.

3)  Reduce environmental and health impacts attributed to land use and
    the built environment.

4)  Improve the chronic disease profile for Polk County by increasing
    physical activity of the community population.

####### ***Determinant:***

The effectiveness of this project will be determined by whether the
Health Impact Assessment review process developed becomes a force for
change in the way development is done in Polk County. Once the process
is established, participation by developers in terms of designing
healthy communities over the long run is critical. We will be able to
monitor how many design recommendations actually get implemented; i.e.
sidewalks built. As the results of the review process for proposed
developments are not currently enforceable and can only be
recommendations, there must be sufficient non-regulatory impetus to
implement healthy designs. We will be able to monitor how many new
subdivisions or developments earn the "Healthy Design" designation from
the health department. Another measure of effectiveness is whether
existing communities, through our PACE-EH process, make design
modifications that address environmental and health impacts of the built
environment by revitalization or retrofitting of the community.

####### ***Impact Objectives:***

1)  Improve the design of communities to encourage physical activities
    such as walking and cycling.

2)  Bring the Health Department and health issues to the attention of
    stakeholders in the land development and growth management
    industries.

3)  Incorporate healthy design requirements into Polk County's Land
    Development Code.

4)  Development of a process and tool that can be used as a model for
    the rest of the state.

####### ***Contributing Factors:***

1)  The Health Department and other regulatory agencies are inherently
    viewed as adversaries of the building and land development
    industries.

2)  The Health Department and other regulatory agencies, such as the
    Planning and Growth Management departments have a historically weak
    relationship and poor coordination in land use and development
    decisions.

3)  The land development and building industries are a very large part
    of the local economy and as a result are very powerful politically.

4)  Participation in a Health Impact Assessment review is strictly
    voluntary at this time and the results of that review can only be
    recommendations and are not enforceable.

####### ***Process Objectives***

# METHODOLOGY:

####### ***Events and Activities:***

1)  Become familiar with the variety of HIAs in existence and evaluate
    their potential for use or modification in Polk County (and
    potentially statewide). Research applicable websites or other
    resources on HIAs. (by September 15, 2005 and ongoing)

2)  Access background health statistics on local (Polk County)
    population to assess any health data and or trends with the
    potential to be impacted by land use decisions. This can be done on
    a community or county-wide basis. (start by September 1, 2005 and
    ongoing)

3)  Contact stakeholders in Polk County. These would include, Health
    Department Director (by December 1, 2005) and health care providers,
    Polk County Development Services Director and staff (by December 1,
    2005), Planning Director and staff (by January 15, 2006),
    development industry such as developers and builders through the
    Polk County Builders Association (by January 15, 2005), political
    entities such as the planning commission (by March 15, 2006), board
    of county commissioners (by May 1, 2006), and the general public.

4)  Develop a process or implement an access point of the current
    development review process, to provide data-driven recommendations
    on ways to reduce short and long term health impacts on current land
    use decisions. (by January 1, 2006 and ongoing)

5)  Become a permanent and integral part of the Polk County land
    development process by amending any applicable sections of the Polk
    County Land Development Code (LDC). (by end of project, June 2006)

6)  Expand HIA use into the 17 incorporated communities (cities and
    towns) also in the geographical boundaries of Polk County not under
    the purview of the county LDC.

# NEXT STEPS:

When researching health statistics for Polk County, indicators clearly
showed chronic disease rates and behavioral risk factors that lagged far
behind the state rates and Healthy People 2010 goals. Many of these
indicators such as obesity and hypertension are directly related to the
level of physical activity in a community. Physical activity can be
discouraged when easy access to facilities is not available. Facilities,
such as sidewalks, are most effective at encouraging physical activities
when they are located in direct proximity to residential development.
The inability to walk or cycle, even short distances, will encourage
people to use motor vehicles, and thereby further limit physical
activity and increase the likelihood of being overweight, hypertensive
or obese. Addressing the design and construction of these facilities in
a residential development is best done at the planning stage. Performing
a Health Impact Assessment (HIA) of the proposed development is the best
way to do so.

Research into HIAs revealed a wide variety of methodologies, ranging
from highly detailed analyses to short commentaries of a few sentences.
The intention of this project was to develop a more moderately sized
instrument, but also one with sufficient detail as to make a full review
of any particular project complete, yet convenient. Many HIAs are
completed on a single unique project, such as a proposed power plant,
which should receive greater scrutiny than a subdivision. When such a
large and detailed project such as that is proposed in Polk County, one
of the more detailed and comprehensive assessments tools will be
utilized. HIAs of this nature involve the five steps of screening,
scoping, assessing risks and benefits, reporting and evaluating. This
project is to develop a simple and effective HIA to be used for the
majority of projects being proposed in Polk County, which are
residential subdivisions and planned unit developments. Approximately 8
to 10 new S/Ds or PUDs are proposed and under review by county staff,
each week. The HIA will consist of a scoring system similar to a density
calculation already utilized by the county planning department.

The majority of development and building construction in Polk County is
residential. Since people spend much of their time in residential areas,
developing and implementing HIAs for this type of development would be
the way to have the greatest impact in the shortest period of time.
Design modifications cost can be shared across a large number of
eventual property owners and not unfairly affect any single owner. Being
a part of a residential setting will also allow homeowners to develop a
sense of ownership of the amenities provided.

Upon contacting various stakeholders, it became clear that the health
department and the planning department were very supportive of this
process. Inserting the health department into the development review
process was not a difficult task. The health department already had a
small role in the review process, but could only comment on areas with
specific statutory authority, such as septic tank permitting.
Implementing the HIA and comments from that review process will be an
expansion of the health department's role. The Polk County Land
Development Division is currently modernizing the review process to
require fully electronic submittals of projects. The health department
was added as an agency required to receive and review proposed
developments. The Polk County Land Development Code dictates how
proposals are reviewed and what is required for approval, in terms of
land use zoning and infrastructure requirements. This Land Use Code is
currently undergoing a comprehensive revision. The health department, as
a full partner in the review process, will provide input to include the
HIA process and other specific infrastructure requirements in that
revision. The HIA review process will be a requirement of the
development review process and will be done by the health department,
but many of the design recommendations may not be enforceable.

The Polk County Builders Association was initially hesitant and
questioned the effect of such a process on their ability to proceed
without unnecessary delays. The HIA will be designed to not be a time
consuming process and will easily be able to be completed within the
existing timeframes of the review process. As an incentive to the
development industry, the health department will designate those
projects which score high enough as a "Healthy Design Community." This
designation can be an effective marketing tool to entice homebuyers and
exact a higher price for their properties. Another incentive will be to
provide expedited permitting, when necessary, for those developments
earning such a designation. The health department will have performed a
sufficient enough evaluation of the proposal and the site, so as to be
able to expedite our normal permitting timeframes. These incentives have
convinced some representatives of the builders association, at this
time, to take a position of no objection to the implementation of the
HIA review process.

The revision of the Land Development Code is scheduled to begin in March
or April and should take upwards of 8-12 months to complete. The final
revisions will become effective after obtaining final approval through
the Polk County Planning Commission and the Board of County
Commissioners. The Health Department has started and will continue to
provide recommendations on proposed developments based on HIA
principles. The specific HIA tool for Polk County residential
developments should be completed by the end of March 2006. It will
contain a list of preferred design components that reduce negative
health effects by promoting increased physical activity and
environmentally sound design.

# LEADERSHIP DEVELOPMENT OPPORTUNITIES

####### ***Timothy G. Mayer, R.S., M.P.H.***

I'll admit that I had absolutely no idea what I was getting myself into
or what to expect, when I started this fellowship. I found the sessions
and assignments time consuming and intense, but tremendously beneficial.
I had been successful (or so I thought) at what I was doing. I had been
working off intuition and what I thought was the best way to do things.
Some of the concepts presented during the year were vaguely familiar and
some were totally new. As the year progressed and we worked through the
assignments and our projects, I found there was a lot I didn't know. I
was stretched to open my eyes about myself and others. I am now much
more aware of my own strengths and weaknesses and how to use each of
them as an asset. The Institute helped me to a fuller understanding of
system dynamics, how things fit and can affect other things, and how
these relationships can be used to enhance a wide variety of
circumstances. With the tools I now have, I am better equipped to
perform my responsibilities as a leader, an administrator, and as a
person.

# ABOUT THE EPHLI FELLOW

Tim Mayer currently serves as the Environmental Administrator for the
Polk County Health Department, in Polk County, Florida. He began his
career in 1982 as a field inspector in Monroe County Florida, the
Florida Keys. He transferred to the Polk County Health Department (his
hometown) in 1989. In 1993, he accepted the position as Environmental
Specialist III at the State Health Office, Bureau of Onsite Sewage
Programs, in Tallahassee. He was appointed Environmental Administrator
of the Polk County Health Department in the fall of 2000. He was awarded
a Bachelors of Science in Biological Sciences from Florida State
University in 1980 and a Masters of Public Health in Environmental and
Occupational Health from the University of South Florida in 1997. He
received his certificate as a Registered Sanitarian in 1992.

In his over 23 years of service, he has served on a wide variety of
local and statewide committees and associations, most recently
completing a term as President of the Florida Environmental Health
Association. He administers a staff of over 35 in all Environmental
Health programs in Polk County, a county larger in area than the state
of Rhode Island.

# REFERENCES

1.  The Bureau of Economic and Business Research, University of Florida,
    2005 estimates

2.  The United States Census Bureau, 2000 census

3.  The Ledger, research, January 19, 2006

4.  FloridaCHARTS.com provided by the Florida Department of Health,
    Office of Planning, Evaluation and Data Analysis

5.  Florida Department of Health, Office of Vital Statistics

6.  Florida Department of Health, Bureau of Epidemiology

7.  Transportation Research Board, National Research Council, National
    Academy of Sciences, National Academy of Engineering, and the
    Institute of Medicine, TRB Special Report 282, Number 24, January
    2005.

8.  The Public Health Functions Project, Adopted Fall 1994. Public
    Health Functions Steering Committee, Office of Disease Prevention
    and Health Promotion, Office of Public Health Science, Office of the
    Secretary United States Department of Health and Human Services.

9.  McCann BA, Ewing R, Measuring the Health Effects of Sprawl. A
    national Analysis of Physical activity, Obesity and Chronic Disease,
    *Surface Transportation Policy Project, Smart Growth America*,
    September 2003