Influencing Public Transportation Policy Through Community Engagement and Coalition Building: Process and Preliminary Outcomes

Abstract

The Problem:

Public transportation is a social determinant of health and is crucial to aspects of health like access to healthcare, employment, and nutrition. Existing health inequities are exacerbated by inefficient or inaccessible public transportation systems.

Purpose:

To provide a detailed analysis of the issues and concerns related to public transportation in Winston-Salem, North Carolina, and describe how coalition-building was used to influence positive change in transportation policy.

Key Points:

Members from various organizations aligned with local transit riders to create the Transportation Coalition and advocate for extended night and weekend services for the Winston-Salem public transportation system.

Conclusions:

Partnerships between community-based organizations are crucial to identifying and addressing the needs of a community. The Transportation Coalition will continue its work in local public transportation policy. A long-term policy objective is fare-free transit on the city bus system.

Over the last two decades, Winston-Salem, North Carolina, has experienced economic growth. Despite this economic growth and a well-established health care presence, health inequities persist and are driven by social determinants of health.¹ Social determinants of health are socially constructed systems that act to promote or constrain the health of individuals. Public transportation is a critical social determinant of health.² Introducing, expanding, and improving public transportation systems could increase access to and use of public transit, reduce traffic congestion and associated pollution, decrease traffic-related injuries and fatalities, boost physical activity by walking to and from bus stops, improve access to health care and other resources (e.g., grocery stores), and influence economic growth.²

Lack of transportation is a common reason that individuals in Winston-Salem, North Carolina, delay health care or miss medical appointments, according to the 2014 Forsyth Futures Understanding Access to Healthcare survey.³ Without regular visits to primary care providers, preventable or manageable illnesses can quickly become life threatening. As a result, emergency rooms become a primary source of health care, and patient health is further compromised by long wait times and high health care costs.⁴

According to the Forsyth Futures Poverty Thought Force Report, the poverty rate in Winston-Salem is 23%—exceeding the national average of 14%. Furthermore, African Americans and Hispanics/Latinos are almost three times and four times as likely to be in poverty, respectively.¹ Lower income neighborhoods already have fewer resources available to achieve good health (e.g., physical activity facilities, primary care facilities, hospitals, and grocery stores).⁴,⁵ Access to nutritious foods and health care facilities are hampered by an inefficient or ineffective public transportation system. In Winston-Salem, grocery stores often are not within walking distance of low-income neighborhoods. Difficulty in getting to grocery stores typically means that people purchase shelf-stable processed foods and are likely more calorie-dense and less healthy. Thus, low-income residents often lack access to healthier foods like fresh fruits and vegetables if they cannot access public transportation.⁴ All told, given that public transportation is crucial to employment, accessing healthcare, and overall community health, health inequities are only worsened by an inefficient or inaccessible public transportation system.⁴

The Winston-Salem Transit Authority (WSTA) serves approximately 3.4 million passengers a year, averaging 14,000 passengers per day.⁶ WSTA runs a fixed route bus system and a demand-response system for riders with special needs, known as Transaid. More than 80% of WSTA riders lack a car, and 69% have an annual household income less than $20,000. Most riders travel between work and home, making the trip at least 4 times a week.⁷ Most riders depend on public transportation.⁸

In the U.S. South, public transportation is primarily used by the working poor and individuals from racial and ethnic minority neighborhoods, and is often their primary means of mobility. Transit riders’ employment must be accessible by public transportation.⁸ A study in Chicago found that while 100% of all entry-level jobs were accessible within 90 minutes, only 60% were accessible by public transportation in 90 minutes.⁹ This dependence on public transportation can limit economic mobility.⁸ Thus, public transportation and related public policies directly affect lives of riders and communities already beset by health inequities. Community-engaged methods are needed to address the issues faced by transit riders who live distinct and separate lives from policy makers and other concerned citizenry who have cars.

Academic medical centers are well-positioned to influence patient and public health by working directly with community members to influence public transit. Although academic medical centers have historically faced challenges in addressing social determinants of health within their communities, community engagement may play an important role for translating research into public health.¹⁰ Identifying local concerns through community engagement could result in academic medical centers focusing on community-driven solutions to improve local health. Translating current health research to positively influence public transportation is an opportunity for academic medical centers to engage with the community to address a critical social determinant of health.

PURPOSE OF ARTICLE

This article describes how coalition-building was harnessed to promote positive transportation policy change within Winston-Salem, North Carolina, by expanding night and weekend service on 11 bus routes in the city. Policy change can influence public health by improving structures and systems that enable health. Community coalitions are an effective strategy to promote policy change.¹¹ We used a community-engaged approach with longstanding partnerships to systematically organize for public transit-related policy change. It describes how a few backbone community organizations in partnership with an academic medical center were able to have a collective impact on expanding public transportation in the city.

Within the Wake Forest School of Medicine’s Clinical and Translational Science Institute, the Program in Community Engagement works to improve community and population health by promoting and facilitating community-relevant and engaged research. Essential to the Program in Community Engagement is the Stakeholder Advisory Committee, composed of about 40 community and academic representatives. This committee meets quarterly to provide guidance to the Clinical and Translational Science Institute and the Program in Community Engagement on setting research and practice priorities, fostering authentic community partnerships, and designing effective research strategies. In 2015, the Stakeholder Advisory Committee established a policy subcommittee to connect community policy-related priorities with medical center health expertise. The subcommittee helped identify and advocate for local policies that could promote health. The first issue the subcommittee addressed was with expanding the Saturday hours of the hazardous household waste facility so that more residents could access the environmental health benefits of proper disposal. In 2016, the subcommittee identified public transportation as a critical area ripe for policy change, given the impact of public transportation on access to care, economic development, and quality of life for the community and formed the Transportation Coalition in October 2016. The coalition was formed while a changing landscape of issues was affecting mobility of the community. Urbanization and growth in downtown Winston-Salem caused traffic congestion, which prompted a major planned remodel of a primary thoroughfare.¹² At the same time, in an effort to modernize bus routes, WSTA launched redesigned transit routes as of January 2, 2017. However, these new routes were criticized by riders because they reduced service. These changes afforded an opportunity for the Transportation Coalition to advocate for expanded service.

The Coalition grew to include representatives from 20 organizations and transit riders who were concerned about public transportation within Winston-Salem, North Carolina. The lead author was identified as a champion of this issue because of his connections with transportation leadership and his own use of the bus system to commute to work.

Coalition building allowed successful expansion of public transportation services as a result of the input and collective action of the Coalition’s membership. The key points below detail how the Transportation Coalition influenced the successful translation of social determinant of health research to local policy change via community engagement. By working with the transit authority and city planners to draft revisions to the system redesign, the Coalition was influential in the City Council’s approval of an $800,000 budget increase to expand night and weekend service on 11 routes. Other wins included getting WSTA bus routes into Google Maps and restoring service to excluded neighborhoods.

KEY POINTS

Table 1 provides key points from the process of influencing public transportation policy through community engagement.

Table 1.

Key Points from the Process of Influencing Public Transportation Policy Through Community Engagement

Key Point	Explanation
Authentic Engagement	Longstanding intentional relationships with stakeholders
Building Broad Constituency	Garnering policy influence through the expanded constituency of partner organizations and their network of relationships
Foster Dialogue Around Public Health Impact	Allowing key issues and practical strategies to emerge from the Coalition while addressing public health implications of local policy decisions
Building Empathy	Hearing from those most affected by the issue and becoming familiar with their lived experiences to increase the Coalition’s commitment to policy change
Overcoming Timidity	Ensuring coalition members overcome their fear and reservations about speaking out on an issue that is outside of their normal mission
Tyranny of the Urgent	The challenge of attending to temporary issues and tangential concerns that potentially distract from the overall goal
Perseverance	Having the commitment and patience to see an issue through even though it does not affect all stakeholders to the same degree

Authentic Engagement

The Transportation Coalition had collaborative partnership from its inception. The Coalition sought to shape discourse around transportation, and so it prioritized the need to engage with policy makers early in the process.¹³ Longstanding and intentional relationships with stakeholders allowed authentic engagement; community members felt comfortable to join the Coalition and share their transit concerns with other members. Conversations about community concerns led to identification of priorities related to public transportation. These concerns included: barriers to accessing community-based programs due to lack of transportation, the bus route redesign, and the anticipated closure of the interstate highway for renovation—a project with citywide long-term impact on mobility.¹² Through authentic engagement, once the Winston-Salem City Council prepared to vote on expanding the transportation budget, they were already aware of the Coalition and its views.

Building Broad Constituency

Invitations to participate in the Coalition were sent on an ongoing basis, based on salience of public transportation to those organizations. Table 2 lists the 20 organizations that joined the coalition in its first year. Building this broad coalition garnered policy influence through the expanded constituency of partner organizations and their network of relationships. On average, 18 people participated in the 8 meetings of the Coalition during its first year.

Table 2.

Initial Transportation Coalition Member Organizations

Organization	Description
Adaptables	Works to alleviate barriers that keep people with disabilities from full participation in the community and provides advocacy, independent living skills training, peer support, information, and referral services that together help people with disabilities exercise control over their own lives.
Center for Design Innovation	Establishes and sustains substantive inter-institutional, interdisciplinary, and inter-sectoral programs that bring (UNC School of the Arts and Winston-Salem State University) faculty and students of all ages and disciplines into diverse experiences to develop meaningful solutions to relevant contemporary challenges.
City of Winston-Salem Transportation Department	Moves people and goods safely and efficiently on the surface transportation system in Winston-Salem and Forsyth County.
Creative Corridors Coalition	Influences community and architectural design over the major redesign of Interstate Business 40 that bisects downtown Winston-Salem.
Second Harvest Food Bank	Works to provide essential food assistance through a network of partners, while educating and engaging our communities in the elimination of hunger and its causes.
Forsyth Futures	Studies the challenges facing the community through data-based analyses conducted by our team of experts.
Health Department	Prevents disease and promotes a healthy community through regulation, education and partnerships.
MudPies Childcare	Serves over 700 children across Forsyth, Stokes and Davie counties at accredited child development centers with a special outreach to parents who work second shift.
Neighbors for Better Neighborhoods	Believes that long term change in communities only happens when residents participate in creating solutions and seeks to support neighborhood groups and encourage resident-led problem solving; involving residents in research and policy change.
Piedmont Authority for Regional Transportation	Enhances all forms of transportation in the Piedmont Triad Region.
Piedmont Together	Builds a resilient, prosperous economy and a better quality of life for all of North Carolina’s Piedmont Triad residents through advocacy around the importance of public transportation.
Transit Riders	Community members who ride public transportation and directly benefit from its service.
Transit Alliance of the Piedmont	Convenes together organizations, leaders and citizens to advocate for public transit in the Piedmont Triad region of North Carolina.
Wake Forest Baptist Medical Center	Improves health in the local community, state and nation and is the only academic medical center in western North Carolina.
Wake Forest School of Medicine, Clinical And Translational Science Institute, Program in Community Engagement	Works to improve community and population health through promoting and facilitating community-relevant and engaged research.
Wake Forest University- Pro Humanitate Institute	Serves as a core of learning, teaching, service, and action that transforms the ethos of WFU into an explicit mission connected to clear practices with meaningful social justice outcomes.
Winston-Salem City Council	Adopts and provides support for all ordinances, rules and regulations as necessary for the general welfare of the city
Winston-Salem Foundation	A community foundation comprised of more than 1,300 funds created by charitable individuals and organizations that provides grants to meet community needs.
Winston-Salem Planning Department	Serves Winston-Salem and unincorporated Forsyth County as well as the smaller municipalities of Bethania, Tobaccoville, and Rural Hall to plan city ordinances and land use zoning.
Winston-Salem Transit Authority	Operates the bus transportation system.
Winston-Salem Urban League	Empowers and advocates for African Americans and other disenfranchised communities, and promotes socioeconomic progress and parity through education, training and civic engagement.

The Coalition sought to raise awareness of the importance of transit well before the city was slated to make budgetary decisions. The active participation of multiple stakeholders allowed for diverse perspectives and creative input, and facilitated development of strong relationships with partner organizations and City Council members. These relationships were built through one-on-one meetings and demonstrated commitment to shared values. As a result, the coalition was uniquely situated to influence policy because its membership understood the local policy context that facilitated change, and it sought to engage community members in policy and practice.¹⁴ The Coalition advocated with the WSTA as allies, not antagonists.

Fostering Dialogue Around Public Health Impact

Coalition meetings featured rich debate as to which transportation-related issue should be prioritized. Fare-free transit was the first approach considered to expand transit ridership. The Transportation Coalition developed a policy brief (Appendix 1) highlighting the role of public transportation as an important health policy issue.¹⁵ The policy brief was circulated via email to community leaders and received attention from City Council and Medical Center executives. The WSTA budget included $1.7 million dollars in fare revenue, finding further public subsidy to cover this cost was a concern. The brief was used to engage decision-makers within the community as they sought to consider how the highway closure would impact business and hospital operations.

Initial meetings centered on the importance of public transportation; subsequent meeting focused on prioritization and strategy development. Meetings were characterized by active listening, recapitulating main ideas and agreement on action ideas. Giving preference to the voice of transit riders was paramount. Every meeting had at least three transit riders present. Riders were recruited through member organizations. The lead author has ridden transit since 2010. Involving healthcare providers and organizations like the Adaptables lent voice to access to care concerns and the need for health equity in all policies. The Coalition’s commitment to expanding transit service was unwavering; how to accomplish that goal was flexible.

The Coalition identified the following short- and long-term policy objectives: service every 30 minutes during peak hours on popular routes, more expansive weekend and night service, fewer holiday closures, better system mapping, better marketing and rider communications, and elimination of bus fares for all riders.

In 2017, there were 685,848 fewer rides than the previous year. The route redesign was meant to modernize the system by making it more linear and effective. One blind spot in the plan was that it offered fewer buses on nights and weekends. In light of the 2017 route redesign, the Transportation Coalition decided that its most urgent policy priority was service expansion. Because the Coalition involved those who implemented the bus system, the policy recommendations were grounded in reality. Our partnership approach brought the expertise of various stakeholders to bear on an issue that affected riders. During coalition meetings bus riders were adamant that expanding night and weekend service be the priority.

Building Empathy

Coalition members, who were not regular transit riders, were encouraged to use the WSTA system to travel to Coalition meetings to better understand the experiences of riders. Coalition members thus developed a heightened awareness of issues riders face daily and brought attention to potential areas for improvements. Additionally, several bus riders were members of the Coalition and attended meetings, adding their voice based on their lived experiences to the policy-making process.

The Urban League’s strong interest in the issue of public transportation and their work with the communities most affected by transit policy made them a natural leader of the Transportation Coalition. The Urban League, with the help of its constituency, wrote and circulated its own recommendations for expanded transit service. The need for expanded service was fully realized during a holiday transit closure, when Urban League employees were unable to pick up their paychecks unless they walked to the office.

Overcoming Timidity

Coalition members attended two City Council hearings to testify and present information regarding the role of public transportation as an important social determinant of health. Many members were fearful to depart from our initial focus of fare-free transit, but the outcry from riders and the belief that their experiences should dictate the direction of the coalition won out. For example, staff from the Neighbors for Better Neighborhoods, a nonprofit community organization, used a one-page summary to highlight how the lack of weekend service erodes the mobility of those who depend on the bus. These type of summaries, policy briefs, and public statements were created in partnership with academics using data and evidence to substantiate that public transportation was not only a priority of the local community but is a critical social determinant of health. Through literature review, Coalition members learned that 22% of riders said they simply would not make the trip if public transportation was not available.⁴ These lost trips included trips to grocery stores, parks, primary care doctors, and hospitals. Coalition members held informal meetings and one-on-one meetings with various stakeholders (e.g., WSTA leadership and city planning staff), wrote to their respective City Council members, and testified at City Council hearings for expansion of bus services.

Perseverance

During an early Coalition meeting, a politician expressed her resentment of how academic medical centers seem willing to ask for infrastructure but unwilling to finance it. The perception of the role and resources of the local academic medical center was a constant source of tension. The issue of who would fund expanded public transportation caused the group consternation and slowed the process. Moreover, some Coalition members felt hampered by their affiliation with nonprofit community organizations that are hesitant to be involved in politics, even as advocates. Despite these fears, the group was able to sustain its advocacy efforts because of the authentic belief that expansion was the “right thing to do.” The authentic community engagement kept members of the coalition involved and active. Having multiple stakeholders involved was critical for effectively changing policy. Through perseverance and motivation to continue applying political pressure, policy change eventually occurred.

Tyranny of the Urgent

Attending to temporary issues and tangential concerns can potentially distract from overall goals. The Coalition’s initial goal was to expand transit service, but there were multiple opportunities to lose sight of that target over time. Because Coalition meetings were open, tangential issues did arise and had to be negotiated with care. Attendance at meetings fluctuated and members’ agendas were not always met. A group member suggested coordinating with churches to use their vans to make up for lost bus service. While a reasonable idea, this strategy did not align with the priorities of Coalition members. Furthermore, some coalition members were frustrated that our initial goal of fare-free transit was not pursued due to the urgent need of addressing lost service due to the route redesign. Returning to the goal of expanding public transit as an important social determinant of health helped the group realize that working together to meet short-term goals like expanded service was worth the effort. The Coalition redirected its concerns and realized the most pressing concern was restoring service on nights and weekends. When the City Council voted to expand the budget to accommodate more bus service in June 2017, Coalition members were present to present their views. As a result, 11 bus routes received expanded service on nights and weekends, an $800,000 annual increase in funding for public transportation. Furthermore, City Council members thanked Coalition members for their involvement in the policy process.

CONCLUSIONS

Transportation is recognized as a critical social determinant of health. Due to the impact of transportation on public health, the Transportation Coalition sought to promote positive policy change to expand public transportation services in Winston-Salem. Community engagement allowed the need to improve public transportation emerge as an issue that required collective impact. The Transportation Coalition, composed of transit riders and members of various community organizations, was created with the goal of improving conditions for public transportation riders in Winston-Salem. After 7 months of promoting local transportation policy change, the Coalition successfully expanded weekend and night transportation services. This expansion increased access to and use of public transit, and may have reduced traffic congestion and associated pollution, traffic-related injuries and fatalities on one hand; and on the other, improved physical activity, access to health care and resources, and economic growth. The Coalition’s work influenced the Urban League to release their own policy recommendations for public transportation. Thus, the collective action of the Coalition plus a community organization amplified the voice of riders who had felt unheard.

Looking forward, the Coalition hopes to expand transit ridership by establishing a fare-free transit route that links major health-serving organizations, including the two large medical centers and community organizations that address other social determinants of health. The Coalition will work to make this “health-connecter” free of charge for all passengers. Coalition building with a local academic medical center is a powerful way to convene stakeholders and influence local policy. Ensuring that the voice of those who endure health inequities in the advocacy process is paramount to effectively intervening to improve health.

APPENDIX 1. POLICY BRIEF

Transportation Coalition

POLICY BRIEF

Fare-Free Transit

Purpose

This policy brief advocates for the implementation of fare-free public transportation in Winston-Salem in anticipation of the temporary closing of Business 40. Fare-free transit would yield benefits in the health, economy, and livability of Winston-Salem, and satisfy the community’s current and future demands for mobility and connectivity.

Background

The Winston-Salem Transit Authority (WSTA) serves approximately 3.4 million passengers a year, averaging 14,000 per day.¹ The WSTA Origin-Destination Survey determined that 81% of riders do not have a car and 69% have an annual household income less than $20,000. The majority of riders travel between work and home, making the trip at least 4 times a week.²

Fare-free transit is public transit that is at no cost to the rider. Implementation can be temporary, route-specific, or comprehensive, provided by a major employer or the whole transit system. Public transit provides enhanced access to all of the community’s resources and amenities. It enables people to attend doctor’s appointments, get to work, and patron local restaurants and shops. Furthermore, public transit decreases street congestion, reduces transportation-related air pollution, and encourages active transportation, which is any kind of human-powered transportation like biking or walking. Investing in public transportation brings benefits, not only to passengers, but to the entire community. In fact, communities see a $4 return for every dollar that they invest in public transit.¹ By further investing in fare-free public transit, the community can expect to see even greater returns.

Research and Local Findings

• A lack of transportation is one of the most common reasons that residents delay health care or miss appointments according to the 2014 Forsyth Futures access to health care survey.³

• A lack of public transportation exacerbates household transportation costs, road congestion, air pollution, and hinders job growth due to difficult commutes. Additionally, improved public transportation improves air quality, road congestion, public health due to increased walking and bicycling, and access to natural and recreational resources according to the Piedmont Together’s 2012-2013 survey given to community stakeholders and residents.⁴

• People walk an average of 24.3 minutes to and from the bus stop. People who use mixed modes of transportation (i.e. biking to bus stop, Park-and-Ride service) walk an average of 8.3 minutes according to the U.S. National Household Travel Survey. An intense walking speed for 8.3 minutes can burn 39.0 kcal of energy a day, preventing weight gain in 60% of the population, and saving $6,600 in obesity-related health costs.⁵

Fare-Free Transit Examples

Implementation and Outcomes of Fare-Free Transit Systems

• Currently, there are at least 39 fare-free transit systems in the United States.

• The Transportation Research Board with the National Academies found that fare-free transit can increase ridership by 20-60%. Eliminating fare collection speeds up boarding times and increases transit efficiency. Although the public subsidy and total cost might increase, there is a significant drop in the subsidy per passenger. Cities with fare-free transit have been recognized as the most appealing and livable cities in the country.⁶

Implementation due to Road Construction

• The Duluth Transit Authority in Duluth, MN provided free round-trip express services during peak hours in response to traffic congestion concerns in 2010 when the major highway 1-35 underwent a 2-year construction project. During the highway closure, Duluth Transit Authority served over 3 million riders, seeing and maintaining many new riders.⁷

Route-Specific

• Orbit is a public transit service in Tempe, AZ that has multiple fare-free routes connecting the residential areas to local destinations surrounding Arizona State University.

• The Bull City Connector is a fare-free hybrid electric bus service that runs between Duke University campus, Duke medical facilities, and the downtown Durham area.

Major Employers

• St. Luke’s Health System in Boise, ID has an Employee Transportation Alternatives Program which allows employees to ride the ValleyRide transit system for free using their ID badge.

• University of Wisconsin-Madison Transportation Services gives employees bus passes for unlimited rides on the Madison Metro Transit.

Comprehensive Fare-Free Systems

• Chapel Hill Transit and AppalCart are both completely fare-free transit systems in North Carolina, serving multiple towns as well as major universities, UNC-Chapel Hill, and Appalachian State University, respectively. Chapel Hill Transit, in particular, is noted for contributing to Chapel Hill being named the 2009 “Most Livable City” in America.⁶

The planned 2018 closing of Business 40 for improvements provides the opportunity to consider changes to the public transit system. Fare-free transit would promote greater mobility around the city and generate greater returns in the form of improved health, economy, and livability. Policy change that improves public transit would further distinguish Winston-Salem as the city of arts and innovation.