Parent Satisfaction With a Telehealth Parent Coaching Intervention to Support Family Participation.

COVID-19 catalyzed telehealth practice creating opportunities for clients and providers to discern best applications. Parent satisfaction with services supports partnership within therapy processes, potentially augmenting outcomes. We examined parent satisfaction levels and experiences with the telehealth approach of a parent coaching intervention for families of children with special health care needs (CSHCNs). We used a mixed-methods descriptive design. Fifteen parents completed the Telehealth Usability Questionnaire (TUQ) and a semistructured interview. We analyzed TUQ ratings using descriptive statistics, and we thematically analyzed participants' telehealth experiences. Parents found telehealth useful, easy to use, effective, reliable, and satisfactory. Parents described that telehealth addressed needs conveniently, enhanced parent-provider communication, and fostered shared parent involvement. Telehealth appears to be a satisfactory occupational therapy service delivery approach for parents of CSHCN. Findings build preliminary evidence for understanding for whom telehealth is well suited, supporting determination of relevant, fundable telehealth services.

Effects of Telehealth Parent Coaching in Supporting Family Participation, Cohesion, and Adaptability.

Families provide foundational contexts in which most children develop and grow. For families of children with special health care needs (CSHCN), interdisciplinary supports can build family participation capacities, beyond individualistic child supports. This single-group pretest-posttest quasi-experimental study sought to determine the preliminary effects of the Healthy Families Flourish Program (HFFP), a telehealth occupation-based parent coaching intervention to promote participation, cohesion, adaptability, and communication for families of CSHCN. Eleven families, including 17 parents and 27 children, completed the 10-session intervention consisting of parent education and individualized coaching. Participants completed the Canadian Occupational Performance Measure, Goal Attainment Scaling, and the Family Adaptability and Cohesion Evaluation Scales pre-/post-intervention. Within-group comparisons showed improvements in family participation, cohesion, adaptability, and communication with Cohen's d effect sizes ranging from 0.55-3.32. Researchers found positive relationships between family participation and cohesion as well as participation and adaptability. Findings provide considerations for supporting families within socioecological contexts.

Metagenomics to characterize sediment microbial biodiversity associated with fishing exposure within the Stellwagen Bank National Marine Sanctuary.

Microbes in marine sediments constitute a large percentage of the global marine ecosystem and function to maintain a healthy food web. In continental shelf habitats such as the Gulf of Maine (GoM), relatively little is known of the microbial community abundance, biodiversity, and natural product potential. This report is the first to provide a time-series assessment (2017-2020) of the sediment microbial structure in areas open and closed to fishing within the Stellwagen Bank National Marine Sanctuary (SBNMS). A whole metagenome sequencing (WMS) approach was used to characterize the sediment microbial community. Taxonomic abundance was calculated across seven geographic sites with 14 individual sediment samples collected during the summer and fall seasons. Bioinformatics analyses identified more than 5900 different species across multiple years. Non-metric multidimensional scaling methods and generalized linear models demonstrated that species richness was inversely associated with fishing exposure levels and varied by year. Additionally, the discovery of 12 unique biosynthetic gene clusters (BGCs) collected across sites confirmed the potential for medically relevant natural product discovery in the SBNMS. This study provides a practical assessment of how fishing exposure and temporal trends may affect microbial community structure in a coastal marine sanctuary.

Assuring Healthy Populations During the COVID-19 Pandemic: Recognizing Women's Contributions in Addressing Syndemic Interactions.

A syndemic framework examines disease interactions and the contributions of structural, social, economic, and environmental factors that synergistically interact to contribute to adverse health outcomes. Populations residing in environments with structural susceptibilities experience health disparities and syndemics to a greater extent than their less vulnerable counterparts. The interactions among the social determinants of health (SDoH) and the COVID-19 pandemic have had different results for marginalized populations and have worsened health outcomes for many in this synergistic pandemic. Also, the exposome, the exposure measures for an individual over their lifetime and how those exposures relate to the individual's health, may help to explain why some populations experience more serious cases of COVID-19 compared to other groups. The purpose of this perspective is to: (1) examine the relationship between the syndemic model and the SDoH-exposome; (2) highlight, via specific examples, the contributions of female health professionals to SDoH and the COVID-19 syndemic in response to the Women in Science Research Topic, and (3) propose health policy to address syndemic-exposome interactions to help mitigate or prevent public health challenges. By investing in policies that assure health for all populations, the investments could pay dividends in the form of a less severe syndemic next time since we are starting from a place of health and not disease. Lastly, due to the magnification of underlying societal inequities laid bare during the COVID-19 syndemic, we support the expansion of the disease-focused syndemic model to include societal syndemics, such as systemic racism.

Social-ecological theory, substance misuse, adverse childhood experiences, and adolescent suicidal ideation: Applications for community-academic partnerships.

Suicide is the second leading cause of death among youth in the United States. Data from the 2015 Youth Risk Behavior Survey of 9th-12th grade students in New Hampshire (N = 14,837) were utilized. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated using logistic regression models to evaluate associations between suicidal ideation, adverse childhood experiences (ACEs), and other risk factors including using opioids/drugs without a prescription and food insecurity. We also examined whether potentially protective behaviors may attenuate the relationship between ACEs and suicidal ideation. The prevalence of suicidal ideation was 15.4% (girls 20.15; boys 10.67). In unadjusted models, the crude odds ratio reflecting the relationship between suicidal ideation and higher ACE scores was 1.85 (95% CI 1.76-1.94). In adjusted models, suicidal ideation remained positively associated with higher ACE scores (aOR 1.61, 95% CI 1.52-1.70). Risk and protective behavioral factors identified in relation to suicidal ideation and ACEs are discussed within the context of community-academic partnerships and policy.

Improvements in Speech of Children with Apraxia: The Efficacy of Treatment for Establishing Motor Program Organization (TEMPOSM).

Purpose: This study investigated the efficacy of Treatment for Establishing Motor Program Organization (TEMPOSM) in childhood apraxia of speech (CAS).Method: A mixed between- and within-participant design with multiple baselines across participants and behaviors was used to examine acquisition, generalization, and maintenance of skills. TEMPOSM was administered in four one-hour sessions a week over a four-week period for eleven participants (ages 5 to 8), allocated to either an immediate treatment group or a wait-list control group. Acoustic and perceptual variables were measured at baseline, immediate post-treatment, and one-month post-treatment.Results: Children demonstrated significant improvements in specific acoustic measures of segmentation and lexical stress, as well as perceptual measures of fluency, lexical stress, and speech-sound accuracy. Treatment and generalization effects were maintained one-month post-treatment with generalization to untreated stimuli.Conclusion: TEMPOSM was efficacious in improving segmental and suprasegmental impairments in the speech of children with CAS.

Neural Mechanisms of Acceptance and Commitment Therapy for Chronic Pain: A Network-Based fMRI Approach.

Over 100 million Americans suffer from chronic pain (CP), which causes more disability than any other medical condition in the United States at a cost of $560-$635 billion per year (Institute of Medicine, 2011). Opioid analgesics are frequently used to treat CP. However, long term use of opioids can cause brain changes such as opioid-induced hyperalgesia that, over time, increase pain sensation. Also, opioids fail to treat complex psychological factors that worsen pain-related disability, including beliefs about and emotional responses to pain. Cognitive behavioral therapy (CBT) can be efficacious for CP. However, CBT generally does not focus on important factors needed for long-term functional improvement, including attainment of personal goals and the psychological flexibility to choose responses to pain. Acceptance and Commitment Therapy (ACT) has been recognized as an effective, non-pharmacologic treatment for a variety of CP conditions (Gutierrez et al., 2004). However, little is known about the neurologic mechanisms underlying ACT. We conducted an ACT intervention in women (n = 9) with chronic musculoskeletal pain. Functional magnetic resonance imaging (fMRI) data were collected pre- and post-ACT, and changes in functional connectivity (FC) were measured using Network-Based Statistics (NBS). Behavioral outcomes were measured using validated assessments such as the Acceptance and Action Questionnaire (AAQ-II), the Chronic Pain Acceptance Questionnaire (CPAQ), the Center for Epidemiologic Studies Depression Scale (CES-D), and the NIH Toolbox Neuro-QoLTM (Quality of Life in Neurological Disorders) scales. Results suggest that, following the 4-week ACT intervention, participants exhibited reductions in brain activation within and between key networks including self-reflection (default mode, DMN), emotion (salience, SN), and cognitive control (frontal parietal, FPN). These changes in connectivity strength were correlated with changes in behavioral outcomes including decreased depression and pain interference, and increased participation in social roles. This study is one of the first to demonstrate that improved function across the DMN, SN, and FPN may drive the positive outcomes associated with ACT. This study contributes to the emerging evidence supporting the use of neurophysiological indices to characterize treatment effects of alternative and complementary mind-body therapies.

Network Analysis of Induced Neural Plasticity Post-Acceptance and Commitment Therapy for Chronic Pain.

Chronic musculoskeletal pain is a costly and prevalent condition that affects the lives of over 50 million individuals in the United States. Chronic pain leads to functional brain changes in those suffering from the condition. Not only does the primary pain network transform as the condition changes from acute to persistent pain, a state of hyper-connectivity also exists between the default mode, frontoparietal, and salience networks. Graph theory analysis has recently been used to investigate treatment-driven brain network changes. For example, current research suggests that Acceptance and Commitment Therapy (ACT) may reduce the chronic pain associated hyper-connectivity between the default mode, frontoparietal, and salience networks, as well as within the salience network. This study extended previous work by examining the associations between the three networks above and a meta-analytically derived pain network. Results indicate decreased connectivity within the pain network (including left putamen, right insula, left insula, and right thalamus) in addition to triple network connectivity changes after the four-week Acceptance and Commitment Therapy intervention.

Whole metagenomic sequencing to characterize the sediment microbial community within the Stellwagen Bank National Marine Sanctuary and preliminary biosynthetic gene cluster screening of Streptomyces scabrisporus.

Understanding the marine sediment microbial community structure is of increasing importance to microbiologists since little is known of the diverse taxonomy that exists within this environment. Quantifying microbial species distribution patterns within marine sanctuaries is necessary to address conservation requirements. The objectives of this study were to characterize the relative abundance and biodiversity of metagenome samples of the sediment microbial community in the Stellwagen Bank National Marine Sanctuary (SBNMS). Related to the need for a comprehensive assessment of the microbial habitat within marine sanctuaries is the increased threat of antibiotic-resistant pathogens, coupled with multi-resistant bacterial strains. This has necessitated a renewed search for bioactive compounds in marine benthic habitat. An additional aim was to initiate quantification of biosynthetic gene clusters in species that have potential for natural product and drug discovery relevant to human health. Surficial sediment from 18 samples was collected in the summer and fall of 2017 from three benthic sites in the SBNMS. Microbial DNA was extracted from samples, and sequencing libraries were prepared for taxonomic analysis. Whole metagenome sequencing (WMGS) in combination with a bioinformatics pipeline was employed to delineate the taxa of bacteria present in each sample. Among all sampling sites, biodiversity was higher for summer compared to fall for class (p = 0.0013; F = 4.5) and genus (p = 0.0219; F = 4.4). Actinobacteria was the fifth most abundant class in both seasons (7.81%). Streptomyces was observed to be the fourth most abundant genus in both seasons with significantly higher prevalence in summer compared to fall samples. In summer, site 3 had the highest percentage of Streptomyces (1.71%) compared to sites 2 (1.62%) and 1 (1.37%). The results enabled preliminary quantification of the sequenced hits from the SBNMS sites with the highest potential for harboring secondary metabolite biosynthetic gene clusters for Streptomyces scabrisporus strain (NF3) genomic regions. This study is one of the first to use a whole metagenomics approach to characterize sediment microbial biodiversity in partnership with the SBNMS and demonstrates the potential for future ecological and biomedical research.

Developing Core Capabilities for Local Health Departments to Engage in Land Use and Transportation Decision Making for Active Transportation.

OBJECTIVE: To develop a core set of capabilities and tasks for local health departments (LHDs) to engage in land use and transportation policy processes that promote active transportation. DESIGN: We conducted a 3-phase modified Delphi study from 2015 to 2017. SETTING: We recruited a multidisciplinary national expert panel for key informant interviews by telephone and completion of a 2-step online validation process. PARTICIPANTS: The panel consisted of 58 individuals with expertise in local transportation and policy processes, as well as experience in cross-sector collaboration with public health. Participants represented the disciplines of land use planning, transportation/public works, public health, municipal administration, and active transportation advocacy at the state and local levels. MAIN OUTCOME MEASURES: Key informant interviews elicited initial capabilities and tasks. An online survey solicited rankings of impact and feasibility for capabilities and ratings of importance for associated tasks. Feasibility rankings were used to categorize capabilities according to required resources. Results were presented via second online survey for final input. RESULTS: Ten capabilities were categorized according to required resources. Fewest resources were as follows: (1) collaborate with public officials; (2) serve on land use or transportation board; and (3) review plans, policies, and projects. Moderate resources were as follows: (4) outreach to the community; (5) educate policy makers; (6) participate in plan and policy development; and (7) participate in project development and design review. Most resources were as follows: (8) participate in data and assessment activities; (9) fund dedicated staffing; and (10) provide funding support. CONCLUSIONS: These actionable capabilities can guide planning efforts for LHDs of all resource levels.

Network Alterations in Comorbid Chronic Pain and Opioid Addiction: An Exploratory Approach.

The comorbidity of chronic pain and opioid addiction is a serious problem that has been growing with the practice of prescribing opioids for chronic pain. Neuroimaging research has shown that chronic pain and opioid dependence both affect brain structure and function, but this is the first study to evaluate the neurophysiological alterations in patients with comorbid chronic pain and addiction. Eighteen participants with chronic low back pain and opioid addiction were compared with eighteen age- and sex-matched healthy individuals in a pain-induction fMRI task. Unified structural equation modeling (SEM) with Lagrange multiplier (LM) testing yielded a network model of pain processing for patient and control groups based on 19 a priori defined regions. Tests of differences between groups on specific regression parameters were determined on a path-by-path basis using z-tests corrected for the number of comparisons. Patients with the chronic pain and addiction comorbidity had increased connection strengths; many of these connections were interhemispheric and spanned regions involved in sensory, affective, and cognitive processes. The affected regions included those that are commonly altered in chronic pain or addiction alone, indicating that this comorbidity manifests with neurological symptoms of both disorders. Understanding the neural mechanisms involved in the comorbidity is crucial to finding a comprehensive treatment, rather than treating the symptoms individually.

Qualitative Exploration of Cross-Sector Perspectives on the Contributions of Local Health Departments in Land-Use and Transportation Policy.

INTRODUCTION: Transportation and land-use policies can affect the physical activity of populations. Local health departments (LHDs) are encouraged to participate in built-environment policy processes, which are outside their traditional expertise. Cross-sector collaborations are needed, yet stakeholders' perceptions of LHD involvement are not well understood. The objective of this study was to describe the perceived value of LHD participation in transportation and land-use decision making and potential contributions to these processes among stakeholders. METHODS: We analyzed qualitative data from 49 semistructured interviews in 2015. Participants were professionals in 13 US states and 4 disciplines: land-use planning (n = 13), transportation/public works (n = 11), public health (n = 19), and other (municipal administration and bike and pedestrian advocacy [n = 6]). Two analysts conducted directed content analysis. RESULTS: All respondents reported that LHDs offer valuable contributions to transportation and land-use policy processes. They identified 7 contributions (interrater agreement 91%): 1) physical activity and health perspective (n = 44), 2) data analysis and assessment (n = 41), 3) partnerships in the community and across sectors (n = 35), 4) public education (n = 27), 5) knowledge of the public health evidence base and best practices (n = 23), 6) resource support (eg, grant writing, technical assistance) (n = 20), and 7) health equity (n = 8). CONCLUSION: LHDs can leverage their strengths to foster cross-sector collaborations that promote physical activity opportunities in communities. Our results will inform development of sustainable capacity-building models for LHD involvement in built-environment decision making.

A case study characterizing animal fecal sources in surface water using a mitochondrial DNA marker.

Water quality impairment by fecal waste in coastal watersheds is a public health issue. The present study provided evidence for the use of a mitochondrial (mtDNA) marker to detect animal fecal sources in surface water. The accurate identification of fecal pollution is based on the notion that fecal microorganisms preferentially inhabit a host animal's gut environment. In contrast, mtDNA host-specific markers are inherent to eukaryotic host cells, which offers the advantage by detecting DNA from the host rather than its fecal bacteria. The present study focused on sampling water presumably from non-point sources (NPS), which can increase bacterial and nitrogen concentrations to receiving water bodies. Stream sampling sites located within the Piscataqua River Watershed (PRW), New Hampshire, USA, were sampled from a range of sites that experienced nitrogen inputs such as sewer and septic systems and suburban runoff. Three mitochondrial (mtDNA) gene marker assays (human, bovine, and canine) were tested from surface water. Nineteen sites were sampled during an 18-month period. Analyses of the combined single and multiplex assay results showed that the proportion of occurrence was highest for bovine (15.6%; n = 77) compared to canine (5.6%; n = 70) and human (5.7%; n = 107) mtDNA gene markers. For the human mtDNA marker, there was a statistically significant relationship between presence vs. absence and land use (Fisher's test p = 0.0031). This result was evident particularly for rural suburban septic, which showed the highest proportion of presence (19.2%) compared to the urban sewered (3.3%), suburban sewered (0%), and agricultural (0%) as well as forested septic (0%) sites. Although further testing across varied land use is needed, our study provides evidence for using the mtDNA marker in large watersheds.

Measuring Physical Activity in Outdoor Community Recreational Environments: Implications for Research, Policy, and Practice.

Chronic diseases such as cardiovascular disease (CVD) are major contributors to escalating health care costs in the USA. Physical activity is an important protective factor against CVD, and the National Prevention Strategy recognizes active living (defined as a way of life that integrates physical activity into everyday routines) as a priority for improving the nation's health. This paper focuses on developing more inclusive measures of physical activity in outdoor community recreational environments, specifically parks and trails, to enhance their usability for at-risk populations such as persons with mobility limitations. We develop an integrated conceptual framework for measuring physical activity in outdoor community recreational environments, describe examples of evidence-based tools for measuring physical activity in these settings, and discuss strategies to improve measurement of physical activity for persons with mobility limitations. Addressing these measurement issues is critically important to making progress towards national CVD goals pertaining to active community environments.

Spatial and temporal patterns of North Carolina pedestrian and bicycle plans.

CONTEXT: Pedestrian and bicycle plans support community-level physical activity. In North Carolina, pedestrian/bicycle plans are becoming more prevalent. However, no studies have examined the spatial and temporal diffusion of pedestrian/bicycle plans. OBJECTIVES: This study assessed (a) temporal trends associated with municipal pedestrian/bicycle planning from 1974 to 2011 and (b) spatial patterns associated with municipal plans, specifically, whether the publication of a pedestrian/bicycle plan in a given year was associated with the number of neighboring municipalities with plans. SETTING: North Carolina from 1974 to 2011. MAIN OUTCOME MEASURES: The main outcome was date of publication of all North Carolina municipal pedestrian and bicycle plans (1974-2011). We calculated Euclidean distances from each municipality center to all other municipality centers to derive whether municipalities were within 20 and 50 miles of each other. Sociodemographic covariates (eg, education, grant funding status, poverty, urbanicity, racial composition, population size, population growth) were collected from the US Census of Population (1980-2010) and the American Community Survey (2006-2010). Time series models fitted by generalized estimating equations were used to assess relationships between plan presence and the temporal and spatial predictor variables. RESULTS: The number of pedestrian and bicycle plans significantly increased over time, especially after 2006 when a state grant funding program was initiated. Unadjusted models indicated that municipalities were significantly more likely to have a pedestrian plan if higher numbers of neighboring municipalities had pedestrian plans. After adjustment for sociodemographic covariates and funding source, this relationship was attenuated but remained statistically significant. For bicycle plans, no significant associations were observed between plan presence and the number of neighboring municipalities with bicycle plans in adjusted models. CONCLUSIONS: Findings from this study can be used to generate hypotheses to test theories about diffusion of innovation and social contagion processes in pedestrian/bicycle planning.

Pedestrian and bicycle plans and the incidence of crash-related injuries.

This study examined the association between the presence of pedestrian and bicycle plans to pedestrian and bicyclist nonfatal and fatal injuries from 1997 to 2009 among 553 North Carolina (NC) municipalities. We considered all municipal plans (n=92; 49 pedestrian; 34 bicycle; and 9 combined plans featuring pedestrian and bicyclist components) published through 2009. Counts of pedestrian and bicyclist nonfatal and fatal injuries came from the NC Department of Transportation crash database, and the estimated number of pedestrian and bicycle trips per municipality in one year were used to calculate pedestrian and bicyclist nonfatal and fatal injury rates. In the 13-year study period, pedestrian/combined municipality plans and bicycle/combined municipality plans were present for 189 (2.6%) and 238 (3.3%) municipality-years, respectively. There were 11,795 nonfatal injuries, 9237 possible nonfatal injuries, and 1075 fatal injuries sustained by pedestrians in pedestrian-motor vehicle crashes. There were 4842 nonfatal injuries, 3666 possible nonfatal injuries, and 134 fatal injuries sustained by bicyclists in bicyclist-motor vehicle crashes. Although not statistically significant, unadjusted nonfatal and fatal injury rates among pedestrians and bicyclists were lower in those municipality-years in which plans had been published that year or in a year prior, compared to municipality-years lacking a plan. Adjusted rate ratios (RR) indicated that pedestrian nonfatal and fatal injury rates decreased in municipality-years with publication of pedestrian/combined plans (nonfatal injury RR: 0.75, 95% confidence interval (CI): 0.68, 0.82; fatal injury RR: 0.63, 95% CI: 0.46, 0.85). However, bicyclist nonfatal and fatal injury rates did not significantly change with publication of bicyclist/combined plans. Our research suggests that plan publication is associated with lower rates of nonfatal and fatal injury in pedestrians; this association was not observed for bicyclists. Further work must determine how the extent of implementation and quality of safety-related content within these plans affects changes in nonfatal and fatal injury rates.

Exploring a public health perspective on pedestrian planning.

A pedestrian plan is a public document that explains a community's vision and goals for future pedestrian activity. This study explored whether involvement by public health professionals in the development of pedestrian plans was associated with certain characteristics of the plan (vision, goals, identified programs, and evaluation). This study identified, collected, and analyzed content of all pedestrian plans in North Carolina through 2008. Among the 46 plans, 39% reported involvement by public health professionals in their development. Overall, 72% of pedestrian plans included a vision statement; health was mentioned four times and quality of life was mentioned five times. Slightly more than half (52%) of the plans included goals to improve public health. Plans that involved public health professionals more often included the type of physical activity, safety, or education program. Only 22% of all pedestrian plans included a proposal to evaluate their implementation. Plans that included public health professionals were less likely to include an evaluation proposal (11%) compared with those that did not involve public health professionals (21%). Public health professionals are encouraged to seek involvement in the pedestrian planning process, particularly in the areas of health program development, implementation, and evaluation.

Planning for pedestrians and bicyclists: results from a statewide municipal survey.

BACKGROUND: We surveyed North Carolina (NC) municipalities to document the presence of municipal walking- and bicycling-related projects, programs, and policies; to describe whether prevalence of these elements differed if recommended in a plan; and to characterize differences between urban and rural municipalities. METHODS: We surveyed all municipalities with ≥ 5000 persons (n = 121) and sampled municipalities with < 5000 persons (216/420), with a response rate of 54% (183/337). Responses were weighted to account for the sampling design. RESULTS: From a list provided, staff reported on their municipality's use of walking- and bicycling-related elements (8 infrastructure projects, 9 programs, and 14 policies). The most commonly reported were projects on sidewalks (53%), streetscape improvements (51%), bicycle/walking paths (40%); programs for cultural/recreational/health (25%), general promotional activities (24%), Safe Routes to School (24%), and law enforcement (24%); and policies on maintenance (64%), new facility construction (57%), and restricted automobile speed or access (45%). Nearly all projects, programs, or policies reported were more likely if included in a plan and more prevalent in urban than rural municipalities. CONCLUSION: These results provide cross-sectional support that plans facilitate the implementation of walking and bicycling elements, and that rural municipalities plan and implement these elements less often than urban municipalities.

Barriers to municipal planning for pedestrians and bicyclists in North Carolina.

BACKGROUND: The Guide to Community Preventive Services recommends implementing community- and street-scale urban design, as well as land use policies and practices, to promote walking and bicycling. To better understand barriers to municipal walking and bicycling projects and policies, we surveyed municipal staff in North Carolina. METHODS: We surveyed all 121 municipalities with at least 5,000 persons, and 62% responded. We also surveyed 216 of 420 municipalities with less than 5,000 persons, and 50% responded. The municipal staff member most knowledgeable about walking and bicycling planning was asked to complete the survey. Responses were weighted to account for the sampling design, to reflect prevalence estimates for all North Carolina municipalities. RESULTS: Common barriers to walking and bicycling projects and policies were selected from a 14-item list. For walking, barriers included lack of funding (93% of responding municipalities), other infrastructure priorities (79%), automobile infrastructure priorities (66%), and staffing challenges (65%). For bicycling, barriers included lack of funding (94% of responding municipalities), other infrastructure priorities (79%), automobile infrastructure priorities (73%), issues were not high priorities for the municipality (68%), staffing challenges (68%), and insufficient support from residents (63%). Barriers generally were more prevalent among rural municipalities than among urban municipalities (9 of 14 barriers for walking and 5 of 14 for bicycling; P < .10). LIMITATIONS: The study relied on 1 respondent to report for a municipality. Additionally, job titles of respondents varied with municipality size. CONCLUSIONS: Health professionals and multidisciplinary partners can assist in overcoming the common local- and state-level barriers to walking and bicycle projects and policies that are reported by North Carolina municipalities.

Pedestrian and bicycle planning in rural communities: tools for active living.

Pedestrian and bicycle planning has traditionally been viewed from an urban design perspective, rather than a rural or regional planning perspective. This study examined the prevalence and quality of pedestrian and bicycle plans in North Carolina according to geography, regional planning, and sociodemographics. Plan prevalence was lower, but plan quality tended to be higher, in rural areas compared with urban areas. Correlations between plan prevalence and active commuting were strongest in lower-income rural areas. By engaging in the planning process, rural residents and other stakeholders can support active living.