School-based health centers as an approach to address health disparities among rural youth: A study protocol for a multilevel research framework.

School-Based Health Centers (SBHCs) are important healthcare providers for children in medically underserved communities. While most existing research on SBHCs has focused on urban environments, this study protocol proposes a mixed-methods, multi-level research framework to evaluate the role of SBHCs in addressing health disparities among underserved children and adolescents in rural communities. The study area includes four high-poverty rural counties in New York State served by Bassett Healthcare Network that permits a comparison of school districts with SBHCs to those without SBHCs, all served by providers within the Bassett Healthcare Network. We employ a human ecological framework that integrates the micro layer of individuals and families, the meso layer of school districts and community institutions, and the macro layer of local and state policies. Our research framework first identifies the socioecological health risk factors, and then proposes innovative strategies to investigate how SBHCs impact them. We propose evaluating the impact of SBHCs on the individual (micro) level of child healthcare utilization using patient records data. At the meso level, we propose to investigate how School-SBHCs partnership may facilitate greater cross-agency collaboration and broader structural and social determinist of health to address health disparities. At the macro level, we propose to assess the impact of SBHCs and cross-agency collaboration on outcomes associated with a culture of community health. This study protocol will enable researchers to assess how SBHCs reduce rural health disparities, and provide evidence for organizational and public policy change.

Cross-Agency Collaboration to Address Rural Aging: The Role of County Government.

Age-friendly community planning and design mainly focus on urban aging and may be less applicable in rural communities. We collaborated with the Tompkins County Age-Friendly Center for Excellence in New York State to assess strategies for rural aging. This commentary argues that density and mixed-use development, as age-friendly development strategies, leave rural communities underserved. County governments, by supporting cross-agency collaboration and encouraging civic engagement, can link the age-friendly domains regarding built environment, service delivery, and community together to help address age-friendly issues and support rural aging.

Factors limiting US public health emergency authority during COVID-19.

Since the onset of the COVID-19 pandemic, many states in the United States have limited emergency public health authority. These limits could undermine public health efforts and raise concerns about how states and localities will prevent and respond to future public health challenges. We examined which of the 50 US states passed laws to set limits on public health emergency authority in 2021 through 2022, and their relationship to COVID-19 death rates. We explored five government characteristics: COVID-19 policy response, political partisanship (Republican control), legislative professionalism, local government autonomy, and broader non-COVID-19 related preemptions. Results of T-tests and a Generalised Structural Equation Model show that states with unified Republican control had greater odds of limiting emergency public health authority of the state executive, state governor, state health official, and local health officials. Limits of emergency public health authority were associated with a higher COVID-19 death rate. We found that states setting limits on emergency authority are primarily related to politicisation and political competition between state executives/governors and legislatures, rather than pushback against the COVID-19 public health response. Limiting emergency public health authority is less common in states with more professional state legislatures. Structural changes related to party control, legislative professionalism, and local autonomy may facilitate public health authority.

Age-Friendly Cities in Latin America: A Human Ecological Framework.

Despite the demographic aging of Latin America, the uptake of the WHO's Age-Friendly Cities Framework remains extremely low, with the notable exceptions of Chile, Mexico and Brazil. We argue for a broader human ecological framework, which focuses on the macro, meso and micro levels, to better address the context, challenges and opportunities for age-friendly cities in the Latin American region. The WHO's age-friendly city domains are primarily at the meso (community) scale, with a focus on built environment, services and participation. We call for more attention to be paid to the macro policy scale to address concerns regarding migration, demography and social policy context. More attention also should be given to the micro scale to recognize the critical role of family and informal care supports. It is possible that the WHO domains are the result of a design bias, with Global North settings in mind for their development. We find the domains of UNICEF's Child-Friendly Cities Initiative, which give more attention to the realities of the Global South, helpful to broaden the WHO's Age-Friendly Cities Framework.

Linking Urban Planning, Community Environment, and Physical Activity: A Socio-Ecological Approach.

Lack of physical activity is a growing concern among public health advocates and urban planners. Our socio-ecological model incorporates urban planning and World Health Organization actions on physical activity to identify key factors related to leisure-time physical activity at the community level. Our 2019 nationwide US survey of 1312 communities enables examination of the influence of individual, community, and policy levels on physical activity. Individual factors-poverty, aging, minority population, and longer commuting time-result in lower physical activity. Community-level factors have both positive and negative effects. Physical activity is lower in rural and suburban communities, but higher in communities with more transportation services, recreation and social activities, and safety. Communities with mixed-use neighborhoods and complete streets also show higher levels of physical activity. At the policy level, zoning and cross-agency collaboration have an indirect effect on physical activity by increasing these community-level factors. This suggests an alternative approach to promoting physical activity. Local governments can promote transportation, recreation and safety, especially in rural and minority communities lacking active-friendly built environments and facing challenges from aging population, poverty, and longer commuting time. This socio-ecological approach can assess multilevel factors related to physical activity in other countries.

Water Shutoff Moratoria Lowered COVID-19 Infection and Death Across U.S. States.

INTRODUCTION: A total of 34 U.S. state governments imposed moratoria on water shutoffs between March and May 2020 to ensure equitable access to water during the COVID-19 pandemic. However, by the end of 2020, most of these moratoria had expired, and millions of people were exposed to the risk of water disconnections. This study examines the linkage between water equity and public health and provides policy recommendations for improving water access and health equity. METHODS: Event study was used to analyze the impact of a water shutoff moratorium on COVID-19 daily infection growth rate and daily death growth rate from April 17, 2020 to December 31, 2020. The data were collected at the state level. The model controlled for mask mandates, at-risk groups (percentage Hispanic population, percentage essential workers), and percentage health insurance coverage. RESULTS: During the study period, having a water shutoff moratorium in place significantly lowered the COVID-19 infection daily growth rate by 0.235% and significantly lowered the death growth rate by 0.135%. In addition, a comprehensive moratorium covering all water systems (public and private) significantly lowered the infection growth rate by 0.169% and significantly lowered the death growth rate by 0.228%. CONCLUSIONS: This study raises attention to the importance of water equity and the need for government actions to create more uniform protections from water shutoffs across all states. A comprehensive approach to water equity can protect the health and safety of all communities.

Healthy Places for Children: The Critical Role of Engagement, Common Vision, and Collaboration.

Planning plays a critical role in promoting healthy communities for children. We conducted a national survey of United States (US) cities and counties in 2019 and found only half of the 1312 responding communities report they give attention to the needs of children in their community plans. Those that do, provide more services and have more child-friendly zoning codes. We use a human ecological framework to build structural equation models of child-friendly zoning and services. We find communities with more engagement of families with children and youth and a common vision across generational, race, and ethnic lines report higher levels of child-friendly zoning and services. Collaboration between health providers and schools builds trust and leads to more services. However, child-friendly zoning is lower in communities with higher child poverty, and in suburbs and rural areas. Our results support a dynamic human ecological model where the processes of collaboration, inclusion, and engagement are key to creating healthy places for children. These processes may be especially important in addressing the unique challenges of suburban and rural communities.

COVID-19 Policy Differences across US States: Shutdowns, Reopening, and Mask Mandates.

This work used event study to examine the impact of three policies (shutdowns, reopening, and mask mandates) on changes in the daily COVID-19 infection growth rate at the state level in the US (February through August 2020). The results show the importance of early intervention: shutdowns and mask mandates reduced the COVID-19 infection growth rate immediately after being imposed statewide. Over the longer term, mask mandates had a larger effect on flattening the curve than shutdowns. The increase in the daily infection growth rate pushed state governments to shut down, but reopening led to significant increases in new cases 21 days afterward. The results suggest a dynamic social distancing approach: a shutdown for a short period followed by reopening, combined with universal mask wearing. We also found that the COVID-19 growth rate increased in states with higher percentages of essential workers (during reopening) and higher percentages of minorities (during the mask mandate period). Health insurance access for low-income workers (via Medicaid expansion) helped to reduce COVID-19 cases in the reopening model. The implications for public health show the importance of access to health insurance and mask mandates to protect low-income essential workers, but minority groups still face a higher risk of infection during the pandemic.

Which states and cities protect residents from water shutoffs in the COVID-19 pandemic?

Many U.S. states and cities have imposed water disconnection moratoriums during the COVID-19 pandemic. Using logistic and Cox Proportional-Hazards models, we assess factors that differentiate which governments imposed moratoriums. States, which have economic regulation of private water utilities, were more likely to impose moratoriums, and those with higher COVID-19 case rates imposed moratoriums earlier. States with unified Republican Control and cities with more 2016 Trump voters were less likely to impose moratoriums on water disconnection. Cities in states without statewide moratoriums, were more likely to impose moratoriums if they had higher income, more minority residents, and more income inequality.

Does public ownership of utilities matter for local government water policies?

What differentiates local governments that implement water policies on equity and the environment? Analyzing a 2015 national survey of 1,897 U.S. municipalities, we find municipalities that own their water utilities are more likely to report policies to protect low-income residents from disconnection and implement water resource management. Respondents from 8% of municipalities report protecting residents from disconnection. State economic regulation of municipally owned utilities and Democrat-majority municipal governments are positively associated with local policies to protect low-income households from shutoffs but bear no association with resource management. Both municipal ownership of utilities and state economic regulation may play a role in meeting certain local water policy goals.

Can Age-Friendly Planning Promote Equity in Community Health Across the Rural-Urban Divide in the US?

In the US, rural communities face challenges to meet the community health needs of older adults and children. Meanwhile, rural areas lag in age-friendly built environment and services. AARP, a US based organization promoting livability for all ages, has developed a Livability Index based on the World Health Organization's (WHO) domains of age-friendly communities: health, housing, neighborhood, transportation, environment, engagement, and opportunity. This study links the 2018 AARP Livability Index categories with demographic structure and socio-economic factors from the American Community Survey at the county level in the US to examine if the physical, built and social environment differentiate communities with better community health across the rural-urban divide. Results show that the neighborhood built environment has the largest impact on community health for all county types. Although rural areas lag in community health, those which give more attention to engagement and opportunity rank higher. Rural communities with more African Americans, children, and poor Whites, rank lower on community health. While neighborhood characteristics have the strongest link to community health, a broader approach with attention to age, race, poverty and engagement and opportunity is needed for rural areas.

What Explains Differences in Availability of Community Health-Related Services for Seniors in the United States?

OBJECTIVE: This study analyzes the links between planning, the built environment, and availability of health-related community services across U.S. urban and rural communities. METHOD: We analyze the first national survey of health-related community services for seniors (2010 Maturing of America), covering 1,459 U.S. cities and counties. We tested the influence of morbidity (diabetes and obesity), city management, socioeconomic characteristics, planning and the built environment, metro status, and government finance. RESULTS: Community health-related services are more common in places that plan for and involve seniors in planning processes. Places with higher need and government capacity also show higher levels. Service levels in rural communities are not lower after controlling for other population characteristics. Morbidity measures (diabetes and obesity) do not explain differences in service availability. DISCUSSION: Policies promoting planning for aging and elder involvement in the planning process have the greatest impact on the level of community health-related services for seniors.

Not Your Mother's Suburb: Remaking Communities for a More Diverse Population.

The United States is a suburban nation with a majority of Americans living and working in this landscape. But the suburb is more than a physical location; it is also a social production. Built upon a middle class, white, nuclear family ideal, the suburb is now diversifying demographically and economically, yet zoning ordinances and the built environment continue to reflect this outdated ideal. Today's suburb is not your mother's suburb. We argue that these demographic changes create both a point of rupture that challenges traditional land use regulations and actual uses of space, and an opening for communities to embrace and plan for new residents. In order to respond to the needs of a diversifying suburban population, communities need to challenge the underlying assumptions of traditional zoning ordinances - the separation of uses and preference for single-family housing. We present an agenda for the future that includes planning responses that rethink the zoning hierarchy, promote new forms of densification, move beyond restrictive family definitions, and experiment with new forms of service delivery.