Burden of fatal drowning in California, 2005-2019.

OBJECTIVE: To characterise risk factors for fatal drowning in California, USA to inform priorities for prevention, policy and research. METHODS: This retrospective population-based epidemiological review of death certificate data evaluated fatal drowning events in California from 2005 to 2019. Unintentional, intentional, and undetermined drowning deaths and rates were described by person (age, sex, race) and context-based variables (region and body of water). RESULTS: California's fatal drowning rate was 1.48 per 100 000 population (n=9237). Highest total fatal drowning rates occurred in the lower population density northern regions, among older adults (75-84 years: 2.54 per 100 000 population; 85+: 3.47 per 100 000 population) and non-Hispanic American Indian or Alaska Native persons (2.84 per 100 000 population). Male drowning deaths occurred at 2.7 times the rate of females; drowning deaths occurred mainly in swimming pools (27%), rivers/canals (22.4%) and coastal waters (20.2%). The intentional fatal drowning rate increased 89% during the study period. CONCLUSIONS: California's overall fatal drowning rate was similar to the rest of the USA but differed among subpopulations. These divergences from national data, along with regional differences in drowning population and context-related characteristics, underscore the need for state and regional level analyses to inform drowning prevention policy, programmes and research.

Probabilistic walking models using built environment and sociodemographic predictors.

BACKGROUND: Individual sociodemographic and home neighborhood built environment (BE) factors influence the probability of engaging in health-enhancing levels of walking or moderate-to-vigorous physical activity (MVPA). Methods are needed to parsimoniously model the associations. METHODS: Participants included 2392 adults drawn from a community-based twin registry living in the Seattle region. Objective BE measures from four domains (regional context, neighborhood composition, destinations, transportation) were taken for neighborhood sizes of 833 and 1666 road network meters from home. Hosmer and Lemeshow's methods served to fit logistic regression models of walking and MVPA outcomes using sociodemographic and BE predictors. Backward elimination identified variables included in final models, and comparison of receiver operating characteristic (ROC) curves determined model fit improvements. RESULTS: Built environment variables associated with physical activity were reduced from 86 to 5 or fewer. Sociodemographic and BE variables from all four BE domains were associated with activity outcomes but differed by activity type and neighborhood size. For the study population, ROC comparisons indicated that adding BE variables to a base model of sociodemographic factors did not improve the ability to predict walking or MVPA. CONCLUSIONS: Using sociodemographic and built environment factors, the proposed approach can guide the estimation of activity prediction models for different activity types, neighborhood sizes, and discrete BE characteristics. Variables associated with walking and MVPA are population and neighborhood BE-specific.

The Association Between Park Facilities and Duration of Physical Activity During Active Park Visits.

Public parks provide places for urban residents to obtain physical activity (PA), which is associated with numerous health benefits. Adding facilities to existing parks could be a cost-effective approach to increase the duration of PA that occurs during park visits. Using objectively measured PA and comprehensively measured park visit data among an urban community-dwelling sample of adults, we tested the association between the variety of park facilities that directly support PA and the duration of PA during park visits where any PA occurred. Cross-classified multilevel models were used to account for the clustering of park visits (n = 1553) within individuals (n = 372) and parks (n = 233). Each additional different PA facility at a park was independently associated with a 6.8% longer duration of PA bouts that included light-intensity activity, and an 8.7% longer duration of moderate to vigorous PA time. Findings from this study are consistent with the hypothesis that more PA facilities increase the amount of PA that visitors obtain while already active at a park.

The association between park facilities and the occurrence of physical activity during park visits.

Prior research has found a positive relationship between the variety of park facilities and park-based physical activity (PA), but has not provided an estimate of the effect that additional different PA facilities have on whether an individual is active during a park visit. Using objective measures of park visits and PA from an urban sample of 225 adults in King County, Washington, we compared the variety of PA facilities in parks visited where an individual was active to PA facilities in parks where the same individual was sedentary. Each additional different PA facility at a park was associated with a 6% increased probability of being active during a visit. Adding additional different PA facilities to a park appears to have a moderate effect on whether an individual is active during a park visit, which could translate into large community health impacts when scaled up to multiple park visitors.

Geographic disparities in Healthy Eating Index scores (HEI-2005 and 2010) by residential property values: Findings from Seattle Obesity Study (SOS).

BACKGROUND: Higher socioeconomic status (SES) has been linked with higher-quality diets. New GIS methods allow for geographic mapping of diet quality at a very granular level. OBJECTIVE: To examine the geographic distribution of two measures of diet quality: Healthy Eating Index (HEI 2005 and HEI 2010) in relation to residential property values in Seattle-King County. METHODS: The Seattle Obesity Study (SOS) collected data from a population-based sample of King County adults in 2008-09. Socio-demographic data were obtained by 20-min telephone survey. Dietary data were obtained from food frequency questionnaires (FFQs). Home addresses were geocoded to the tax parcel and residential property values were obtained from the King County tax assessor. Multivariable regression analyses using 1116 adults tested associations between SES variables and diet quality measured (HEI scores). RESULTS: Residential property values, education, and incomes were associated with higher HEI scores in bivariate analyses. Property values were not collinear with either education or income. In adjusted multivariable models, education and residential property were better associated with HEI, compared to than income. Mapping of HEI-2005 and HEI-2010 at the census block level illustrated the geographic distribution of diet quality across Seattle-King County. CONCLUSION: The use of residential property values, an objective measure of SES, allowed for the first visual exploration of diet quality at high spatial resolution: the census block level.

Obesity, diet quality, physical activity, and the built environment: the need for behavioral pathways.

BACKGROUND: The built environment (BE) is said to influence local obesity rates. Few studies have explored causal pathways between home-neighborhood BE variables and health outcomes such as obesity. Such pathways are likely to involve both physical activity and diet. METHODS: The Seattle Obesity Study (SOS II) was a longitudinal cohort of 440 adult residents of King Co, WA. Home addresses were geocoded. Home-neighborhood BE measures were framed as counts and densities of food sources and physical activity locations. Tax parcel property values were obtained from County tax assessor. Healthy Eating Index (HEI 2010) scores were constructed using data from food frequency questionnaires. Physical activity (PA) was obtained by self-report. Weights and heights were measured at baseline and following 12 months' exposure. Multivariable regressions examined the associations among BE measures at baseline, health behaviors (HEI-2010 and physical activity) at baseline, and health outcome both cross-sectionally and longitudinally. RESULTS: None of the conventional neighborhood BE metrics were associated either with diet quality, or with meeting PA guidelines. Only higher property values did predict better diets and more physical activity. Better diets and more physical activity were associated with lower obesity prevalence at baseline and 12 mo, but did not predict weight change. CONCLUSION: Any links between the BE and health outcomes critically depend on establishing appropriate behavioral pathways. In this study, home-centric BE measures, were not related to physical activity or to diet. Further studies will need to consider a broader range of BE attributes that may be related to diets and health.

A Longitudinal Study of Changes in Prenatal Care Utilization Between First and Second Births and Low Birth Weight.

OBJECTIVES: Because previous analyses of prenatal care (PNC) utilization and risk of low birth weight (LBW) may have been influenced by selection bias, we conducted a study using longitudinal data of women with repeat pregnancies. METHODS: We analyzed Washington State birth certificates of first and second live births (2003-2012). We estimated relative risk (RR) of LBW at second birth associated with Kotelchuck Index PNC level among women stratified by level of PNC in their first birth (n = 67,571). RESULTS: Among women with inadequate PNC prior to their first birth (n = 10,355), women with intermediate or adequate PNC before their second birth (n = 7464) had a reduced risk of LBW (adjusted RR 0.61, 95% CI: 0.48, 0.78) compared to those whose PNC level remained inadequate. Likewise, among women with intermediate or adequate PNC prior to their first birth (n = 57,216), those with inadequate PNC before the second birth (n = 7095) had higher risk of LBW (adjusted RR 1.59, 95% CI: 1.36, 1.85) compared to those who remained at intermediate or adequate PNC. CONCLUSIONS: Our findings support the hypothesis that PNC decreases LBW risk at second birth, independent of factors related to the utilization of PNC at first birth.

The built environment and utilitarian walking in small U.S. towns.

OBJECTIVES: The role of the built environment on walking in rural United States (U.S.) locations is not well characterized. We examined self-reported and measured built environment correlates of walking for utilitarian purposes among adult residents of small rural towns. METHODS: In 2011-12, we collected telephone survey and geographic data from 2152 adults in 9 small towns from three U.S. regions. We performed mixed-effects logistic regression modeling to examine relationships between built environment measures and utilitarian walking ("any" versus "none"; "high" [≥150min per week] versus "low" [<150min per week]) to retail, employment and public transit destinations. RESULTS: Walking levels were lower than those reported for populations living in larger metropolitan areas. Environmental factors significantly (p<0.05) associated with higher odds of utilitarian walking in both models included self-reported presence of crosswalks and pedestrian signals and availability of park/natural recreational areas in the neighborhood, and also objectively measured manufacturing land use. CONCLUSIONS: Environmental factors associated with utilitarian walking in cities and suburbs were important in small rural towns. Moreover, manufacturing land use was associated with utilitarian walking. Modifying the built environment of small towns could lead to increased walking in a sizeable segment of the U.S. population.

Neighborhood Environments and Utilitarian Walking Among Older vs. Younger Rural Adults.

Introduction: Walking has the potential to promote health across the life span, but age-specific features of the neighborhood environment (NE), especially in rural communities, linked with walking have not been adequately characterized. This study examines the relationships between NE and utilitarian walking among older vs. younger adults living in US rural towns. Methods: Data for this cross-sectional study came from telephone interviews in 2011-2012 with 2,140 randomly sampled younger (18-64 years, n = 1,398) and older (65+ years, n = 742) adults, collecting personal and NE perception variables. NE around each participant's home was also measured objectively using geographic information system techniques. Separate mixed-effects logistic regression models were estimated for the two age groups, predicting the odds of utilitarian walking at least once a week. Results: Perceived presence of crosswalks and pedestrian signals was significantly related to utilitarian walking in both age groups. Among older adults, unattended dogs, lighting at night, and religious institutions were positively while steep slope was negatively associated with their walking. For younger adults, traffic speed (negative, -), public transportation (positive, +), malls (-), cultural/recreational destinations (+), schools (+), and resource production land uses such as farms and mines (-) were significant correlates of utilitarian walking. Conclusion: Different characteristics of NE are associated with utilitarian walking among younger vs. older adults in US rural towns. Optimal modifications of NE to promote walking may need to reflect these age differences.

A Quality Strategy to Advance the Triple Aim in California's Medicaid Program.

The California Department of Health Care Services (DHCS) administers the nation's largest Medicaid program. In 2012, DHCS developed a Quality Strategy modeled after the National Quality Strategy to guide the Department's activities aimed at advancing the Triple Aim. The Triple Aim seeks to improve the patient experience of care and the health of populations as well as reduce the per capita cost of health care. An academic team was contracted to assist DHCS in developing the strategy, which also was informed by extensive stakeholder input, an advisory committee, and a comprehensive inventory of DHCS quality improvement (QI) activities. From 2012 to 2018, the strategy included 129 unique QI activities. Most activities were intended to deliver more effective, efficient, affordable care or to advance disease prevention. This qualitative assessment of the DHCS Quality Strategy provides insights that may inform other Medicaid programs or large health systems as they develop quality strategies.

Why neighborhood park proximity is not associated with total physical activity.

This study explored how parks within the home neighborhood contribute to total physical activity (PA) by isolating park-related PA. Seattle-area adults (n = 634) were observed using time-matched accelerometer, Global Positioning System (GPS), and travel diary instruments. Of the average 42.3 min of daily total PA, only 11% was related to parks. Both home neighborhood park count and area were associated with park-based PA, but not with PA that occurred elsewhere, which comprised 89% of total PA. This study demonstrates clear benefits of neighborhood parks for contributing to park-based PA while helping explain why proximity to parks is rarely associated with overall PA.

The Causal Effect of Bus Rapid Transit on Changes in Transit Ridership.

Numerous studies have reported ridership increases along routes when Bus rapid transit (BRT) replaces conventional bus service, but these increases could be due simply to broader temporal trends in transit ridership. To address this limitation, we compared changes in ridership among routes where BRT was implemented to routes where BRT was planned or already existed in King County, Washington. Ridership was measured at 2010, 2013, and 2014. Ridership increased by 35% along routes where BRT was implemented from 2010 to 2013 compared to routes that maintained conventional bus service. Ridership increased by 29% along routes where BRT was implemented from 2013 to 2014 compared to consistent existing BRT service. These results provide stronger evidence for a causal relationship between BRT and increased transit ridership and a more accurate estimate of the independent effect of BRT on ridership.

Light Rail Leads to More Walking Around Station Areas.

Areas around Light Rail Transit (LRT) stations offer ideal conditions for Transit-Oriented Development (TOD). Relatively dense, mixed-use neighborhoods can have positive impacts on mobility, health, and perceptions of neighborhood safety among nearby residents, primarily through walking activity for both transit and other purposes. To examine how station areas may attract new activity, this study analyzed changes in walking around station areas among people living close to an LRT station before and after the opening of a new transit system. This study examined walking behavior among the subset of 214 participants living within one mile of one of 13 LRT stations from among a sample of residents living close or further away from a new LRT line in Seattle. They completed a survey and a travel log and wore an accelerometer and a GPS for 7 days both before (2008) and after the opening of the Seattle area LRT (2010). Walking bouts were derived using a previously developed algorithm. The main outcome was the individual-level change in the proportion of daily walking within one quarter Euclidean mile of an LRT station. Overall walking decreased from before to after the LRT opening while station area walking did not change significantly, indicating a shift in walking activity to the station areas after the introduction of LRT. Increases in the proportion of station area walking were negatively related to participants' distance between home and the nearest LRT station, peaking at <0.25 mile and decaying beyond >0.75 mile. Male gender, college education, normal weight status, less access to cars, and frequent LRT use were also significantly associated with greater positive changes in the proportion of station area walking. The shift in walking to station areas after the completion of light rail provides evidence that the local proximate population is attracted to station areas, which may potentially benefit both transit use and TOD area economic activity. The residential catchment area for the shift in LRT area walking was < 0.75 mile of the LRT stations.

The association between park visitation and physical activity measured with accelerometer, GPS, and travel diary.

Public parks are promoted as places that support physical activity (PA), but evidence of how park visitation contributes to overall PA is limited. This study observed adults living in the Seattle metropolitan area (n=671) for one week using accelerometer, GPS, and travel diary. Park visits, measured both objectively (GPS) and subjectively (travel diary), were temporally linked to accelerometer-measured PA. Park visits occurred at 1.4 per person-week. Participants who visited parks at least once (n=308) had an adjusted average of 14.3 (95% CI: 8.9, 19.6)min more daily PA than participants who did not visit a park. Even when park-related activity was excluded, park visitors still obtained more minutes of daily PA than non-visitors. Park visitation contributes to a more active lifestyle, but is not solely responsible for it. Parks may best serve to complement broader public health efforts to encourage PA.

Secondary GIS built environment data for health research: guidance for data development.

Built environment (BE) data in geographic information system (GIS) format are increasingly available from public agencies and private providers. These data can provide objective, low-cost BE data over large regions and are often used in public health research and surveillance. Yet challenges exist in repurposing GIS data for health research. The GIS data do not always capture desired constructs; the data can be of varying quality and completeness; and the data definitions, structures, and spatial representations are often inconsistent across sources. Using the Small Town Walkability study as an illustration, we describe (a) the range of BE characteristics measurable in a GIS that may be associated with active living, (b) the availability of these data across nine U.S. small towns, (c) inconsistencies in the GIS BE data that were available, and (d) strategies for developing accurate, complete, and consistent GIS BE data appropriate for research. Based on a conceptual framework and existing literature, objectively measurable characteristics of the BE potentially related to active living were classified under nine domains: generalized land uses, morphology, density, destinations, transportation system, traffic conditions, neighborhood behavioral conditions, economic environment, and regional location. At least some secondary GIS data were available across all nine towns for seven of the nine BE domains. Data representing high-resolution or behavioral aspects of the BE were often not available. Available GIS BE data - especially tax parcel data - often contained varying attributes and levels of detail across sources. When GIS BE data were available from multiple sources, the accuracy, completeness, and consistency of the data could be reasonable ensured for use in research. But this required careful attention to the definition and spatial representation of the BE characteristic of interest. Manipulation of the secondary source data was often required, which was facilitated through protocols.

Multistate evaluation of safe routes to school programs.

PURPOSE: State Safe Routes to School (SRTS) programs provide competitive grants to local projects that support safe walking, bicycling, and other modes of active school travel (AST). This study assessed changes in rates of AST after implementation of SRTS projects at multiple sites across four states. DESIGN: One-group pretest and posttest. SETTING: Florida, Mississippi, Washington, and Wisconsin. SUBJECTS: Convenience sample of 48 completed SRTS projects and 53 schools affected by a completed SRTS project. INTERVENTION: State-funded SRTS project. MEASURES: AST was measured as the percentage of students walking, bicycling, or using any AST mode. SRTS project characteristics were measured at the project, school, and school neighborhood levels. ANALYSIS: Paired-samples t-tests were used to assess changes in AST. Bivariate analysis was used to identify SRTS project characteristics associated with increases in AST. Data were analyzed separately at the project (n = 48) and school (n = 53) levels. RESULTS: Statistically significant increases in AST were observed across projects in all four states. All AST modes increased from 12.9% to 17.6%; walking from 9.8% to 14.2%; and bicycling from 2.5% to 3.0%. Increases in rates of bicycling were negatively correlated with baseline rates of bicycling. CONCLUSION: State-funded SRTS projects are achieving one of the primary program goals of increasing rates of AST. They may be particularly effective at introducing bicycling to communities where it is rare. The evaluation framework introduced in this study can be used to continue tracking the effect of state SRTS programs as more projects are completed.