Exploring the association between campus environment of higher education and student health: A systematic review of findings and measures.

Numerous studies have investigated the relationship between the neighborhood environments and residents' health. However, other important settings, such as university campuses, have received little attention. This paper conducted a systematic review and synthesized existing empirical works examining the association between the university/college campuses built and natural environments and students' health. Following the PRISMA guidelines, we searched nine databases using keywords related to higher-education campuses and health-related outcomes. A total of 19 articles were identified, including fifteen cross-sectional studies, three experimental studies, and one longitudinal study. The majority of the studies were conducted in Asian countries and published in the past five years. The findings indicate that active transportation infrastructure, such as increased road intersections and better walkability, were found to be positively associated with students' physical activity. The natural environments, including perceived naturalness, blue space, and greenness was shown to support student's mental health and quality of life. Specifically, blue space was found to be the most preferred place for mental restoration, and scattered trees demonstrated a supportive effect in reducing depression symptoms. Even just viewing virtual trees had a restorative effect and feel less anxiety. Additionally, during the summer, tree shadows were identified as the most important factors for enhancing thermal comfort. This review emphasizes the crucial role of campus environments in promoting college students' health. Future longitudinal studies and investigations using multiple campuses would provide a more comprehensive understanding of this relationship. Such endeavors can contribute to the development of evidence-based strategies for designing and planning healthy campus environments that optimize students' well-being.

Examining the impacts of public transit on healthy aging through a natural experiment: study protocols and lessons learned from the Active El Paso project.

This paper describes protocols and experiences from a seven-year natural-experiment study in El Paso, Texas, a border city of predominantly Latino/Hispanic population. The study focuses on how Bus Rapid Transit (BRT) impacts physical activity and thus plays a role in alleviating obesity and related chronic diseases that impact healthy aging. Our protocols describe a longitudinal and case-comparison study, which compared residents exposed to new BRT stations with those who were not. This paper also introduces lessons and experiences to overcome the following challenges: delays in the BRT opening (the main intervention), the COVID-19 pandemic, methodological challenges, participant recruitment and retention, and predatory survey takers. Our transdisciplinary approach was pivotal in addressing these challenges. We also proposed and tested multi-level intervention strategies to reduce modifiable barriers to transit use. Our most important takeaway for researchers, practitioners, and policy makers is the importance of being flexible and ready to adapt to new circumstances. Future natural-experiment researchers need to become more versatile in an increasingly volatile and uncertain world.

Moving to an Activity-Friendly Community Can Increase Physical Activity.

BACKGROUND: Creating activity-friendly communities (AFCs) is an important strategy to increase physical activity (PA). While cross-sectional links between community environments and PA are well documented, their causal relationships remain insufficiently explored. METHODS: Using the accelerometer and survey data collected from adults who moved to an AFC (cases) and similar non-AFC-residing adults who did not move (comparisons), this pre-post, case-comparison study examines if moving to an AFC increases PA. Data came from 115 participants (cases = 37, comparisons = 78) from Austin, Texas, who completed 2 waves of 1-weeklong data collection. Difference-in-difference analyses and fixed-effect models were used to test the significance of the pre-post differences in moderate-to-vigorous PA (MVPA) between cases and comparisons, for the full sample and the subsample of 37 pairs matched in key covariates using the Propensity Score Matching method. RESULTS: Average treatment effect generated based on Propensity Score Matching and difference-in-difference showed that moving to this AFC led to an average of 10.88 additional minutes of daily MVPA (76.16 weekly minutes, P = .015). Fixed-effect models echoed the result with an increase of 10.39 minutes of daily MVPA after moving to the AFC. We also found that case participants who were less active at baseline and had higher income increased their MVPA more than their counterparts. CONCLUSIONS: This study showed that, among our study sample, moving to an AFC increased residents' PA significantly when compared to their premove level and the comparison group. This causal evidence suggests the potential of AFCs as sustainable interventions for PA promotion.

Designing for Health in Healthcare Deserts: A Medical City Master Planning Project in Nigeria.

BACKGROUND: Many countries and communities in sub-Saharan Africa suffer from inadequate access to healthcare and healthy lifestyles as reflected in their high mortality and morbidity rates. Large-scale interventions like the medical city project presented in this article are necessary to address the significant health burdens faced by populations in this region. OBJECTIVES: This article shows how evidence-based approaches and multisectoral partnerships guided the development of the 327-acre Medical City master plan in Akwa Ibom, Nigeria. This is envisioned to be the first-of-its-kind medical city in this medically underserved "healthcare desert." METHODS: The five-phased, seven-year (2013-2020) master planning process was guided by the overarching design framework of "sustainable one health" along with its 11 objectives and 64 performance measures. The data/evidence used to guide the planning decision-making process came from case studies, literature reviews, stakeholder interviews, and on-site investigations. RESULTS: The outcome of this project is a comprehensive medical city master plan that includes a self-contained, mixed-use community anchored by a hospital and a primary healthcare village. This medical city provides access to the full range of healthcare services (e.g., curative-to-preventive, traditional-to-alternative) and is supported by multimodal transportation systems and extensive green infrastructure. CONCLUSIONS: This project offers theoretical and practical insights on "designing for health" in a frontier market while responding to the complex local contexts that present many unique challenges and opportunities. Those insights provide useful lessons for researchers and professionals interested in promoting health and healthcare services in healthcare deserts.

COVID-19 and campus users: A longitudinal and place-based study of university mobilities in Texas.

The COVID-19 pandemic has disrupted people's daily routines, including travel behaviors, social interactions, and work-related activities. However, the potential impacts of COVID-19 on the use of campus locations in higher education such as libraries, food courts, sports facilities, and other destinations are still unknown. Focusing on three largest universities in Texas (Texas A&M university, the University of Texas at Austin, and Texas Tech University), this study compares changes in campus destination visitations between pre and post COVID-19 outbreak (2019 Fall and 2021 Fall semesters, respectively) using the mobility data from SafeGraph. It also examines the potential moderation effects of walkable distance (i.e. 1 km) and greenery (i.e. NDVI value). The results presented the significant effects of COVID-19 on decreasing visitations to various campus places. The visitation decreased more significantly for people living within 1 km (defined as a walkable distance) of campus and for the food, eating, and drinking places and the sports, recreation, and sightseeing places. This finding suggests that those living near campus (mostly students) decreased their reliance on campus destinations, especially for eating/drinking and recreation purposes. The level of greeneries at/around campus destinations did not moderate campus visitations after COVID-19. Policy implications on campus health and urban planning were discussed.

Environmental and Mobility Strategies During Early COVID-19: Insights From an Empirical Study Focusing on Park Visitations in El Paso, TX.

OBJECTIVES: We explored the importance of environmental and mobility strategies during early COVID-19 by age and ethnicity and investigated predictors of park visitations considering the COVID-19 impacts. BACKGROUND: Parks are safe and accessible venues to stay active and reduce social isolation, which is especially important considering COVID-19 and the associated lockdowns. METHODS: We analyzed online survey data from 683 residents (collected July 2020) of El Paso, TX, and objective measures of neighborhood park characteristics. Chi-square tests and mixed-effects logistic regression analyses were performed to examine the environmental/mobility strategies, personal and environmental factors, and park visitations, considering the COVID-19 impacts. RESULTS: The percentage of those who visited (1+ times/week) parks or trails/paths in the neighborhood dropped from 41.7% to 19.5% since the start of COVID-19 (OR = 0.015, p < .001). Before COVID-19, middle-aged and older adults were less likely to visit parks than younger adults, while this difference became insignificant during early COVID-19. Hispanic adults were more likely to visit parks than non-Hispanics both before and during early COVID-19. Positive environmental predictors of park visitations included park availability in the neighborhood, proximity to the closest park, seeing people being physically active in the neighborhood, and neighborhood aesthetics. CONCLUSIONS: Proximately located parks, trails, and paths well integrated into residential communities, and high aesthetic quality of the neighborhood are the potential features of pandemic-resilient communities and should be considered an important national priority to maintain and promote the health and well-being of the population, especially during pandemics like COVID-19.

Location-based collective distress using large-scale biosignals in real life for walkable built environments.

Biosignals from wearable sensors have shown great potential for capturing environmental distress that pedestrians experience from negative stimuli (e.g., abandoned houses, poorly maintained sidewalks, graffiti, and so forth). This physiological monitoring approach in an ambulatory setting can mitigate the subjectivity and reliability concerns of traditional self-reported surveys and field audits. However, to date, most prior work has been conducted in a controlled setting and there has been little investigation into utilizing biosignals captured in real-life settings. This research examines the usability of biosignals (electrodermal activity, gait patterns, and heart rate) acquired from real-life settings to capture the environmental distress experienced by pedestrians. We collected and analyzed geocoded biosignals and self-reported stimuli information in real-life settings. Data was analyzed using spatial methods with statistical and machine learning models. Results show that the machine learning algorithm predicted location-based collective distress of pedestrians with 80% accuracy, showing statistical associations between biosignals and the self-reported stimuli. This method is expected to advance our ability to sense and react to not only built environmental issues but also urban dynamics and emergent events, which together will open valuable new opportunities to integrate human biological and physiological data streams into future built environments and/or walkability assessment applications.

Contextual and environmental factors that influence health: A within-subjects field experiment protocol.

Background: Despite the growing research on environment-physical activity (PA) relationships, field experimental studies are limited. Such studies offer opportunities to focus on real-world environmental exposure and related PA and health outcomes, allowing researchers to better isolate the causal effect of exposures/interventions. Focusing on the street/pedestrian environment as a routine setting for people's daily activities, this research aims to develop and test a field experiment protocol that integrates instantaneous assessments of the environment, PA, and health outcomes. The protocol involves the use of state-of-the-art environmental monitoring and biosensing techniques and focuses on physically active road users (pedestrians and bicyclists) who are more directly exposed to their surrounding environment than others such as drivers. Methods/Design: An interdisciplinary research team first identified the target measurement domains for the health outcomes (e.g., stress, thermal comfort, PA) and the street-level environmental exposures (e.g., land use, greenery, infrastructure conditions, air quality, weather) guided by the previous literature which was primarily observational. Portable or wearable measurement instruments (e.g., GPS, accelerometer, biosensor, mini camera, smartphone app, weather station, air quality sensor) were identified, pilot tested, and selected for the identified measures. We ensured that these measures are readily linkable using the time stamp and include eye-level exposures as they impact the users' experiences more directly yet missing in most prior studies relying on secondary, aerial-level measures. A 50-min experimental route was then determined to include typical everyday environments in park and mixed-use settings and to engage participants in three common modes of transportation (walking, bicycling, and driving). Finally, a detailed staff protocol was developed, pilot-tested, and used in a 36-participant within-subject field experiment in College Station, TX. The experiment was successfully executed, showing its potential to support future field experiments that can provide more accurate real-time, real-environment, and multi-dimensional information. Discussion: Our study demonstrates the feasibility of capturing the multifold health benefits/harms related to walking and bicycling in varying urban environments by combining field experiments with environmental, behavioral, and physiological sensing. Our study protocol and reflections can be helpful for a broad spectrum of research addressing the complex and multi-level pathways between the environment, behavior, and health outcomes.

Street environments and crime around low-income and minority schools: Adopting an environmental audit tool to assess crime prevention through environmental design (CPTED).

Crime prevention through environmental design (CPTED) suggests an association between micro-scale environmental conditions and crime, but little empirical research exists on the detailed street-level environmental features associated with crime near low-income and minority schools. This study focuses on the neighborhoods around 14 elementary schools serving lower income populations in Seattle, WA to assess if the distribution of crime incidences (2013-2017) is linked with the street-level environmental features that reflect CPTED principles. We used a total of 40 audit variables that were included in the four domains derived from the broken windows theory and CPTED principles: natural surveillance (e.g., number of windows, balconies, and a sense of surveillance), territoriality (e.g., crime watch signs, trees), image/maintenance (e.g., graffiti and a sense of maintenance/cleanness), and geographical juxtaposition (e.g., bus stops, presence of arterial). We found that multiple crime types had significant associations with CPTED components at the street level. Among the CPTED domains, two image/maintenance features (i.e., maintenance of streets and visual quality of buildings) and two geographical juxtaposition features (i.e., being adjacent to multi-family housing and bus stops) were consistently associated with both violent and property crime. The findings suggest that local efforts to improve maintenance of streets and visual quality of buildings and broader planning efforts to control specific land uses near schools are important to improve safety in marginalized neighborhoods near schools that tend to be more vulnerable to crime. Our research on micro-scale environmental determinants of crime can also serve as promising targets for CPTED research and initiatives.

COVID-19 impacts on non-work travel patterns: A place-based investigation using smartphone mobility data.

The COVID-19 pandemic has brought unprecedented changes to our mobility. It has not only changed our work-related travel patterns but also impacted leisure and other utilitarian activities. Non-work-related trips tend to be more seriously affected by the neighborhood/contextual factors such as socioeconomic status (SES), and destination accessibility, and COVID-19 impact on non-work trips may not be equal across different neighborhood SES. This study compares non-work-related travel patterns between the pre- and during COVID-19 pandemic in the City of El Paso, Texas. By utilizing smartphone mobility data, we captured the visitation data for major non-work destinations such as restaurants, supermarkets, drinking places, religious organizations, and parks. We used Census block groups (n = 424) within the city and divided them into low- and high-income neighborhoods based on the citywide median. Overall, the total frequency of visitations and the distances traveled to visit these non-work destinations were influenced by the COVID-19 pandemic. However, significant variations existed in their visitation patterns by the type of non-work destinations. While the overall COVID-19 effects on non-work activities were evident, its effects on the travel patterns to each destination were not equal by neighborhood SES. We also found that COVID-19 had differently influenced non-work activities between high- and low-income block groups. Our findings suggest that the COVID-19 pandemic may exacerbate neighborhood-level inequalities in non-work trips. Thus, safe and affordable transportation options together with compact and walkable community development appear imperative to support daily travel needs for various utilitarian and leisure purposes, especially in low-income neighborhoods.

Perceived risks of transit use during COVID-19: Correlates and strategies from a case study in El Paso, Texas.

Introduction: COVID-19 has led to public transportation ridership plummeting and thus created fiscal crises and operational difficulties for transit operators. Although transit services remain essential for people with limited access to alternative transportation modes, the unfavorable public view keeps potential riders from transit. The public transportation industry is in dire need of restoring trust and recovering ridership. Methods: In July 2020, we conducted an online survey in El Paso, Texas, to investigate COVID-19 risk perceptions related to transit use. A total of 712 valid responses, consisting of 613 English and 99 Spanish responses, were included in the analyses. Results and conclusions: Descriptive and bivariate analyses showed many choice transit riders changed their mobility patterns by abandoning public transportation. Survey participants reported that social distancing and cleaning services were very important in encouraging them to return to transit. The free fare policy was also a stimulus for the existing riders to continue their transit use during the pandemic. The multivariable analysis results highlighted that public knowledge plays a vital role in COVID-19 risk perceptions and transit use decisions. Major opportunities exist in terms of public awareness campaigns that inform the public about the COVID-19 related safety measures transit operators are implementing. We further suggest some practical strategies to enhance public communication and help transit operators recover from COVID-19. This study offers timely insights for public policy stakeholders, including transit agencies, to better utilize their resources to protect public health, regain public confidence, and bring passengers back.

Developing the Intergenerational Community Survey for older adults: Assessing neighborhood environments, social and physical activities, and health.

Many survey instruments have been developed to assess neighborhood environments for their impacts on people's health and daily activities. However, no instruments are available for capturing social interactions with different age groups among older populations. This study introduces a four-phase process of developing a comprehensive Intergenerational Community Survey (ICS) covering six domains: (1) physical activities, walking, and sedentary activities; (2) mental health and quality of life; (3) social activities (e.g. intergenerational and peer interactions) in and outside the neighborhood; (4) neighborhood environments (e.g. safety, streets and sidewalks); (5) supportive services or programs (e.g. intergenerational programs, transportation services); and (6) personal characteristics. Test-retest reliability assessments among 38 community-dwelling older adults (aged 65+) showed fair to good reliability results. ICS can serve as a useful tool to facilitate future research on intergenerational communities and interactions for older adults.

COVID-19 impacts on mobility, environment, and health of active transportation users.

Active transportation could be an effective way to promote healthy physical activity, especially during pandemics like COVID-19. A comprehensive evaluation of health outcomes derived from COVID-19 induced active transportation can assist multiple stakeholders in revisiting strategies and priorities for supporting active transportation during and beyond the pandemic. We performed a two-step reviewing process by combining a scoping review with a narrative review to summarize published literature addressing the influence of COVID-19 on mobility and the environment that can lead to various health pathways and health outcomes associated with active transportation. We summarized the COVID-19 induced changes in active transportation demand, built environment, air quality, and physical activity. The results demonstrated that, since the pandemic began, bike-sharing users dropped significantly while recreational bike trips and walking activities increased in some areas. Meanwhile, there have been favorable changes to the air quality and the built environment for active transportation users. We then discussed how these changes impact health outcomes during the pandemic and their implications for urban planning and policymaking. This review also suggests that walking and biking can make up for the reduced physical activities during the pandemic, helping people stay active and healthy.

Physical Activity Impacts of an Activity-Friendly Community: A Natural Experiment Study Protocol.

Background: Stakeholders from multiple sectors are increasingly aware of the critical need for identifying sustainable interventions that promote healthy lifestyle behaviors. Activity-friendly communities (AFCs) have been known to provide opportunities for engaging in physical activity (PA) across the life course, which is a key to healthy living and healthy aging. Purpose: Our purpose is to describe the study protocol developed for a research project that examines: (a) the short- and long-term changes in total levels and spatial and temporal patterns of PA after individuals move from non-AFCs to an AFC; and (b) what built and natural environmental factors lead to changes in PA resulting from such a move, either directly or indirectly (e.g., by affecting psychosocial factors related to PA). Methods: This protocol is for a longitudinal, case-comparison study utilizing a unique natural experiment opportunity in Austin, Texas, USA. Case participants were those adults who moved from non-AFCs to an AFC. Matching comparison participants were residents from similar non-AFCs who did not move during the study period. Recruitment venues included local businesses, social and print media, community events, and individual referrals. Objectively measured moderate-to-vigorous PA and associated spatial and temporal patterns served as the key outcomes of interest. Independent (e.g., physical environments), confounding (e.g., demographic factors), and mediating variables (e.g., psychosocial factors) were captured using a combination of objective (e.g., GIS, GPS, Tanita scale) and subjective measures (e.g., survey, travel diary). Statistical analyses will be conducted using multiple methods, including difference-in-differences models, repeated-measures linear mixed models, hierarchical marked space-time Poisson point pattern analysis, and hierarchical linear mixed models. Conclusion: Natural experiment studies help investigate causal relationships between health and place. However, multiple challenges associated with participant recruitment, extensive and extended data collection activities, and unpredictable intervention schedules have discouraged many researchers from implementing such studies in community-based populations. This detailed study protocol will inform the execution of future studies to explore how AFCs impact population health across the life course.

Differential Effects of a Global Public Health Crisis on Physical Activity: Evidence From a Statewide Survey From the United States.

AIM: We aimed to identify how the COVID-19 lockdown affected changes, including the potential for longer term sustained changes, in physical activity, as compared to immediately prior to the pandemic. BACKGROUND: Physical activity's significant role in overall health is known to be influenced by the surrounding environment, such as one's neighborhood, prompting this study of physical activity and its relationship with individual-level and neighborhood-level factors within the pandemic timeline. METHODS: A statewide online survey assessed adults' self-reported weekly minutes of moderate-to-vigorous physical activity (MVPA) comparing a typical week immediately prior to the pandemic and during the pandemic (prewidespread vaccination) using negative binomial models. RESULTS: Overall, MVPA decreased during the pandemic, though the decrease was driven largely by the reduction in MVPA outside one's neighborhood. In contrast, MVPA done within one's neighborhood increased over time. This change in MVPA done within one's neighborhood was not uniform across several characteristics including income level favoring those with the highest income (p < .05) and race/ethnicity favoring those self-reporting as non-Hispanic White (p < .05). While several factors, including higher Walk Scores, were associated with higher levels of MVPA without evidence of change over time, evidence of a differential effect over time was seen for other key indicators of social and structural determinants of health including income and race/ethnicity. CONCLUSIONS: This study can add to the existing literature surrounding not only COVID-19 but also neighborhood built environmental research seeking to identify factors associated with changes in MVPA, a known indicator of overall health and health-related outcomes.

Impact of COVID-19 on physical activity: A rapid review.

Background: Physical activity is a commonly prescribed medicine for people with conditions such as obesity and diabetes who are also at increased risk of being hospitalized or severely ill from COVID-19. However, many people are reporting challenges in engaging in a healthy dose of physical activity amid the pandemic. Objective: This rapid review synthesizes the current empirical evidence about the impacts of COVID-19 on people's outdoor physical activity and sedentary behavior while highlighting the role of community environments in promoting or hindering physical activity during the pandemic. Methods: Literature searches were conducted using keywords related to COVID-19: physical activity, mobility, and lifestyle behaviors. Eligibility criteria were peer-reviewed empirical and quantitative studies published in English, addressing COVID-19 and using physical activity and/or sedentary behavior as the study outcomes. Results: Out of 61 eligible studies, the majority (78.3%) were conducted in Asian and European countries, with only four (6.7%) being US studies. The results showed that COVID-19 was linked with significant decreases in mobility, walking, and physical activity, and increases in sedentary activity. A few studies also reported contradicting results including increased uses of parks/trails and increased recreational activity among certain groups of population. Conclusions: Evidence suggests an overall negative impact of COVID-19 on physical activity, with differential effects across different sub-populations. Significant knowledge gaps are also found in the roles of social and physical attributes that can promote physical activity during pandemics with reduced safety risks.

COVID-19 in Long-Term Care Facilities: A Rapid Review of Infection Correlates and Impacts on Mental Health and Behaviors.

BACKGROUND: Long-term care facilities (LTCFs) with compact, group-living arrangements have become COVID-19 hot spots during the pandemic. Systematic research is needed to understand factors associated with COVID-19 infections in LTCFs and the inadvertent effects of preventive measures adopted by LTCFs. OBJECTIVES: This rapid review identifies factors associated with LTCF residents' COVID-19 infections and the impacts of the pandemic and the corresponding preventive measures on residents' mental health and behavioral problems. METHODS: Following the preferred reporting items for systematic reviews and meta-analyses guidelines, we identified and reviewed relevant literature in Medline, PsycINFO, and AgeLine. RESULTS: Thirty-seven articles were identified and reviewed, including 30 reporting factors associated with COVID-19 infections in LTCFs and seven reporting the impact of the pandemic and corresponding prevention measures on LTCF residents. Results revealed four domains of factors associated with COVID-19 infections: facility physical environments, resident characteristics, facility management and testing, and community factors. The pandemic and infection control measures increased residents' depression, anxiety, loneliness, and behavioral problems (e.g., agitation, hallucinations). Residents without cognitive impairments were more vulnerable to these adverse effects. CONCLUSION AND IMPLICATIONS: LTCF managers/policymakers and healthcare designers can help mitigate COVID-19 infections by (1) providing additional resources to vulnerable LTCFs; (2) enhancing the training of personal protective equipment use and guideline compliance; and (3) investing in amenities, such as sinks, quarantine rooms, and outdoor spaces. Digital activities and accessible green spaces can mitigate mental health and behavior issues. Future LTCF design can benefit from flexible spaces, natural ventilation, and reducing crowding.

People living in disadvantaged areas faced greater challenges in staying active and using recreational facilities during the COVID-19 pandemic.

This study aimed to understand the perceived effects of the COVID-19 pandemic on physical activity, recreation walking, and use of recreational facilities; and if the COVID-19 pandemic amplified disparities in physical activity, recreational walking, and use of recreational facilities related to the levels of neighborhood disadvantage. Recreational walking and the use of neighborhood streets and green spaces significantly decreased in high deprivation areas but not in low deprivation areas during the pandemic. While COVID-19 has negatively affected overall recreational activities, the inequitable impact on recreational walking and use of outdoor recreational facilities has been more evident in disadvantaged neighborhoods with greater deprivation.

Nursing Home Design and COVID-19: Implications for Guidelines and Regulation.

OBJECTIVES: Nursing homes (NHs) are important health care and residential environments for the growing number of frail older adults. The COVID-19 pandemic highlighted the vulnerability of NHs as they became COVID-19 hotspots. This study examines the associations of NH design with COVID-19 cases, deaths, and transmissibility and provides relevant design recommendations. DESIGN: A cross-sectional, nationwide study was conducted after combining multiple national data sets about NHs. SETTING AND PARTICIPANTS: A total of 7785 NHs were included in the study, which represent 50.8% of all Medicare and/or Medicaid NH providers in the United States. METHODS: Zero-inflated negative binomial models were used to predict the total number of COVID-19 resident cases and deaths, separately. The basic reproduction number (R0) was calculated for each NH to reflect the transmissibility of COVID-19 among residents within the facility, and a linear regression model was estimated to predict log(R0 - 1). Predictors of these models included community factors and NHs' resident characteristics, management and rating factors, and physical environmental features. RESULTS: Increased percentage of private rooms, larger living area per bed, and presence of a ventilator-dependent unit are significantly associated with reductions in COVID-19 cases, deaths, and transmissibility among residents. After setting the number of actual residents as the exposure variable and controlling for staff cases and other variables, increased number of certified beds in the NH is associated with reduced resident cases and deaths. It also correlates with reduced transmissibility among residents when other risk factors, including staff cases, are controlled. CONCLUSIONS AND IMPLICATIONS: Architectural design attributes have significant impacts on COVID-19 transmissions in NHs. Considering the vulnerability of NH residents in congregated living environments, NHs will continue to be high-risk settings for infection outbreaks. To improve safety and resilience of NHs against future health disasters, facility guidelines and regulations should consider the need to increase private rooms and living areas.