Neighborhood-level COVID-19 hospitalizations and mortality relationships with built environment, active and sedentary travel

Most of the existing literature concerning the links between built environment and COVID-19 outcomes is based on aggregate spatial data averaged across entire cities or counties. We present neighborhood level results linking census tract-level built environment and active/sedentary travel measures with COVID-19 hospitalization and mortality rates in King County Washington. Substantial variations in COVID-19 outcomes and built environment features existed across neighborhoods. Using rigorous simulation-assisted discrete outcome random parameter models, the results shed new lights on the direct and indirect connections between built environment, travel behavior, positivity, hospitalization, and mortality rates. More mixed land use and greater pedestrian-oriented street connectivity is correlated with lower COVID-19 hospitalization/fatality rates. Greater participation in sedentary travel correlates with higher COVID-19 hospitalization and mortality whereas the reverse is true for greater participation in active travel. COVID-19 hospitalizations strongly mediate the relationships between built environment, active travel, and COVID-19 survival. Ignoring unobserved heterogeneity even when higher resolution smaller area spatial data are harnessed leads to inaccurate conclusions.