Average temperatures in New York State (NYS) have been increasing in recent years (Horton et al., 2014; Rosenzweig et al., 2011; New York State Department of Health, 2018) and are predicted to continue to increase during the 21st century along with the number of extreme hot days (individual days of maximum temperatures at or above 90 °F) (Horton et al., 2014). With these rises in summertime temperatures and heat events in NYS, we may see an increase in heat-related morbidity and mortality, especially among heat-vulnerable populations, as a greater number of extreme heat events (EHEs) and a rapidly aging population can offset a relative decline in vulnerability to heat (Sheridan and Allen, 2018). Over the past three decades, heat-related fatalities have exceeded all other causes of weather-related fatalities (United States Environmental Protection Agency, 2016; United States Natural Hazard Statistics, 2017a) in the United States (US) and since 2005, 25–58% of these deaths each year were attributed to extended exposure to outdoor heat or having little or no air-conditioning (A/C) (United States Natural Hazard Statistics, 2017b). Effects of extreme heat are largely preventable and spending a few hours in a cool or air-conditioned environment during EHEs can prevent or significantly reduce the impact of heat on health (Madrigano et al., 2000; Rosenthal et al., 2014; Uejio et al., 2011; Ostro et al., 2010). About 20% of homes in NYS do not have A/C and among those that have A/C about 10% do not use it (US Energy Information Administration, 2009). Residents of NYS including New York City (NYC) who opt not to use A/C most often cite costs of the equipment and utility bills as deterrents from purchase and utilization (Lane et al., 2014; Lu et al., 2017). The lack or under-utilization of A/C at home can affect an individual’s ability to avoid adverse health effects of heat, especially if they are already vulnerable to heat (Madrigano et al., 2000; Nayak et al., 2018). To provide communities with a place to cool down during hot summer days, local agencies set up cooling centers, which are usually publicly available air-conditioned or cool recreation spaces (Nayak et al., 2017).

Cooling centers can be a valuable resource for heat-vulnerable populations without access to A/C or those who cannot afford them (Widerynski et al., 2017). This intervention is typically implemented as part of a larger heat response plan which can consist of a variety of activities such as health hot lines, a warning communication system (alerts and advisories), and emergency measures customized for a community or region (Toloo et al., 2013). Cooling centers are considered a relatively low-cost strategy to help reduce the impact of heat on health. They are intended to provide shelter to large groups of people during an EHE and can be easily implemented by local agencies and stakeholders using existing infrastructure and personnel.

Usually there is no single agency or organization that sets up cooling centers in a community; instead, a variety of stakeholders play a role in planning and implementing cooling centers. In NYS, several local agencies (municipalities, fire departments, library systems, county agencies and non-profit organizations like the American Red Cross) have set-up cooling centers over the past few years, as a heat-adaptation resource for their residents (Nayak et al., 2017; New York State Department of Health, 2017). Cooling centers are usually set up in/at facilities that are accessible to the public and can include libraries, senior and community centers, fairgrounds, recreation parks, malls and grocery stores. NYS counties without cooling centers have cited numerous reasons for not prioritizing cooling centers including the absence of heat events over the past several years, sparse population, understaffed or underfunded programs, and the availability of adequate green space and natural cool down resources (Nayak et al., 2017).

An assessment of the accessibility of cooling centers could provide local agencies with important information to help guide their heat adaptation planning in their jurisdictions (Widerynski et al., 2017). To our knowledge, there has been no previous effort to assess accessibility of cooling centers in NYS. Transportation-related factors have often been cited as barriers to visiting cooling centers (Lane et al., 2014; Toronto Public Health, 2011; Sampson et al., 2013). For instance, while urban areas have frequent and reliable public transportation that facilitate access to cooling centers, many smaller towns and rural areas have limited or no public transportation, thus limiting accessibility (American Public Transportation Association, 2017). Availability of transportation has been noted to impact utilization of health care services and frequency of visits to healthcare providers (Nemet and Bailey, 1982; Arcury et al., 2005; Mattson, 2011). Similarly, we believe that distance and availability of transportation to cooling centers can impact their utilization, as well as a community’s ability to adapt to heat and prevent heat-related illness. Therefore, our primary objective in this study was to assess the accessibility of the cooling centers to general and heat-vulnerable populations in rural and urban areas of NYS by various modes of transportation including walking, public transportation, and driving. Results from this study will be shared with local agencies to help inform them on the accessibility of cooling centers in the context of heat vulnerability and help make decisions when setting up cooling centers in preparation for future EHEs.

We assessed cooling center accessibility in terms of their proximity to the general and heat-vulnerable populations (Nayak et al., 2018) by various modes of transportation in New York State (excluding NYC). Based on the 2010 US Census Bureau data (United States Census Bureau, 2010), the study area included a population of 11,148,037 residents.

In this study, we estimated cooling center accessibility in terms of distance from urban, rural and heat-vulnerable NYS residents to the nearest cooling center by walking, public transportation, or driving.

Cooling centers were observed to be primarily located in urban areas. Despite the largely urban distribution of cooling centers, only about one-third of NYS population (excluding NYC) was within walking distance of a cooling center. However, accessibility of cooling centers from heat-vulnerable tracts was considerably higher with almost 50% of heat-vulnerable population within walking distance of a cooling center. About 20% of homes in NYS do not have A/C (US Energy Information Administration, 2009) so accessibility to cooling centers during EHEs could significantly reduce the impact of heat in vulnerable populations, especially among those who do not have access to A/C.

In the four metropolitan areas that provided transportation data, about 80% of cooling centers overall, and 100% of those in heat-vulnerable tracts were within walking distance of a public transportation stop. In addition, almost all heat-vulnerable tracts had a public transportation stop within walking distance, showing that cooling center accessibility improved once public transportation was considered in these four metropolitan areas. Urban areas tend to have high building density and less green space so accessibility to A/C and cooling centers could be crucial in protecting urban populations. It is therefore noteworthy that cooling centers in our study are largely accessible by walking or public transportation to those residing in heat-vulnerable tracts in urban areas. We also observed that cooling centers in Niagara county within the GBNRTC had the longest distances from public transportation and the smallest proportion of cooling centers that were accessible via public transportation. Our findings are consistent with the Western New York Community Health Needs Assessment which found that public transit was weak or non-existent outside of major cities in that region (New York State Department of Health Centers for Medicare and Medicaid Services, 2014). Lack of transportation has often been cited as a barrier to visiting cooling centers (Lane et al., 2014; Toronto Public Health, 2011; Sampson et al., 2013). If provision of public transportation encourages use of cooling centers, as found in studies assessing the role of transportation in healthcare service utilization (Mattson, 2011), communities could potentially see a reduction in heat distress calls with a corresponding cost benefit from reduced heat-related hospitalizations. While many jurisdictions across the state provide transportation or ensure public transportation is available to cooling centers during heat events (Nayak et al., 2017), there is currently no information on use of transportation to get to cooling centers in NYS. Other states and local agencies providing transportation to cooling centers have noted that factors like cost of bus fare, having to wait at a bus stop, absence of A/C during the ride, long distances, and prolonged time due to multiple stops can be deterrents from using public transportation to visit cooling centers (Sampson et al., 2013; New York State Department of Health Centers for Medicare and Medicaid Services, 2014; Berisha et al., 2016; White-Newsome et al., 2014). One study noted that even though public transportation was available, the cooling centers were not on the direct route (White-Newsome et al., 2014). Therefore, besides the availability of transportation, these are important considerations to address towards improving cooling center utilization during a heat event. Unawareness of cooling center locations and public transportation schedules can hinder utilization. Therefore, to help the public find a cooling center near them, the NYSDOH has developed an interactive mapping application (New York State Department of Health, 2014) which allows residents to locate cooling centers near them during the summer. The mapping application provides the user with cooling center contact information, street address, directions (walking and driving), as well as timing and route information of the next scheduled bus where transportation is available.

Far fewer rural residents live within accessible distance of a cooling center than urban residents. Driving distance to cooling centers as we observed can be longer than in urban areas and public transportation could be limited (American Public Transportation Association, 2017). Our finding is consistent with rural area studies where long distances to access to healthcare and benefits is a major concern as population density decreases and geographic isolation increases (New York State Department of Health Centers for Medicare and Medicaid Services, 2014; Jones et al., 2009; Stanford Medicine). Although the overall rural population in the US is declining, ridership via public transportation in rural areas has increased (American Public Transportation Association, 2017). However, only a handful of counties (13%) in NYS have reported provision of public transportation to cooling centers (Nayak et al., 2017) so, increasing availability and frequency of transportation to cooling centers during hot days can help improve accessibility in these areas. Rural areas often do not have air-conditioned homes (Matz et al., 2015) or cooling centers for numerous reasons including the rarity of EHEs in these areas (Nayak et al., 2017). These upstate areas in NYS experience lower baseline temperatures relative to other areas in the state (Horton et al., 2014; Rosenzweig et al., 2011) and although rare, in the event of an EHE, rural residents may not be prepared to handle the heat. However, it is likely that these areas have other resources like local and state parks where people can cool off. Although rural area residents are likely to own a vehicle, local agencies are encouraged to provide rural area residents with cool-down resources in the community and provide transportation to these resources to maximize their use. Air-conditioned transportation could serve as both a means to get to a cooling center as well as a means to cool down while doing so. This could also considerably improve access among individuals that have limited mobility or no other means of transportation.

To the best of our knowledge, this is the only study that has assessed cooling center accessibility in terms of heat-vulnerable populations and modes of transportation in NYS. However, there are some limitations in our study. We restricted our analysis to cooling centers that were reported by local agencies at the start of the warmer season in NYS. Our database therefore does not include additional locations that were set up as cooling centers briefly for the duration of an EHE. This leads to the possibility of some overestimation of distance to nearest cooling center but we do not expect significant differences as we have not been notified of many changes in the locations during the summer season in NYS (New York State Department of Health, 2014). Estimating distances from census tract centroids instead of specific residential addresses could be considered as another limitation of this study. But centroids are commonly used as an aggregate approximation of residential addresses (Judge et al., 2012; Boscoe et al., 2012; Bliss et al., 2012). To further improve proximity to residential population we used population-weighted centroids, which take account of population location and can give a more relevant measurement of distance (Luo and Wang, 2003; Hwang and Rollow, 2000). Another limitation in distance calculations may be the use of straight-line measurements. Although ideal, driving distance estimations from the approximately 8.1 million housing units in NYS are resource- and time-intensive. Straight-line distance estimations in urban areas have been found to be reasonable proxies for walking distance and have been noted to be relatively comparable to distance computed via Google Maps (Boscoe et al., 2012; Bliss et al., 2012). We noted larger differences in distances computations in rural areas, but our findings by both methods demonstrate that only a small proportion of the population was within accessible distance of a cooling center. We were unable to determine accessibility of cooling centers via other transportation options including ride-shares, taxis and community shuttles due to the lack of data on schedules and utilization of these services for individual requests. Such data would be difficult to obtain from private taxi companies and the only recently available ride-share services across the state. Results from a survey of local agencies in NYS (Nayak et al., 2017) showed that some cooling centers provide shuttle services on request or as needed during a heat event. Pick up locations and frequency of shuttles would depend on requests the cooling center receives and that could vary daily. But even in these instances, data are difficult to obtain. We believe that exclusion of these data does not affect our study findings as we are estimating accessibility in terms of distance, and there would be no difference between owner-driven or taxis or ride-share vehicles.

To prevent heat-related illness, a common recommendation for immediate heat relief is to spend a few hours in an air-conditioned place. Towards this recommendation, the NYS Office of Temporary Disability Assistance offers cooling assistance benefits to enable eligible NYS residents to obtain an air-conditioner unit or fan during the summer to cool down their homes (Office of Temporary and Disability Assistance (OTDA), 2018). But many households may not be aware of the program or may not meet the eligibility criteria. Therefore, setting up cooling centers during EHEs can be an effective strategy to reduce or prevent heat-related morbidities and mortalities, specifically among heat-vulnerable populations with limited access to A/C (Widerynski et al., 2017). While existing air-conditioned facilities such as shopping malls or libraries can easily be utilized as cooling centers and impose minimal economic burden on individuals, accessibility factors including distance from cooling centers and lack of transport can influence utilization of these resources (Sampson et al., 2013; Berisha et al., 2016; White-Newsome et al., 2014; Sheridan, 2007). The provision of safe, reliable and affordable transportation to cooling centers during hot days and heat events can overcome these barriers (Widerynski et al., 2017). A simple preventive measure such as spending a few hours in an air-conditioned environment such as a cooling center or even air-conditioned transportation can provide reprieve from the heat outdoors and result in a significant reduction in heat-related emergency room visits and hospitalizations in a community (Madrigano et al., 2000; Rosenthal et al., 2014; Uejio et al., 2011; Ostro et al., 2010; Widerynski et al., 2017; Sampson et al., 2013). This accessibility assessment was performed with the goal to provide health officials with information needed for heat preparedness plans. Knowledge about vulnerable populations that may have difficulty accessing cooling centers due to restricted mobility, vehicle ownership, distance issues or lack of public transportation can aid local health officials in program planning during EHEs. In these situations, cooling centers can be set up in heat-vulnerable areas, and free or affordable transportation can be provided as needed.

In this study, we assessed accessibility in terms of geographic proximity to cooling centers but there are several other reasons why they may not be accessible or utilized. People may prefer to cool off at places that are not official cooling centers like a local eatery or a relative’s house, but we are unable to capture this information without a survey tool. Utilization of a cooling center or reasons for non-utilization, will be explored as a next step, using a survey instrument that can help understand these and other behavioral aspects not explored in this study.

The accessibility assessment in this study focused on cooling center proximity to general and heat-vulnerable populations and accessibility via different modes of transportation in NYS. Spatial patterns of accessibility varied substantially across the state. Within the four metropolitan areas, while many residents are not within walking distance of a cooling center, most, and nearly all in the most heat-vulnerable areas, are within walking distance of public transportation to a cooling center. In rural locations, where there may be less of a critical need for cooling centers due to other options for cooling off, distances are longer, and accessibility is a greater issue. Availability and awareness of affordable, reliable and convenient transportation that integrate accommodation for people with disabilities play key roles in cooling center utilization and can thereby significantly reduce the impact of heat on health in the state. This said, there are several other factors that influence the utilization of these facilities during heat events including poor health, disability, unawareness of risk, unavailability of transportation and the preference to stay at home even though it’s hot. In many of these situations, having A/C at homes can help residents find relief from the heat, even at night, when cooling centers are not open. But as the next best alternative to A/C at home, the benefits of cooling centers should be maximized to the public. Recognizing that lack of awareness of cooling centers and transportation can impede utilization, to help prevent and reduce heat-related illness, the NYSDOH developed the interactive mapping application for NYS residents to locate cooling centers near them and obtain timing and route information of the next scheduled public transportation where available. While cooling centers are an important component of heat adaptation, they are most effective to vulnerable populations when implemented along with other components of heat response including transportation, heat alerts, and cooling assistance programs. Overall, it is therefore, important for health officials to address barriers to cooling center utilization in their heat preparedness plans, by considering the HVI as a factor in where cooling centers should be, as well as improving cooling center accessibility for heat-vulnerable populations.