Health equity in urban and rural settings: implementation of the place standard tool in Spain

The physical, social, and economic characteristics of neighborhoods and municipalities determine the health of their residents, shaping their behaviors and choices regarding health and well-being. Addressing local environmental inequalities requires an intersectoral, participatory, and equity-focused approach. Community participation plays a vital role by providing deeper insights into local contexts, integrating community knowledge and values into processes, and promoting healthier, fairer, and more equitable actions. In recent years, various tools have been developed to assess places and transform them into health-promoting settings. One such tool, the Place Standard Tool (PST), facilitates discussions on Social Determinants of Health grouped into 14 themes, serving as a starting point for local health interventions. In this study, that took place between August 2019 and February 2020, we described the resident’s perceptions of two municipalities in the Valencian Community, Spain, using the validated Spanish version of the PST. A mixed-method convergent-parallel design was used to gain a holistic insight into residents’ experiences concerning their physical, economic, and social environment. A total of 356 individuals from both municipalities participated in the study through discussion groups, structured interviews, and online survey. Descriptive analysis of the individual questionnaire answers was conducted, and differences between municipalities were explored. Qualitative thematic analysis was conducted on structured interviews and discussion groups. Quantitative and qualitative data were integrated to facilitate their comparison and identify areas of convergence or divergence in the findings. Overall, rural areas received more favorable evaluations compared to urban ones. Public Transport as well as Work and Local Economy were consistently rated the lowest across all groups and contexts, while Identity and Belonging received the highest ratings. In the urban area, additional negative ratings were observed for Traffic and Parking, Housing and Community, and Care and Maintenance. Conversely, Identity and Belonging, Natural Spaces, Streets and Spaces, Social Interaction, and Services emerged as the highest-rated themes overall. In the rural context, positive evaluations were given to Walking or Cycling, Traffic and Parking, Housing and Community, and Influence and Sense of Control. Significant differences (p < 0.01) between urban and rural settings were observed in dimensions related to mobility, spaces, housing, social interaction, and identity and belonging. Our study illustrated the capacity of the PST to identifying aspects within local settings that influence health, revealing both positive and challenging factors. Successful implementation requires appropriate territorial delineation, support from local authorities, and effective management of expectations. Furthermore, the tool facilitated community participation in decision-making about local environments, promoting equity by connecting institutional processes with citizen needs.


(GD5) V2
There's an avenue where seniors walk, and there isn't a single bench.(GD8)

V3
There's a lack of trees on the streets to provide shade and cool down the environment in the summer […] there are streets where you can't escape the heat.(GD8) V4 Public toilets are needed on the road to Les Rotes (beach promenade).(GD8)

V5
There are benches, streetlights, and signs that make it difficult to walk on sidewalks for wheelchair users, the blind, parents with strollers, and people carrying groceries.(GD2)

V6
In general, bike lanes are not safe; they are full of potholes and very narrow.Often, you have to ride on the sidewalk because the bike lane suddenly ends […] and you have to go on the road to the beach with cars passing too close.(GD7) V7 Crosswalks are not respected; cars don't stop.(GD3)

V8
The area of Les Marines is dangerous for walking; you have to go on the shoulder, and there's heavy traffic.

(GD2) V9
There's always traffic in front of the school, and it's dangerous.(GD2)

V10
There are places where you feel scared when riding a bicycle; cars don't respect cyclists.(GD5) Rural context V11 You can walk everywhere; this is a small town.(GD2)

V12
There are many streets with very narrow, sloping sidewalks, full of potholes […] you can't use a wheelchair or a walker, there are no ramps anywhere, or lowered curbs, you have to walk in the middle of the street.(GD3)

V13
There are many hills, and not everyone can go up to the supermarket located in the upper part of the town. .(GD8) V14 There are places that don't even have a bench to sit on. .(GD8)

V15
If you ride a bike, you have to use the road with the cars; there's no other way.

V23
The train and bus schedules are not coordinated; either you arrive long before the train comes, or you have to wait a long time[…] Same for the return trip; in the end, you lose the whole day.(GD5)

V24
There is no good connection to go to the Manises hospital; you have to drive there.(GD8)

V25
The last bus from the train station leaves at 7:20 p.m., and it's impossible to work in shifts or at night in other towns.(GD2) V26 This is a problem throughout the region.(GD1)

TRAFFIC AND PARKING
Urban context

V27
People want to park in front of their homes, and that's not possible; there's not enough space for everyone.(GD6) V28 There's not enough space for all the cars.(GD5)

V29
There are avenues where there's a lot of noise and pollution because lots of trucks pass by […] During summertime, you can't leave your windows open.We would need a bypass road to divert them outside the city. .(GD6)

V30
[…] people use the car for everything; there are trips that would be faster on foot.(GD4) V31 There are traffic jams every day at the school entrance.(GD2) V32 During summertime, the traffic is unbearable.(GD5) Rural context V33 You can park almost anywhere.(GD2)

V34
During summertime, traffic rules and parking regulations aren't followed, but as the population multiplies, it becomes more permissive.(GD1) V35 There's hardly any traffic.(GD5)

V36
People use their car to go to places that are just as close to walk to […] even to take their kids to school, even though it's nearby.(GD8) V37 The healthy habit of walking is being lost.(GD8)

STREETS AND SPACES Urban context V38
Depending on where you go, there are areas with benches and shade, or not.(GD8)

V39
During summertime, there are streets where you can't walk because of the heat.Trees should be planted to provide shade and cool down the environment a bit.(GD5) V40 It's very nice to walk in the city center […] the castle is the city's treasure.(GD4)

V41
Lighting should be improved in some streets that have dark corners […] and there should be an order in the city's aesthetics; in some streets, every building looks different.(GD6)

Rural context V42
It's very pleasant to walk around the village; it's very beautiful and peaceful.(GD2) V43 In the town square, there's a steep slope; it would be good to have a railing.(GD8)

V44
During the winter, there are some streets of the upper part of the village that have no lighting.(GD2) V45 More trees in the streets would be nice to give them a different look.(GD5)

V46
Natural spaces have improved a lot in recent years; we have incredible beaches, mountains nearby, a natural park, a greenway, and a promenade by the sea… (GD5)

V47
Accessibility to natural spaces has improved a lot […] there's even a beach adapted for people with disabilities.(GD1) V48 All the cleaning resources go to the beaches due to the algae problem.(GD6)

V49
We need more parks in the city center and Las Marinas (beach area).There are only five in total for the whole city.(GD5) Rural context

V50
The city council has worked hard to take care of the natural environment, and they have made significant improvements in the Cueva de Las Palomas […] there are projects to conserve the environment and policies aimed at preserving it.(GD1) V51 The area around Mijares need some enhancements.(GD1) V52 We are surrounded by a beautiful mountain range.(GD8) V53 San Vicente Park is fantastic.(GD2)

V54
We lack more cultural activities, such as theater and concerts, and the cultural center closes on Sundays, which is when you can go out.(GD5) V55 We lack a theater or an auditorium.(GD6)

V56
The sports center is in poor condition […] you can't do sports there without paying.(GD5)

V57
The schools are closed on weekends, and children can't play where there are courts and soccer fields.(GD5)

V58
There is nothing for us apart from bars, pubs, and the nightclub; you can walk up and down the street.(GD7) V59 Entertainment is expensive; you have to pay for everything.(GD4)

V60
This center (Llunàtics youth center) is very good; it's the best in the region.Here, we can decide what activities to do; it's a meeting place.We feel like we contribute, and it belongs a bit to us.

V61
There are several sports facilities; we have a gym, a fronton court, soccer and basketball fields … there are Pilates, Zumba, and Karate classes … and there are groups of people who go out for walks.(GD1)

V62
In the senior center, you pay a fee and only play bingo; there's nothing else … if bingos were organized every day, it would always be full.(ES8) V63 There's nothing for older people, and you end up in front of the TV all day.(ES8) V64 Children can still play in the street.(GD2) V65 There's no entertainment for young people, and they go to other towns.(GD2) V66 The winter here is long, and there's nothing to do.(GD3)

V67
For adults, there's nothing to do, but going out to the bar.There are hardly any cultural activities; you have to go to other towns or to Valencia.(GD2) V68 People go to other towns to have fun.GD8

V69
We have more things than other cities; you can even handle all administrative procedures here.(GD1)

V70
There is a lot of doctor turnover at the hospital, which results in poor care; professionals are just passing through, and they end up leaving over time.There is only one health center for the entire city, and it's far from many neighborhoods.(GD6) Rural context V71 You can buy practically everything in town; there's everything basic.(GD8)

V72
There are bakeries, butcher shops, a basic supermarket, and a municipal market on Thursdays where they sell clothing, fruits, and vegetables… (GD1)

V73
People go shopping by car in another town with large supermarkets where you can find everything and save money.(GD8) V74 The respite center is the best thing that has been done in recent years.(GD8)

V75
There is no high school; you have to go to Buñol, but at least the transportation is free.(GD5) V76 There is only a pediatrician in Buñol.(GD5) V77 We need one more doctor at the health center.(GD2)

V78
We need high-quality bars and restaurants.Some seasons, they are all closed, and you have nowhere to go.(GD1)

(GD4)
Rural context V83 There are very few companies, and therefore, very few jobs are generated.(GD1) V84 There is no industry that promotes job creation.(GD5)

V85
The city council provides you with work for six months, and then you're unemployed.(GD2) V86 Fewer and fewer people from outside come here, not even for vacations.(GD5)

V87
There

V125
The area where people gather to drink outdoors (botellón) is left in pathetic conditions with litter and broken glass in the morning; the city council cleans it up, but the following weekend, it's the same again.(GD5)

V126
[…] there is a lack of civic awareness; the administration can only do so much.(GD6) V127 Dog feces are a problem; owners should be fined.(GD6) Rural context

V128
In general, the town is quite clean, but there are areas that could be improved.(GD2) V129 There are some streets dirty due to dog feces and urine.(GD8) V130 When you report a repair to the city council, they come right away.(GD5)

V131
The area where people gather to drink outdoors (botellón) is left in pathetic conditions with litter and broken glass in the morning.(GD5)

V132
The ecopark is misused, with people disposing of waste where they shouldn't.
[…] If recycling isn't done properly, it costs all of us money.(GD1)

V133
There are many ways to participate, through the app, neighborhood councilors, the city hall office, social media… (GD1) V134 Being part of an association helps with participation.(GD5) V135 Not many people attend meetings with neighborhood councilors.(GD6) V136 There are no formats that encourage the participation of ordinary people.(GD5) V137 There is no culture of participation; people don't get involved in anything.(GD6) V138 They listen to you, but then nothing changes.(GD3)

V139
We don't complain because they don't pay attention to us; citizen participation is not real.(GD2) V140 There are chronic problems that, for some reason, aren't being resolved.(GD6) V141 There is a lack of information and transparency in decision-making.(GD6) Rural context V142 Problems shouldn't be reported on Facebook.(GD1) V143 People can go directly to the town hall or talk to the mayor on the street.(GD3)

V144
Participation is more effective through an association than individually; they pay more attention to you.

NATURAL SPACES
work during summertime, mainly in restaurants or if you clean rooms and apartments.The pay is low, and you only work during the season and for hourly wages.What about the rest of the year?(GD4) V80 It's harder for people over 45, especially women, to find work.(GD2) V81 If you want to work in something other than tourism, you have to go somewhere else.(GD7) V82 […] During the winter, you barely get by.

Supplementary Table 2. Qualitative results: English Translation of Verbatim PARTICIPANTS' EXPERIENCES IN RURAL AND URBAN CONTEXTS 1. WALKING OR CYCLING Urban context V1
You can walk everywhere here.
V22 Not all buses have wheelchair ramps; you have to call ahead, or it's a lottery.(GD3) V20I have to walk to pick up my daughters from school because I can't afford three oneway tickets and three return tickets every day.(GD2) Rural context V21 If you don't have a car, you are disconnected.(GD2)