Electoral governance as a political determinant of health: state policy context, risk perception, and voter safety

Background Electoral governance is a critical political determinant of health, yet the institutional mechanisms shaping population risk remain understudied. During the 2020 U.S. general election, local officials were responsible for administering voting amid COVID 19 threats and within uneven state electoral structures. Understanding how these political institutions influence officials' perceptions of voter safety and related actions is essential for characterizing the political determinants of health. Methods We analyzed data from an October 2020 national CivicPulse survey of 493 local officials linked with county and state level indicators. Multinomial and binary logistic regression models assessed how individual characteristics, local pandemic conditions, and state electoral institutions—measured through voting by mail accessibility—predicted perceived voter safety concerns and municipal risk mitigation measures. Results State electoral institutions were the strongest predictors of heightened voter safety concern, surpassing individual and county-level factors. Although political affiliation influenced perceived risk, higher concern among officials robustly predicted whether municipalities implemented harm reducing measures. Conclusions Political institutions governing electoral access substantially shape local officials' recognition of public health risks and their protective responses. Electoral governance should be considered a structural component of public health preparedness, with implications for strengthening institutional capacity and democratic resilience.