For
rural streets and sidewalks, included sources focused
on the presence of walkability infrastructure/characteristics,
street/sidewalk connectivity, sidewalk quality/condition, population density, destination/land
use diversity, signage, green space, hazards, safety features, bike lanes,
crosswalks, sidewalk buffers/shoulders, lighting, route connections, access to
sidewalks, wider sidewalks, and narrower roads.
For
rural parks and recreational facilities, sources focused on park additions,
park/recreational facility renovations, park/recreational facility proximity,
number of recreational resources, quality, installing bike racks, and
developing age-appropriate facilities (e.g., adult exercise stations).
For
school settings, sources focused on access to PA facilities (e.g.,
walking/running tracks, sports), recreational programming, access to PA
equipment, walkability resources, and prioritization of physical education and
recess.
For
rural trails and greenways, sources focused on implementing trails within parks,
integrating trails and nature, multiple and well-spaced trailheads, wider trails,
using trails to increase connectivity, grade, safety, convenient access, parking,
scenic beauty, degree of difficulty, signage (e.g., StoryWalk features), and extending
trail systems.
Additional
rural settings where environmental changes were studied included natural
environments, workplaces, and churches. For rural natural environments, sources
focused on the importance of creating recreational opportunities in areas with
natural amenities. For rural workplaces, sources focused on connecting
worksites to other destinations via trails or walkable routes, and creating
exercise space at the workplace. For rural churches, sources focused on the
installation of a community garden, and access to PA resources within the
church.
Objective
tools or methods were used in peer-reviewed research to capture environmental features
related to PA in rural U.S. communities (Supplemental Table 4). The types of
tools used to assess environmental features related to PA included environmental
audits or scans (e.g., windshield tours, Rural Active Living Assessment (RALA)), administrative
data (e.g., U.S. Census data), ArcGIS and Environmental System Research
Institute (ESRI) data, and Walk Score® (Griffin et al., 2011; Shores, Moore,
& Yin. 2010).
Healthy
Eating
A
total of 75 original research articles and nine grey literature sources were
identified that included objectively-measured environments for HE (Supplemental
Table 1, Supplemental Table 2, Supplemental Table 3) (Adachi-Mejia et al.,
2013; Ahern et al., 2011; Ahmed & Byker, 2017; Amerson et al., 2014;
Anderson et al., 2015; Askelson, Brady, et al., 2019; Bardenhagen et al., 2017;
Barnes, Freedman, et al, 2016; Bontrager et al., 2014; Bower et al., 2014; Bustillos
et al., 2009; Byker et al., 2015; Creel et al., 2008; D’Angelo et al., 2017;
Davis, Spurlock, et al., 2017; David, Jossefides, et al., 2019; Deller et al.,
2015; Dunn, Sharkey, & Horel, 2012; Dunn, Kalich, et al., 2015; Escaron et
al., 2016; Flamm, 2011; Fretts et al., 2018; Gantner et al., 2011; Gibson,
2011; Graves et al., 2008; Gustafson, Lewis, et al., 2012; Gustafson, Jilcott
Pitts, et al., 2017; Hanawa & Procter, 2019; Honeycutt et al., 2012;
Hosler, Rajulu, et al., 2008; Hosler, 2009; Hosler Varadarajulu, et al., 2006;
Hubley, 2011; Izumi, 2015; Jilcott Pitts, Wu, Demarest, et al., 2015; Jilcott
Pitts, Wu, McGuirt, et al., 2018; Jilcott Pitts, Wu, Truesdale, et al., 2018;
Jithitikulchai et al., 2012; Katapodis et al., 2019; Ko et al., 2018; Lu et al.,
2016; Mann et al., 2015, 2017; Martínez-Donate et al., 2015; Mayo et al., 2013; McCormack,
Eicher-Miller, et al., 2019; McCormack, Igoe, & Stahre, 2017; McGuirt,
Pitts, et al., 2015; Nanney et al., 2019; Nollen et al., 2009; Novotny et al.,
2011; Pereira et al., 2014; Powell et al., 2007; Rigby et al., 2012; Rivera et
al., 2018; Ruelle et al., 2011; Rushakoff et al., 2017; Sharkey & Horel,
2008; Sharkey, Johnson, et al., 2011; Sharkey, Horel, & Dean, 2010;
Thatcher et al., 2017; Yeager & Gatrell, 2014; Zenk et al., 2015; Blanchard
& Lyson, 2006; Holston, Cater, & Broyles, 2020; Rural Health
Infomration Hub, n.d.a; United States Deaprtment of Agriculture, 2018, 2019). Settings for HE
included food retail (n=65), schools (n=19), food assistance programs (n=7), hospitals
or healthcare settings (n=2), community gardens (n=5), churches (n=2), workplaces
(n=2), home environment (n=1), and local food producers (n=1) (Thomson, 2020;
Michimi & Wimberly, 2010).
For
rural food retail settings, included sources focused on access to healthy food
outlets (e.g., small grocers, farmers markets), absence of unhealthy food
outlets (e.g., fast food, full-service restaurants, convenience stores), fruit
and vegetable quality, stocking of heathy foods, healthy food variety,
promotional materials or advertisements, fruit and vegetable samples, canned
fruits and vegetables, price/affordability, distance or travel time to food
retail, stocking of unhealthy foods, and providing pre-prepared healthy food.
For
rural school and childcare settings, sources focused on the presence of healthy
food options, the presence of sugar-sweetened beverages, rearranging the lunch
line or coolers to feature healthier options, promoting or advertising
healthier foods (e.g., adapting names of healthy menu items, signage, menu
boards, tabletop signs with fruit and vegetable facts), precutting fruit, getting
produce from local farmers, school gardens, healthy breakfast, food outlets
around the school, reducing or removing sugar-sweetened beverage options, unhealthy
snack options, agricultural setting, and food quality.
For
food assistance program sources focused on increasing access to nutritional
information, increasing access to healthy foods, ensuring healthy food outlets
accept Supplemental Nutrition Assistance Program or other food assistance
benefits, and distance to food outlets that were authorized to accept program food
vouchers.
Additional
rural settings where environmental changes were examined included healthcare
settings, community gardens, churches, workplaces, and local food producers. For
rural hospital and healthcare settings, sources focused on informational
messages or advertisements, and salt products (e.g., packets, shakers). For
community gardens, sources focused on creating new community gardens, and
growing a variety of fruits and vegetables. For churches, sources focused on providing
healthy breakfast, installing a community garden at the church, and increasing
the amount of greenhouse/shed space. For workplaces, sources focused on promoting/advertising
healthy food options, and offering healthy food in vending machines and
cafeterias. For local food producers, sources focused on connecting local
farmers with schools.
Objective
tools or methods were used in peer-reviewed research to capture environmental features
related to HE in rural U.S. communities (Supplemental Table 4). The types of
tools used to assess environmental features related to HE included environment
audits or scans (e.g., recording content of beverage machines, windshield tours),
administrative data, Nutrition Environment Measurement Surveys, ArcGIS and
Environmental System Research Institute (ESRI) data, the spectrophotometric
Folin-Ciocalteau reagent method to measure fruit and vegetable quality, food
production records, vendor data (e.g., farmer’s market prices), Food Retail
Environment Index (mRFEI), USDA Food Environment Atlas, and ground truthing
methods.
Breastfeeding
A
total of seven original research articles and four grey literature sources were
identified that included objectively-measured environments for breastfeeding (Supplemental
Table 1, Supplemental Table 2, Supplemental Table 3) (Blair et al., 2020;
Ray et al., 2019; Uscher-Pines et al., 2020; Anderson, n.d.; National
Association of County and City Health Officials, n.d.; Oswego County Opportunities,
Inc., 2019; S2ay Rural Health Network, n.d.). Objectively-measured settings for
breastfeeding included hospitals or healthcare settings (n=8), workplaces (n=3),
food retail settings (n=2), and county fairs (n=1).
For
hospitals or healthcare settings, sources focused on access to certified
lactation counselors/consultants, support groups (e.g., mother to mother), training
for lactation counselors, and access to telehealth options for breastfeeding
(“telelactation”). For workplaces, sources focused on the presence of a
lactation room, and establishment of “Baby Cafes”. Within food retail settings,
the price and access to infant feeding resources in rural areas was measured.
Objective
tools or methods were used in peer-reviewed research to capture environmental features
related to breastfeeding in rural U.S. communities (Supplemental Table 4). The
types of tools used to assess environmental features related to breastfeeding included
administrative data, the Infant Feeding Resource Tool, and National
Immunization Survey and the Infant Feeding Practices Survey.
Discussion
This
scoping review outlines the existing body research and findings on objectively-measured
environmental features or change strategies studied in relation to PA, HE,
and/or breastfeeding in rural communities across the U.S. Overall, our results
show that sources focused on PA environments mostly included street and sidewalk,
park and recreational facility, and school settings, and were most commonly measured
using environmental audits or scans and administrative data. Sources focused on
HE environments often looked at food retail and school settings, and similar to
PA environment measurement, most commonly measured environmental features using
environmental audits or scans and administrative data. Sources focused on breastfeeding
environments often occurred in healthcare, workplace, and food retail settings,
and most commonly measured environments using administrative data. Overall,
there was a wide range of environmental strategies or features that can be used
to promote PA, HE, and breastfeeding in rural communities, reflecting a growing
focus on research that informs policy, systems, and
environmental change strategies in rural communities. Environmental
audits and publicly available administrative data are increasingly being used
to track environmental conditions, but there was a profound lack of
standardization when measuring common environmental elements for each behavior,
as is documented in our compiled list of environmental assessment tools (see Supplemental
Table 4).
Rural
PA environments have been studied extensively in recent years, and local rural
communities demonstrate a commitment to evaluating current or changing
environmental conditions that may promote health. According to our results, measuring
or assessing the walkability of neighborhood environments and improving
environments to be more pedestrian-friendly has been a priority for rural
communities in recent years. There is a growing need for pedestrian-friendly
environments in rural areas, given the increasing percentage of older adults
residing in rural areas who engage mostly in outdoor walking for PA (Glasgow
& Berry, 2013; Smith & Trevelyan, 2018). In addition, research shows
that over 67% of rural residents walk in their neighborhoods, and have
expressed a desire for additional neighborhood supports for walking (e.g.,
sidewalks, road buffers, lighting) (Fitzhugh et al., 2023; Whitfield et al.,
2019; Doescher et al., 2014; Guarino et al., 2013). For parks and recreational
facilities, our research shows that adding or improving parks and recreational
facilities has been a priority in rural areas. Similarly, our research outlines
the importance of trails and greenways that connect destinations and have
appropriate amenities.
As
many rural locations experience population growth as a result of the COVID-19
pandemic, these resources are increasingly acknowledged as important and
address a growing concern that rural communities have reduced access to PA
opportunities (Carson et al., 2023; Johnson, 2023, Veitch et al., 2013; Wende,
Stowe, Hallum et al., 2021). There was also consideration for the accessibility
of PA environments, specifically focusing on making sure these resources are
useful for all ages, while acknowledging the diversity of rural populations
according to age, ability, gender, race, ethnicity, and income status (Bopp,
2018). Results show that improving PA facilities and equipment at schools and
ensuring there is PA programming (e.g., physical education) and access to
school facilities after school hours were all important school strategies. These
environmental changes also need to be coupled with systems changes, such as
joint use agreements and Safe Routes to School programs, to ensure PA
opportunities are truly accessible in rural communities (Safe Routes
Partnership, 2015; Lafleur et al., 2013; Lanza et al., 2021; Maddock et al.,
2008; The Guide to Communtity Preventive Servicces, 2021).
HE
environmental research identified in our search included both well-studied environmental
interventions or features and research areas or intervention opportunities needing
further exploration. Food retail was a commonly included HE environmental
change setting, with most studies focused on measuring and/or addressing
inequities in access to healthy food outlets (e.g., grocery stores,
superstores) or fruits and vegetables within food retail outlets. There was
limited research on promoting local food producers, of which most focused on
connecting schools with local farmers for food supply. Environmental impacts of
food sovereignty, or local control of food systems, small-scale farming over
large agribusiness, sustainable agricultural practices, cultural
appropriateness of food practices, equity, and justice, was an understudied
strategy for increasing access to healthy foods (Condra, 2012). Food sovereignty
or local food production practices are in alignment with the overall goals of
improving access to healthy food among rural residents, who are often
negatively affected by extractive practices that denigrate rural environments
and their resources (Borras & Mohammad, 2020; Jernigan, Nguyen, et al.,
2023). This is especially true for Native Nations and Indigenous communities
residing in rural areas (Jernigan, Williams, et al., 2018; Jernigan, Salvatore,
et al., 2012; Jernigan, Demientieffm & Maunakea, 2023; Maudrie et al.,
2021).
Beyond
connecting schools with local food producers, HE environmental changes outlined
in our study focused on assessing healthy food options in schools, introducing
promotional materials for healthy foods, decreasing access to unhealthy foods
and drinks, and addressing unhealthy food environments around schools. Our
results reinforce existing knowledge that schools provide consistent access to
healthy foods, especially for children from disadvantaged backgrounds, and also
highlight the need for increased investment in underfunded school food
environments (Katz et al., 2022; Barnes, McCrabb, et al., 2021). Food
assistance programs (e.g., SNAP, WIC) were also important for increasing
healthy food access in rural communities and emphasized the importance of local
food outlets accepting food vouchers so residents don’t have to travel long
distances to access these benefits.
Increasing
access to hospital and healthcare settings was the most common rural
breastfeeding environmental approach reported in this review. This included staffing
trained lactation professionals on-site to provide consultation, creating
support groups, and providing telehealth options. While workplaces employed
similar changes, they also implemented physical spaces for breastfeeding (e.g.,
lactation rooms, Baby Cafes). Given that hospital and healthcare access is much
lower in rural areas, it is important to acknowledge the importance of these settings
for rural breastfeeding promotion (Cyr et al., 2019; Walsh et al., 2023). It is
recommended that hospitals provide breastfeeding support across the perinatal
period, so efforts should be made to consider rural-specific barriers to
providing this type of health care. It should also be noted that accessibility
to infant feeding resources could also be a factor in rural infant feeding
decisions, although deserves more exploration.
Implications
for Research and Practice
This
scoping review identified various objective tools to measure PA, HE, and
breastfeeding environmental features. There was also diversity in rural
classification systems used to determine the rurality of study sites if a rural
classification system or criteria was even noted (as opposed to just identifying
sites as “rural” without justification). There is a strong need for
standardization in measuring environmental health promotion resources and rural
classification methods to allow for better comparisons across published
findings and provide better opportunities for meta-analysis. Future researchers
and practitioners need to consider how labor-intensive objectively-measured
environmental audits are to inform interventions and evaluation, especially
considering how vast the rural landscape is (making up over 95% of land area in
the U.S.) and the potential exposure of auditors to safety hazards (United
States Census Bureau, 2016b; Conressional Research Service, 2018; Adams et al.,
2022). This could explain a trend in our results, where most assessments of
rural pedestrian environment features occurred on smaller scales (i.e., were not
generalizable). Researchers and practitioners should explore ways to scale up
objective assessments of the environment using innovative new tools, for
example, machine learning methodologies (i.e., computer vision combined with
deep learning) to audit images of rural contexts or streetscapes (e.g., Google
Street View) with greater speed, reliability, validity, and objectivity. This
is especially important since existing machine learning algorithms were created
using data from more urban settings which introduces bias when they are scaled
up across the U.S. and applied in rural contexts (Koo et al., 2022). Finally,
several behavioral settings were identified in our results that showed
potential for environmental changes but had a limited body of research and,
therefore, were not reflected in public health practice. Specifically, for PA environments,
natural
spaces, workplaces, and churches are understudied behavior or environmental change
settings.
For HE environments, healthcare
settings, community gardens, churches, workplaces, and local food producers are
understudied behavior or environmental change settings. Overall, there was a
limited body of research or practice-based evidence on environmental change
approaches for breastfeeding, suggesting that additional research is needed
across all settings.
Limitations
& Strengths
This
study has some limitations. First,
given the substantial number of articles on policy,
systems, and environmental change approaches to enhance PA, HE, and
breastfeeding, this review was divided into multiple papers for publication,
each focusing separately on policies, systems, and subjectively and objectively
assessed environments. We acknowledge that policy, systems, and environmental
change approaches are often intersecting and overlapping, and additional
research is needed to better understand these complex dynamics. Second, we did
not perform reliability checks during the article selection or results
synthesis, nor did we provide confidence or bias ratings for the selected
articles in this scoping review. Although the project's scope restricted our
ability to report these metrics, we adhered to a rigorous protocol and held
regular meetings to ensure our inclusion/exclusion criteria and results
synthesis process were well-defined. Last, our study reviewed the objective measurement
methods to assess environmental changes for PA, HE, and breastfeeding in rural
contexts and revealed a lack of standardized measurement techniques across
studies. While this limited our ability to make direct comparisons across
published work, it was an important finding of this scoping review and can help
guide future research and evaluation of policy,
systems, and environmental approaches in rural areas.
This
review also has notable strengths. First, this study identified a wide variety
of objective measurement tools and recorded the number of existing sources
which used these tools. Compiling the objective tools being used in rural
contexts is useful as it will serve as a resource for future research,
implementation, and evaluationin within rural communities. Second, this scoping
review used rigorous methods: the inclusion of a scientific librarian as a review
partner, strict training protocols, and multiple reviewers for articles. Finally,
this scoping review incorporated grey literature and graduate theses on rural-specific
environmental change approaches related to PA, HE, and breastfeeding. Although
there were very limited findings from graduate research, this study builds on
existing systematic reviews focusing on peer-reviewed original research to
include a wider variety of sources.
Conclusions
This
scoping review underscores the need for improved and standardized measurement
techniques for evaluating environmental changes to promote PA, HE, and
breastfeeding in rural U.S. communities. Future research should focus on
developing reliable and scalable methods for objectively assessing environmental
changes across diverse rural communities. Additionally, researchers should
investigate rural-focused environmental features or changes that increase the
autonomy of rural communities and address persistent health disparities. As
part of this, expanding research on understudied settings, such as natural
spaces, workplaces, churches, community gardens, and local food producers, will
provide a more comprehensive understanding of effective health promotion
strategies in rural areas. These future efforts should be used to help inform
robust opportunities for rural public health surviellence pertaining to
environmental support for PA, HE, and breastfeeding.
Correspondence should be
addressed to
Marilyn E. Wende
Department of Health
Education and Behavior
College of Health and
Human Performance, University of Florida
marilyn.wende@ufl.edu
352-294-8571
M. Renée Umstattd Meyer
Department of Public
Health
Robbins College of Health
and Human Sciences
Baylor University
Hankamer Academic Center
120.14, Waco, TX, USA
renee_umstattd@baylor.edu
(254)-710-4029
Marilyn
E. Wende: 0000-0001-7397-7048
Bailey
Houghtaling: 0000-0003-3301-7258
Kathy
J. Krey: 0009-0007-4379-898X
Randa
Lopez Morgan: 0000-0002-7207-6990
M. Renée Umstattd
Meyer: 0000-0001-5525-943X
Acknowledgements
As
with all research, the success of this project would not have been possible
without the dedication and efforts of many team members serving in different
capacities. We thank each of our team members who made this project possible,
our CDC Division of Nutrition, Physical Activity, and Obesity partners and our
Chickasaw Nation Industries, Inc. (CNI) Project Manager. We would also like to
thank and acknowledge the Expert Advisors who provided us guidance and feedback
throughout this project and the following research assistants for their
contributions on this project: Khawlah Kheshaifaty, Haley Delgado, Stephanie
Eze, Cassady Mecate, and Rebekah Summerall Woodward.
Conflicts
of Interest
We
have no conflicts of interest to disclose.
Funding
This
project was supported through Centers for Disease Control and Prevention (CDC)
Division of Nutrition, PA, and Obesity, dispersed through Chickasaw Nation
Industries (2020; Prime
Contract #: 75D30119C06517, Subaward Contract
#: 782-01528-000-02).
Author
Contributions
MEW synthesized review articles, drafted the
manuscript, and edited, finalized, and approved the submitted manuscript. MRUM
contributed to the conceptualization and design of the study methodology,
interpreted study findings, drafted results, and edited, finalized, and
approved the submitted manuscript. BH contributed to the conceptualization and
design of the study methodology, interpreted study findings, drafted results,
and edited, finalized, and approved the submitted manuscript. RLM contributed
to the design of the study methodology, acquisition of data, and reviewed and
approved the submitted manuscript. KJK contributed to the conceptualization and
design of the study methodology, interpreted study findings, drafted results,
and reviewed and approved the submitted manuscript.
Ethics
Approval and Consent to Participate
Not
applicable in this study.
This
review has been registered in the Open Science Framework Registration DOI:10.17605/OSF.IO/VXMDC.97
Availability
of Data and Materials
The complete search strategy and all data generated or analyzed
from articles meeting inclusion criteria for this study as it pertains to this
manuscript, are included in this published article and its supplementary
information files.
Creative Commons License
This
work is licensed under a Creative Commons
Attribution-Noncommercial 4.0 International License (CC BY-NC 4.0).
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