Barriers to Healthy Country Living: Child Obesity in Rural America, Part 1

Tuesday, February 11, 2014

Child with BallWe might think of country living as inherently healthful: bucolic countryside open for running and playing, fresh fruits and vegetables from a home garden or a nearby friendly farmer, a slower pace of life with time to cook and eat as a family. Given the history of 19th-century urban squalor and poverty, we might be forgiven for thinking that children in urban areas are more likely to suffer from poor health than children in rural areas; but in today’s United States, this is no longer the case.[1], [2] In recent years, researchers have found that children living in rural areas are more likely to be overweight or obese than children living in urban areas.[3], [4], [5], [6] In fact, children living in rural areas are about 25% more likely to be overweight or obese than their peers in metropolitan areas. Children in rural families are also at increased risk of poverty compared to children in urban or suburban families and face lower access to health care, lower levels of physical activity, poorer-quality food, and limited options for transportation.[7], [8]

Rural communities face unique challenges when it comes to obesity prevention. Geographical distances between the home and opportunities for physical activity and healthy eating can place a time and cost burden on families, and rural areas often have limited private and public health care opportunities that give access to childhood obesity interventions.[9] These challenges, along with the challenges associated with the high rate of poverty in rural areas, make it difficult to implement some of the healthy and active living changes that are often recommended by the childhood obesity prevention literature.

Few places to play and no way to get there. One common misconception is that rural residents have more access to “wide open spaces” and other opportunities for physical activity. However, studies of rural areas have found that there is little open public space available.[10], [11], [12] Rural communities may be unincorporated and lack a central government body that can provide or care for public spaces, resulting in a lack of space or neglect of existing spaces.[13] Small population sizes and low tax bases also limit the efficacy of local governments, and sparsely populated communities mean fewer community partners who can unite and cooperate to bring physical activity opportunities to the community.[14]

In communities where space is available, rural children face several barriers to utilizing that space. There are few destinations for physical activity in rural communities, and the distance between the home and these opportunities is a barrier for many families. This is a particularly true for rural youth who rely on adults for transportation to access physical activity opportunities.[15],[16] Another barrier to physical activity is the state of the roads themselves. Residents of rural areas are more likely to be hurt or killed in traffic incidents, and rural communities are more likely to have high speed roads, few marked pedestrian crossings, and a lack of wide shoulders or sidewalks for walking or biking.[17],[18] Finally, some studies have found that a fear of crime in public spaces is a barrier for rural families, even though this problem is more associated with urban areas. A study of the physical activity environment in rural Maine found that fears of crime, “stranger danger,” and encountering groups of ill-behaved youth in public recreational areas such as parks and basketball courts were significant deterrents to physical activity.[19] These findings are corroborated by findings from a PhotoVOICE project exploring rural families’ own perceptions of physical activity barriers, where vacant homes, loitering characters, and drug activities were seen as barriers to both the use of existing common space and allowing children to play unsupervised in the neighborhood.[20]

Promising practices from urban and suburban areas, such as sidewalk development, walking to school, and physical out-of-school time programs can be difficult to implement in rural areas where distances between the school and the home can limit the viability of active transportation and where travel burdens reduce the appeal of driving children to after school activities.[21], [22]

The high (gas) cost of healthy foods. Farms may be found in rural communities, but this is no guarantee that families have access to fresh and healthful foods. Families in rural counties have a higher risk of food insecurity compared to their urban peers.[23] Like urban families, rural families can live in “food deserts,” where there are few grocery stores or other sources of healthy food. Unlike in urban areas, solutions such as increased public or semipublic transportation to shopping centers are difficult to support in areas with few people and long distances between homes, and attracting new stores to open in rural areas with few people to support them is often financially untenable.[24], [25] Rural food deserts are associated with both higher rates of poverty and higher rates of childhood obesity.[26]

As with physical activity, the long distances between food sources and the home and the time and cost constraints of travel are major barriers to healthy eating for rural families. A study of the rural food environment in Maine found that rural shoppers felt that the biggest barrier to obtaining food was high in cost, often choose shopping locations based on sales and coupons. Travel distance to shopping centers was another barrier, with some parents traveling more than 80 miles round trip to shop. Although this is a barrier, the study found that even low-income rural families generally have access to a car and many have large freezers to preserve bargain windfalls or seasonal produce and game. This study suggested that gasoline subsidies and subsidies for freezers might be appropriate “food desert” mitigation strategies in rural communities.[27]

Federal nutrition programs are important to families in rural areas, as about 29% of rural households with children participate in at least one federal nutrition program such as the School Breakfast Program; the Women, Infants, and Children Program; the Child and Adult Care Food Program; and the National School Lunch Program.[28] However, even children with access to food in the schools may not be getting the nutrition that they need for good health. A study of middle school children in a rural Mississippi community found that fruit and vegetable intake was low, with an average intake of less than one fruit serving and less than one vegetable serving per day. The students also consumed relatively large amounts of soft drinks and sodium. A significant amount of the children’s daily calories came from meals at school, including soft drink and snack machines at the schools.[29] Other studies have confirmed that healthy choices can be lacking at schools, and rural schools with small budgets may rely heavily on cheaper but less healthy items over whole grains, fresh fruits, and vegetables.[30], [31]

Despite these barriers, there are many strengths and opportunities for healthier living in rural America. In the second part of this article, we will explore promising practices for combatting and preventing obesity in rural communities.

For Part 2 of this blog, please click here.

 

[1] Leon, D. (2008). Cities, urbanization, and health. International Journal of Epidemiology, 37(1), 4–8. doi:10.1093/ije/dym271

[2] Phillips, C., & McLeroy, K. (2004). Health in rural America: Remembering the importance of place. American Journal of Public Health, 94(10), 1661–1663.

[3] South Carolina Rural Health Research Center. (2010). Diet, physical activity, and sedentary behaviors as risk factors for childhood obesity: An urban and rural comparison. Columbia, SC: South Carolina Rural Health Research Center. Retrieved from http://rhr.sph.sc.edu/report/SCRHRC_KF_DietandPhysicalActivity.pdf.

[4] Williamson, D. A., Champagne, C. M., Han, H., Harsha, D., Martin, C. K., Newton, R. L., ... Webber, L. S. (2009). Increased obesity in children living in rural communities of Louisiana. International Journal of Pediatric Obesity, 4(3), 160–165. doi:10.1080/17477160802596148

[5] Gamble, A., Waddell, D., Ford, M., Bentley, J., Woodyard, C., & Hallam, J. (2012). Obesity and health risk of children in the Mississippi Delta. Journal of School Health, 82(10), 478–483. doi:10.1111/j.1746-1561.2012.00725.x

[6] National Advisory Committee on Rural Health and Human Services. (2011). The 2011 report to the Secretary: Rural health and human service issues. Washington, DC: National Advisory Committee on Rural Health and Human Services. Retrieved from http://www.hrsa.gov/advisorycommittees/rural/2011nacsecreport.pdf.

[7] Dillon, C., & Rowland, C. (2008). Rural obesity: Strategies to support rural counties in building capacity. Washington, DC: National Association of Counties. Retrieved from http://www.leadershipforhealthycommunities.org/images/stories/ruralobesity_naco.pdf.

[8] U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. (2013). Child Health USA 2012. Rockville, MD: U.S. Department of Health and Human Services. Retrieved from http://mchb.hrsa.gov/chusa12/pc/pages/ruc.html.

[9] Hawley, S. R., Beckman, H., & Bishop, T. (2006). Development of an obesity prevention and management program for children and adolescents in a rural setting. Journal of Community Health Nursing, 23(2), 69–80. doi:10.1207/s15327655jchn2302_1

[10] Yousefian, A., Ziller, E., Swartz, J., & Hartley, D. (2009). Active living for rural youth: Addressing physical inactivity in rural communities. Journal of Public Health Management and Practice, 15(3), 223–231. doi:10.1097/PHH.0b013e3181a11822

[11] National Advisory Committee on Rural Health and Human Services. (2011). The 2011 report to the secretary: Rural health and human service issues. Washington, DC: National Advisory Committee on Rural Health and Human Services. Retrieved from http://www.hrsa.gov/advisorycommittees/rural/2011nacsecreport.pdf.

[12] Dillon, C., & Rowland, C. (2008). Rural obesity: Strategies to support rural counties in building capacity. Washington, DC: National Association of Counties. Retrieved from http://www.leadershipforhealthycommunities.org/images/stories/ruralobesity_naco.pdf.

[13] Hennessy, E., Kraak, V. I., Hyatt, R. R., Bloom, J., Fenton, M., Wagoner, C., & Economos, C. D. (2010). Active living for rural children: Community perspectives using PhotoVOICE. American Journal of Preventive Medicine, 39(6), 537–545. doi:10.1016/j.amepre.2010.09.013

[14] Dillon, C., & Rowland, C. (2008). Rural obesity: strategies to support rural counties in building capacity. Washington, DC: National Association of Counties. Retrieved from http://www.leadershipforhealthycommunities.org/images/stories/ruralobesity_naco.pdf.

[15] Yousefian, A., Ziller, E., Swartz, J., & Hartley, D. (2009). Active living for rural youth: Addressing physical inactivity in rural communities. Journal of Public Health Management and Practice, 15(3), 223–231. doi:10.1097/PHH.0b013e3181a11822

[16] Hennessy, E., Kraak, V. I., Hyatt, R. R., Bloom, J., Fenton, M., Wagoner, C., & Economos, C. D. (2010). Active living for rural children: Community perspectives using PhotoVOICE. American Journal of Preventive Medicine, 39(6), 537–545. doi:10.1016/j.amepre.2010.09.013

[17] Smart Growth America, National Complete Streets Coalition. (n.d.). Benefits of complete streets: Complete streets work in rural communities. Washington, DC: National Complete Streets Coalition. Retrieved from http://www.smartgrowthamerica.org/documents/cs/factsheets/cs-rural.pdf.

[18] Hennessy, E., Kraak, V. I., Hyatt, R. R., Bloom, J., Fenton, M., Wagoner, C., & Economos, C. D. (2010). Active living for rural children: Community perspectives using PhotoVOICE. American Journal of Preventive Medicine, 39(6), 537–545. doi:10.1016/j.amepre.2010.09.013

[19] Yousefian, A., Ziller, E., Swartz, J., & Hartley, D. (2009). Active living for rural youth: Addressing physical inactivity in rural communities. Journal of Public Health Management and Practice, 15(3), 223–231. doi:10.1097/PHH.0b013e3181a11822

[20] Hennessy, E., Kraak, V. I., Hyatt, R. R., Bloom, J., Fenton, M., Wagoner, C., & Economos, C. D. (2010). Active living for rural children: Community perspectives using PhotoVOICE. American Journal of Preventive Medicine, 39(6), 537–545. doi:10.1016/j.amepre.2010.09.013

[21] Dillon, C., & Rowland, C. (2008). Rural obesity: Strategies to support rural counties in building capacity. Washington, DC: National Association of Counties. Retrieved from http://www.leadershipforhealthycommunities.org/images/stories/ruralobesity_naco.pdf.

[22] Yousefian, A., Ziller, E., Swartz, J., & Hartley, D. (2009). Active living for rural youth: Addressing physical inactivity in rural communities. Journal of Public Health Management and Practice, 15(3), 223–231. doi:10.1097/PHH.0b013e3181a11822

[23] Halverson, J., Brown, C., Olfert, M., Aher, M., & Abildso, C. (2011). Patterns of food insecurity, food availability, and health outcomes among rural and urban counties. Morgantown, WV: West Virginia Rural Health Research Center. Retrieved from http://publichealth.hsc.wvu.edu/wvrhrc/docs/2010_halverson_final_report.pdf.

[24] Morton, L., Bitto, E., Oakland, M., & Sand, M. (2005). Solving the problems of Iowa food deserts: Food insecurity and civic structure. Rural Sociology, 70(1), 94–112.

[25] Morton, L. W., & Blanchard, T. C. (2007). Starved for access: Life in rural America’s food desert. Rural Realities, 1(4). Retrieved from http://www.iatp.org/files/258_2_98043.pdf.

[26] Kai A., S., Jensen, E. B., & Hinrichs, C. (2009). Food deserts and overweight schoolchildren: Evidence from Pennsylvania. Rural Sociology, 74(2), 153–177.

[27] Yousefian, A., Leighton, A., Fox, K., & Hartley, D. (2011). Understanding the rural food environment—Perspectives of low-income parents. Rural and Remote Health, 11(2), 1631.

[28] Wauchope, B. A., & Shattuck, A. (2010). Federal child nutrition programs are important to rural households. Durham, NH: University of New Hampshire, Carsey Institute. Retrieved from http://www.carseyinstitute.unh.edu/publications/IB_Wauchop_Nutrition.pdf.

[29] Davy, B. M., Harrell, K., Stewart, J., & King, D. S. (2004). Body weight status, dietary habits, and physical activity levels of middle school-aged children in rural Mississippi. Southern Medical Journal, 97(6), 571–577.

[30] Graves, A., Haughton, B., Jahns, L., Fitzhugh, E., & Jones, S. J. (2008). Biscuits, sausage, gravy, milk, and orange juice: School breakfast environment in 4 rural Appalachian schools. Journal of School Health, 78(4), 197–202. doi:10.1111/j.1746-1561.2008.00286.x

[31] Schetzina, K., Dalton, W., Lowe, E., Azzazy, N., Vonwerssowetz, K., Givens, C., & Stern, H. (2009). Developing a coordinated school health approach to child obesity prevention in rural Appalachia: results of focus groups with teachers, parents, and students. Rural and Remote Health, 9(4), 1157.


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