Barriers to Healthy Country Living: Child Obesity in Rural America, Part 2

Thursday, February 13, 2014

Kids PlayingIn the first part of this article, we looked at some of the reasons why childhood obesity is more prevalent in rural areas than in urban areas.[1],[2],[3],[4] We also explored barriers to combating obesity, including a lack of space for active living and the long distances between the home and opportunities for physical activity and healthy foods. Despite these barriers, in recent years, rural communities and stakeholders have developed promising practices tailored for these areas:

Work with the schools. Children spend a significant amount of their time in school, and having school bus schedules and family transportation plans already built around the school day makes improvements to the school environment convenient. Gym class and recess are often the most common sources of physical activity for children in rural areas, and rural families see time for physical education, the availability of recreational equipment and space, and access to the school grounds afterhours as facilitators to physical activity.[5],[6],[7] Afterschool sports clubs are another source of activity, although, as noted above, youth in rural areas often face transportation barriers. In these cases, transportation interventions should focus on finding ways to transport youth to and from these physical activity opportunities, such as late school buses and organized car pools.[8] School meals have been the focus of many well-publicized projects to increase the healthfulness of children’s’ daily diets, and this source of food may be of particular importance to rural children. School meals are an obvious area of improvement, and tactics such as requiring the inclusion of a fruit or vegetable with meals, offering healthy choices among regular and a la carte items, and improving choices in soda and vending machines are often recommended by experts and families alike.[9],[10]

Engage programs and groups already working in rural areas. Rural communities have some unique stakeholders compared to urban communities, and leveraging these existing relationships can be a useful tactic. For example, 4-H Youth Development programs are a common enrichment activity for rural youth and a recent study found that linking a parent-centered obesity prevention intervention to the program could be a promising practice.[11] Telemedicine, a growing practice in communities where specialty clinics are distant, was found to increase participation from rural families in a North Carolina childhood obesity intervention.[12] Rural communities can have an advantage in access to local farms and land suitable for gardening. Collaborations between communities and local farmers or philanthropic organizations capable of teaching gardening skills could be an opportunity.[13]

Engage ethnic and tribal groups. While children in rural areas, particularly small rural areas, are mostly White, there are significant minority populations in these areas. In particular, children from American Indian or Alaska Native families are most likely to reside in small rural areas.[14] Within the rural population, minority children are even more likely to be overweight or obese, with African-American children living in rural areas at the highest level of prevalence.[15],[16],[17] Increasing diversity in rural areas means that providers and community interventions need to be culturally competent to include these populations.[18],[19] Reaching these groups involves working with existing cultural and social institutions, such as the Mvskoke Food Sovereignty Initiative, which works to coordinate clinicians from the Indian Health Services; dietitians and nutritionists; administrators of the tribe’s WIC and Head Start programs; and other community representatives to improve access to fresh, traditional foods.[20] Other rural interventions focusing on minority populations include the Child Health Initiative for Lifelong Eating and Exercise, a Head Start-based intervention aimed at American Indian and Hispanic families in rural communities in New Mexico; and Ninos Sanos, Familia Sana, which engages school and community stakeholders in a predominantly Mexican-American rural community.[21],[22]

Work with employers. Work in rural communities has become more sedentary over time, with heavy farm labor and manufacturing moving to machines.[23] However, obesity is costly to employers, and some employers have started employer-sponsored health promotion efforts. Technical assistance in particular to small employers and rural county governments to help develop employee wellness programs that encourage parents to model healthy behaviors for their children would be an opportunity.[24]

Develop materials specific to rural communities. The Robert Wood Johnson Foundation developed the Rural Active Living Assessment Tools in 2009 specifically to assess physical activity environmental factors in rural areas. These tools are designed for local community stakeholders to use.[25] Empowering local community stakeholders to observe, measure, and decide the future direction of their communities is particularly important for rural communities where independence is valued and few government resources exist.[26]

Other resources include the Rural Assistance Center, funded by the U.S. Department of Health and Human Services Rural Initiative, which features a Rural Obesity Prevention Toolkit developed by the Nutrition Obesity Research Center’s Walsh Center for Rural Analysis, as well as a resource guide for rural areas developed by the University of North Carolina at Chapel Hill’s Active Living by Design.[27] [28]

 

[1] 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.

[2] 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

[3] 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

[4] 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.

[5] 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

[6] Patterson, M. S., Amuta, A., McKyer, E. L. J., McWinney, S., Tisone, C., & Garney, W. R. (2013, November 2–6). Correlates of elementary students in rural, low-income school districts meeting physical activity recommendations: A social ecological approach. Poster session presented at the 141st American Public Health Association Annual Meeting and Exposition, Boston, MA. Retrieved from https://apha.confex.com/apha/141am/webprogram/Paper279821.html.

[7] 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.

[8] 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

[9] 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.

[10] 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.

[11] Lynch, W., Martz, J., Eldridge, G., Bailey, S., Benke, C., & Paul, L. (2012). Childhood obesity prevention in rural settings: Background, rationale, and study design of ‘4-Health,’ a parent-only intervention. BMC Public Health, 12, 255. doi:10.1186/1471-2458-12-255

[12] Irby, M., Boles, K., Jordan, C., & Skelton, J. (2012). TeleFIT: Adapting a multidisciplinary, tertiary-care pediatric obesity clinic to rural populations. Telemedicine Journal and E-Health, 18(3), 247–249. doi:10.1089/tmj.2011.0117

[13] National Advisory Committee on Rural Health and Human Services. (2005). The 2005 report to the Secretary: Rural health and human service issues. Washington, DC: National Advisory Committee on Rural Health and Human Services. Retrieved from ftp://ftp.hrsa.gov/ruralhealth/NAC2005.pdf.

[14] 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.

[15] 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.

[16] 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

[17] 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

[18] 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.

[19] National Advisory Committee on Rural Health and Human Services. (2005). The 2005 report to the Secretary: Rural health and human service issues. Washington, DC: National Advisory Committee on Rural Health and Human Services. Retrieved from ftp://ftp.hrsa.gov/ruralhealth/NAC2005.pdf.

[20] Feiden, K. (2012). Overhauling a tribal food system: Mvskoke Food Sovereignty Initiative. Princeton, NJ: Robert Wood Johnson Foundation. Retrieved from http://www.rwjf.org/content/dam/farm/reports/program_results_reports/2012/rwjf72614.

[21] Davis, S. M., Sanders, S. G., Fitzgerald, C. A., Keane, P. C., Canaca, G. F., & Volker-Rector, R. (2013). CHILE: An evidence-based preschool intervention for obesity prevention in Head Start. Journal of School Health, 83(3), 223–229. doi:10.1111/josh.12018

[22] de la Torre, A., Sadeghi, B., Green, R. D., Kaiser, L. L., Flores, Y. G., Jackson, C. F., ... Schaefer, S. E. (2013). Ninos Sanos, Familia Sana: Mexican immigrant study protocol for a multifaceted CBPR intervention to combat childhood obesity in two rural California towns. BMC Public Health, 13(1), 1–24. doi:10.1186/1471-2458-13-1033

[23] 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.

[24] National Advisory Committee on Rural Health and Human Services. (2005). The 2005 report to the Secretary: Rural health and human service issues. Washington, DC: National Advisory Committee on Rural Health and Human Services. Retrieved from ftp://ftp.hrsa.gov/ruralhealth/NAC2005.pdf.

[25] Yousefian, A., Hennessy, E., Umstattd, M., Economos, C., Hallam, J., Hyatt, R., & Hartley, D. (2010). Development of the Rural Active Living Assessment Tools: Measuring rural environments. Preventive Medicine, 50(Suppl 1), S86–S92. doi:10.1016/j.ypmed.2009.08.018

[26] National Advisory Committee on Rural Health and Human Services. (2005). The 2005 report to the Secretary: Rural health and human service issues. Washington, DC: National Advisory Committee on Rural Health and Human Services. Retrieved from ftp://ftp.hrsa.gov/ruralhealth/NAC2005.pdf.

[27] Active Living by Design. (2011). ALBD rural resource guide. Chapel Hill, NC: University of North Carolina at Chapel Hill. Retrieved from http://www.activelivingbydesign.org/sites/default/files/ALBD%20Rural%20Resource%20Guide%20August%202011-updated%20Aug%202011.pdf.

[28]NORC Walsh Center for Rural Health Analysis. (n.d.). Rural Obesity Prevention Toolkit. Chicago, IL: Walsh Center for Rural Analysis, Nutrition Obesity Research Center at the University of Chicago. Retrieved from http://www.raconline.org/communityhealth/obesity/.


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