Built Environments and Active Living in Rural and Remote Areas: a Review of the Literature

Factors Associated With Leisure-Time Bicycling Among Adults in the United States: An Urban-Rural Comparison

BACKGROUND

Bicycling is a healthy form of physical activity that can be performed by most adults as part of leisure-time (LT) activity. However, little is known about LT bicycling behaviors, especially in the rural areas of the United States. This study sought to contrast the prevalence and factors associated with LT bicycling in populations living in urban settings with those living in rural settings.

METHODS

The 2019 Behavior Risk Factor Survey, which contains information regarding LT physical activity behaviors among adults (N = 396,261) in the United States, was used to determine the prevalence, demographic profile, and likelihood of meeting the physical activity guidelines of LT bicyclists. The 2013 National Center for Health Statistics Urban/Rural Classification Scheme was used to classify respondents living in rural and urban settings.

RESULTS

Among US adults, 3.8% (95% CI, 3.7-3.9) reported LT bicycling activity, the sixth most common physical activity. Adults living in urban counties compared with rural counties had a greater prevalence of LT bicycling (3.9% vs 2.3%, respectively), with adults living in rural counties having a 34% lower probability of LT bicycling. Rural bicycling prevalence rates were lower across all demographics. Urban bicyclists, compared with rural bicyclists, cycled more months of the year. Overall, 85.5% of all bicyclists met the aerobic physical guidelines, with no differences between urban and rural bicyclists.

CONCLUSIONS

Bicycling remains an important LT physical activity among adults in the United States. However, a rural-urban difference in the prevalence does exist for LT bicycling. The reasons for this disparity warrant further investigation.

Associations of family socioeconomic indicators and physical activity of primary school-aged children: a systematic review

BACKGROUND

Family socioeconomic indicators (education, occupation, and household income) are key determinants influencing children's physical activity (PA). This study aims to systematically review the current research about the association between family socioeconomic indicators and PA among primary school-aged children and to quantify the distribution of reported associations by childs' and parents' sex and according to analysis and assessment methods.

METHODS

A systematic literature research in multiple scientific databases (MEDLINE via PubMed, Web of Science, ScienceDirect, SPORTDiscus and ERIC) was performed for literature published between 1st January 2010 and 31st March 2022. Only studies reporting statistical associations between an SES indicator of at least one parent (education, occupation, income, or an SES index) and different types and intensities of PA in primary school-aged children (6 to 12 years) were included in the analysis. The distributions of the reported associations were evaluated across and differentiated by sub-group analysis of assessment methods (objectively measured vs. self-reported PA) and analysis methods (univariate vs. multivariate models).

RESULTS

Overall, 93 studies reported in 77 publications were included in this review. Most of the studies were conducted in Europe and used self-reports (questionnaires) to assess PA. Most studies used only a single SES indicator (commonly maternal education), and only two studies calculated an SES index. The majority of the studies focused on moderate-to-vigorous physical activity (MVPA), total physical activity (TPA), and organized physical activity (OPA). Results showed predominantly positive associations between SES indicators and OPA. In contrast, results regarding different intensities of daily PA (TPA, LPA, MPA, MVPA, VPA, LTPA) were heterogeneous, with overwhelmingly no associations.

CONCLUSION

Overall, the results expand the knowledge about the association between family socioeconomic indicators and children's PA and disprove the hypothesis of a clear positive association. However, large multicenter studies are lacking using a real SES index as a predictor and analyzing gender-specific multivariate models.

A scoping review of policies to encourage breastfeeding, healthy eating, and physical activity among rural people and places in the United States

BACKGROUND

Rural U.S. residents experience a disproportionate burden of diet and physical activity (PA) related chronic disease compared to urban residents, due to resource and economic challenges. Diverse policy approaches for chronic disease prevention have been implemented to address barriers to breastfeeding, healthy eating, and PA. Therefore, the purpose of this paper is to describe policy supports for breastfeeding, healthy eating, and/or PA occurring in rural U.S. areas.

METHODS

A scoping review was conducted March-June 2020 to identify policy, systems, and environment change approaches occurring in the rural U.S. for breastfeeding, healthy eating, and PA. Search procedures were guided by the PRISMA-ScR, Arksey and O'Malley's work (2007), and a science librarian. Medline, PubMed, Web of Science, and Agricola were used to identify peer-reviewed research. ProQuest Dissertations and Theses A&I were used to identify dissertation research. Grey literature searches included Google, Google Scholar, government pages, and public health, federal nutrition assistance program, Cooperative Extension Services, and related webpages. Policy results are reported and inclusion criteria were: (1) breastfeeding, healthy eating, and/or PA focus; (2) about policy factors; (3) specific to U.S. rural populations/places; and (4) English language. Outcomes (study/source design, objective(s), methods/measurement, setting, population characteristics, behavioral focus, policy-specific results) were extracted into a standardized Excel document.

RESULTS

Results include 122 total sources: original research, with some sources referencing multiple behaviors, (n = 74 sources: 8 breastfeeding, 41 healthy eating, 42 PA), grey literature (n = 45 sources: 16 breastfeeding, 15 healthy eating, 27 PA), and graduate research (n = 3 sources: 1 breastfeeding, 2 healthy eating, 1 PA). Breastfeeding policy initiatives included policies or programs at hospitals, increasing access to resources, and improving culture or norms at workplaces. Healthy eating policy initiatives included increasing access to healthy foods, reducing financial burden, implementing programs, food assistance programs, and healthy food prescriptions at healthcare facilities. PA policy initiatives focused on Complete Streets, joint or shared use efforts, Safe Routes to Schools, master plans for greenways, trails, and/or transportation, school health plans, and childcare/school standards.

CONCLUSIONS

Results from this scoping review compile and offer commentary on existing policy solutions to improve breastfeeding, healthy eating, and/or PA in the rural U.S.

Community-Based Participatory Obesity Prevention Interventions in Rural Communities: A Scoping Review

Child obesity is a worldwide public health concern. In America, children from rural areas have greater odds of obesity in comparison to those from urban areas. Community-engaged research is important for all communities, particularly under-represented communities. This paper reports the results of a scoping review investigating community-engaged research in obesity prevention programs tested with school-aged children in rural America. A literature search of Medline Ovid was conducted to identify interventions reporting the results of obesity prevention interventions that promoted a healthy diet or physical activity (PA) behaviors to school-age children in rural communities of the United States (US). After title and abstract review, potentially relevant citations were further examined by assessing the full text. Each stage of review was conducted by two independent reviewers. Twelve studies met the inclusionary criteria and are included in this review. Most of the studies focused on elementary school participants (n = 7) and improving both diet and PA (n = 9). Out of the twelve studies, only five included the target audience in intervention development or implementation. The most popular type of community engagement was community participation (n = 4). This review revealed that community-engaged research is under-utilized in obesity prevention interventions tested with school-aged children in rural US communities.

Systematic review and meta analysis of psychological interventions to prevent or treat pediatric chronic disease in rural communities

OBJECTIVE

The purpose of this systematic review and meta-analysis was to examine the effectiveness of psychological interventions at improving physical or mental health outcomes for youth living in rural communities who have, or are at-risk for, any chronic medical condition in comparison to control interventions conducted in rural communities.

METHODS

Following prospective registration (OSF.IO/7TDQJ), 7 databases were searched through July 1, 2023. Studies were included if they were a randomized control trial of a psychological intervention conducted with youth living in a rural area who had, or were at-risk for, a chronic medical condition. Risk of bias was assessed with the Cochrane risk of bias version 2 tool. A qualitative synthesis and meta-analysis were conducted.

RESULTS

15 studies met inclusion criteria. Obesity studies (n = 13) primarily focused on body mass index metrics, with limited significant findings across studies. Asthma treatment interventions (n = 2) showed no impact on hospitalizations. 3 studies evaluated mental health outcomes with no significant group differences observed. We meta-analytically analyzed 9 studies that evaluated body mass index z-scores and identified an overall null effect (Hedge's g = 0.01, 95% CI [-0.07, 0.09], p = .85).

CONCLUSIONS

Most included studies focused on pediatric obesity, and there was a limited range of health outcomes reported. Compared to controls, minimal significant improvements in health outcomes were identified for psychological interventions for youth living in rural communities. Future efforts may benefit from situating this work more systematically within a health disparities framework with a focus on understanding mechanisms of disparities and translating this work into interventions and policy changes.

Unravelling the complex interplay of factors behind exercise limitations and physical inactivity in COPD

Exercise limitation and physical inactivity are known treatable traits for people with COPD. Maximising exercise capacity and keeping people physically active improves health status and survival rates among people with COPD. However, managing these two treatable traits can be extremely challenging for clinicians due to the complex intersectionality of factors influencing an individual's capacity, opportunity and motivation to engage in physical activity. This review presents the complex factors influencing exercise capacity ("can do"), levels of physical activity ("do do") and sedentary behaviours amongst people with COPD and provides practical recommendations on how clinicians can address some of these factors in practice. Most importantly, it highlights the importance of referring to pulmonary rehabilitation as a way to improve exercise capacity among people with COPD.

Built and natural environment correlates of physical activity of adults living in rural areas: a systematic review

BACKGROUND

According to social-ecological models, the built and natural environment has the potential to facilitate or hinder physical activity (PA). While this potential is well researched in urban areas, a current systematic review of how the built and natural environment is related to PA in rural areas is lacking.

METHODS

We searched five databases and included studies for adults (18-65 years) living in rural areas. We included quantitative studies investigating the association between any self-reported or objectively measured characteristic of the built or natural environment and any type of self-reported or objectively measured PA, and qualitative studies that reported on features of the built or natural environment perceived as barriers to or facilitators of PA by the participants. Screening for eligibility and quality assessment (using the Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields) were done in duplicate. We used a narrative approach to synthesize the results.

RESULTS

Of 2432 non-duplicate records, 51 quantitative and 19 qualitative studies were included. Convincing positive relationships were found between the availability and accessibility of places for exercise and recreation and leisure-time PA as well as between the overall environment and leisure-time PA. Possible positive associations were found between the overall environment and total and transport-related PA, between greenness/natural environment and total PA, between cycling infrastructure and aesthetics and MVPA, and between pedestrian infrastructure and total walking. A possible negative relationship was found between safety and security and total walking. Qualitative studies complemented several environmental facilitators (facilities for exercise and recreation, sidewalks or streets with low traffic, attractive natural environment) and barriers (lack of facilities and destinations, lack of sidewalks, speeding traffic and high traffic volumes, lack of street lighting).

CONCLUSIONS

Research investigating the relationship between the built and natural environment and PA behaviors of adults living in rural areas is still limited and there is a need for more high-quality and longitudinal studies. However, our most positive findings indicate that investing in places for exercise and recreation, a safe infrastructure for active transport, and nature-based activities are possible strategies that should be considered to address low levels of PA in rural adults.

TRIAL REGISTRATION

PROSPERO: CRD42021283508.

Implementation characteristics that may promote sustainability of a rural physical activity initiative: examination of Play Streets through the lens of community implementers

BACKGROUND

Play Streets, which are community-based environmental initiatives where public spaces/streets are temporarily closed to create safe, low-cost physical activity opportunities, have demonstrated feasibility and physical activity benefit in rural US areas. Yet, information is needed to identify implementation characteristics that may promote sustainability. This study examined rural Play Streets implementation characteristics that could impact sustainability from local partners' perspectives.

METHODS

Sixteen Play Streets implementation team members in rural Maryland, North Carolina, Oklahoma, and Texas, USA, participated in interviews. Semi-structured in-person individual and group interviews were conducted in the fall of 2018 (after Play Streets implementation in 2017 and 2018), recorded, and transcribed verbatim. Transcripts were analyzed using iterative, content analyses. Coding frameworks were based on the Public Health Program Capacity for Sustainability Framework, and emergent themes were also identified.

RESULTS

Interviewees' perceived characteristics for facilitating Play Streets implementation aligned with the Public Health Program Capacity for Sustainability Framework: funding stability, political support, partnerships, organizational capacity, program adaption, and communication. Interviewees also noted the importance of cultural alignment/support and the reciprocal impact of community connectedness/engagement.

CONCLUSIONS

Future research should examine the reciprocal role of public health impacts, as both outcomes and factors which may influence sustainability.

Community Participation of Individuals with Mental Illnesses in Rural Areas: Stakeholder Perspectives on Barriers and Facilitators

Community inclusion and participation are social determinants of physical and mental health. This study examines activity preferences, barriers to engagement, and potential strategies for facilitating community participation for individuals with serious mental illness living in rural communities. Data for this qualitative study were collected in a series of focus groups with a stakeholders in rural Pennsylvania. Written responses to questions on activities, barriers, facilitators, and solutions were analyzed by members of the research team. The activities that are important to our participants included both those readily accessible in rural areas and those only accessible in more urban areas. Many of the barriers identified aligned with prior research (e.g., poverty, community mobility issues). A number of novel and feasible solutions to overcome barriers were provided at the policy, program, and practice levels, some of which that can be implemented immediately, to increase participation, and improve overall health of people with mental illnesses.

Spatio-temporal effects of built environment on running activity based on a random forest approach in nanjing, China

Running activity is closely related to the urban built environment in terms of mental and physical health, and this relationship can change as a result of spatio-temporal changes. Most studies, however, do not account for this and assume a linear relationship exists between the built environment and running activity. This study, therefore, collected running data spanning 2019-2022, studied spatial distribution of four-year running activity, established built environment indicators, used a random forest approach to investigate the non-linear relationship between them, and evaluated spatio-temporal changes in the relationships over time. The findings suggested that running activities are spatially clustered and the degree of clustering varies over time, and nonlinear relationships and threshold effects between the built environment and running activity can be found through the random forest algorithm and partial dependence plots. Urban park green space, greenway, and the normalized difference vegetation index had the most significant effects on running activity. The effects of population, buildings, streets, road intersections, and points of interest on running activity changed during the Coronavirus disease 2019 pandemic. In 2022, however, these effects were consistent with those during the pre-pandemic period. Our findings fill research gaps by using spatio-temporal analysis and a non-linear approach; they can also provide a reference for urban planners in building running-suitable and healthy cities.

See Me, Hear Me, Know Me: Perspectives on Diet and Physical Activity Influences among Teens Living in Rural Texas Communities

Teens in rural communities are at greater risk of obesity than teens in urban areas. Diet and physical activity influence obesity risk. Understanding their perspectives is an important step in intervention design. This qualitative investigation explored teen perspectives on how living in a rural community influenced their diet and physical activity choices. Forty parent-teen pairs were recruited. Data collection included surveys and telephone interviews. This paper reports teen perspectives identified in the first interview. Thematic analysis was used to code and analyze the data. Findings revealed that the primary factor driving teens' diet and physical activity behaviors was the teens themselves. They clearly understood their role in the choices they made, although they acknowledged not always making the healthiest choice. This belief was driven by their motivation to engage in healthy behaviors, which was influenced by the perceived benefits derived from making healthy choices and from the synergistic relationship between diet and physical activity. Diet and physical activity, in turn, were influenced by the environment, particularly the home, social, and community environments. Family and friends were particularly influential, as well as resource availability. These findings can serve as a foundation for designing interventions tailored to this population.

Trends in Maternal Weight Disparities: Statewide Differences in Rural and Urban Minnesota Residents From 2012 to 2019

INTRODUCTION

Despite research showing substantial weight disparities along the rural-urban continuum, little work has attempted to identify differences in prepregnancy weight status or gestational weight gain (GWG) outcomes between rural and urban birthing people. As such, the goals of this research were to 1) document the prevalence of prepregnancy overweight and obesity and excessive GWG in rural and urban birthing people and 2) examine changes in rural and urban prepregnancy overweight or obesity and excessive GWG over time.

METHODS

Birth certificate data provided sociodemographic variables, prepregnancy body mass index, GWG, and rurality status on 465,709 respondents who gave birth in Minnesota from 2012 to 2019. A series of regression models estimated risk differences in 1) prepregnancy weight status and 2) excessive GWG between rural and urban respondents over time, controlling for relevant covariates.

RESULTS

Rural individuals had a 4.9 percentage-point (95% confidence interval, 4.5-5.3) higher risk of having prepregnancy overweight or obesity compared with urban individuals, and a 2.6 percentage-point (95% confidence interval, 1.9-3.3) higher risk of gaining excessive gestational weight. The disparities in prepregnancy overweight or obesity and excessive gestational weight between rural and urban individuals widened over time.

CONCLUSIONS

These findings contribute to accumulating evidence documenting notable health disparities between rural and urban individuals during the perinatal period and support the need to develop prevention and treatment efforts focused on improving the weight-related health of individuals living in rural communities.

Physical Activity Among Rural Men: Barriers and Preferences

INTRODUCTION

Physical activity positively affects health. Although 94% of Americans know the health benefits of regular physical activity, more than 75% do not achieve recommended levels. The objective of our study was to identify and define the key components of a physical activity intervention tailored to rural American men.

METHODS

We recruited rural men (N = 447) via Amazon's Mechanical Turk online platform to complete a needs assessment survey focused on their interest in a physical activity intervention, preferred intervention features, and potential intervention objectives. Data were summarized by using descriptive statistics. A cumulative logistic regression model examined associations between the men's perceived importance of physical activity to health and their interest in a physical activity intervention.

RESULTS

Almost all participants (97.7%) rated physical activity as "at least somewhat important" to their health, and 83.9% indicated they would be "at least somewhat interested" in participating in a physical activity intervention. On a scale of 1 (not at all a barrier) to 5 (very much a barrier), motivation (mean 3.4; 95% CI, 3.3-3.5), cold weather (mean, 3.4; 95% CI, 3.3-3.5), and tiredness (mean, 3.3; 95% CI, 3.2-3.4) were rated the biggest barriers to physical activity. Becoming fitter (54.1%) was the top reason for joining a physical activity program. Preferred delivery channels for receiving an intervention were mobile application (ranked from 1 being the most preferred and 9 being the least preferred: mean, 2.8; 95% CI, 2.70-3.09) and e-mail (mean, 4.2; 95% CI, 3.92-4.36). Rural men preferred interventions that taught them how to exercise and that could be done from home.

CONCLUSION

Our findings suggest US men in rural areas are receptive to physical activity programs. A systematic approach and a clear model of development are needed to tailor future physical activity interventions to the special needs of rural men.

Overweight and Obesity in Finnish Children by Parents' Socioeconomic Position-A Registry-Based Study

Objectives: To examine associations between parents' socioeconomic position (SEP) and child overweight and obesity, using registry data. Methods: Data (final n = 194,423) on children's height, weight and parents' SEP were drawn from the national Register of Primary Health Care Visits (Avohilmo) and Statistics Finland. Risk ratios for bernoulli-distributed overweight (RROW) and obesity (RROB) according to SEP were estimated using generalized linear models and using a log -link. Results: The risk for obesity was lower in boys from high-income families (RROB 0.76), for overweight and obesity was lower in boys (RROW 0.72, RROB 0.58) and girls (RROW 0.72, RROB 0.54) with highly educated fathers, in boys (RROW 0.79, RROB 0.58) and girls (RROW 0.78, RROB 0.56) with high-educated mothers and in boys (RROW 0.85, RROB 0.77) and girls (RROW 0.80, RROB 0.69) living in urban areas, as compared to low-income families, low-educated parents, and rural residence, respectively. Conclusion: The risk of overweight and obesity was increased in children with low SEP or rural residence. Administrative registers are a valid approach to monitor childhood obesity by parents' SEP.

Development and reliability testing of an audit toolbox for the assessment of the physical activity friendliness of urban and rural environments in Germany

Background

According to socio-ecological theories, physical activity behaviors are linked to the physical and social neighborhood environment. Reliable and contextually adapted instruments are needed to assess environmental characteristics related to physical activity. This work aims to develop an audit toolbox adapted to the German context, to urban and rural settings, for different population groups, and different types of physical activity; and to evaluate its inter-rater reliability.

Methods

We conducted a systematic literature search to collect existing audit tools and to identify the latest evidence of environmental factors influencing physical activity in general, as well as in German populations. The results guided the construction of a category system for the toolbox. Items were assigned to the categories based on their relevance to physical activity and to the German context as well as their comprehensibility. We piloted the toolbox in different urban and rural areas (100 street segments, 15 parks, and 21 playgrounds) and calculated inter-rater reliability by Cohen's Kappa.

Results

The audit toolbox comprises a basic streetscape audit with seven categories (land use and destinations, traffic safety, pedestrian infrastructure, cycling infrastructure, attractiveness, social environment, and subjective assessment), as well as supplementary tools for children and adolescents, seniors and people with impaired mobility, parks and public open spaces, playgrounds, and rural areas. 76 % of all included items had moderate, substantial, or almost perfect inter-rater reliability (κ > 0.4).

Conclusions

The audit toolbox is an innovative and reliable instrument for the assessment of the physical activity friendliness of urban and rural environments in Germany.

Social participation of older people in urban and rural areas: Canadian Longitudinal Study on Aging

BACKGROUND AND OBJECTIVES

Although the positive influence of social activity on health is now well-established, a complex relationship exists among social participation, personal, social and the environment. Social participation of older adults was examined in rural and urban settings to identify features of the built-environment and perception of neighborhood specific to the locale.

RESEARCH DESIGN AND METHODS

Using cross-sectional data from the Canadian Longitudinal Study on Aging (CLSA), we examined social participation and health of older people (65 + yrs) in relation to the built environment and sociocultural contexts for urban and rural areas. A social participation index was derived from responses on the frequency of participating in 8 social activities over the past 12 months. Personal, household and neighborhood indicators were examined to develop multivariable regression models for social participation in urban and rural cohorts.

RESULTS

No meaningful differences were seen with the frequency of social participation between rural and urban settings; however, the type of community-related activities differed in that a greater proportion of urban participants reported sports and educational/cultural events than rural participants. Service club activities were greater for rural than urban participants. Different neighborhood features were statistically significant factors in explaining social participation in rural than in urban locales, although transportation was a significant factor regardless of locale. Trustworthiness, belonging and safety were perceived factors of the neighborhood associated with higher social participation for rural participants.

DISCUSSION AND IMPLICATIONS

The relationship between home and health becomes stronger as one ages. Social and physical features of built environment specific to urban and rural settings need to be considered when implementing appropriate social activities for older people.

Integrating Civic Engagement Into a Lifestyle Intervention for Rural Women - A Mixed Methods Process Evaluation

PURPOSE

The present study aimed to evaluate the implementation of a civic engagement curriculum (HEART Club) designed to catalyze positive environmental change in rural communities.

DESIGN

The HEART Club curriculum was integrated into a six-month community-based health behavior intervention to reduce cardiovascular disease risk.

SETTING

Participants were recruited from eight rural towns in Montana and New York.

SUBJECTS

101 midlife and older women.

INTERVENTION

Participants worked to address an issue related to their local food or physical activity environment and establish progress monitoring benchmarks.

METHOD

Evaluation components included after-class surveys, program leader interviews (n = 15), participant focus groups (n = 8), and post-intervention surveys.

RESULTS

Intervention sites reported high fidelity (78%) to the curriculum. Average attendance was 69% and program classes were rated as highly effective (4.1 out of 5). Despite positive participant feedback, low readiness for civic engagement and insufficient time were implementation challenges. The majority of HEART Club groups had accomplished two or more benchmarks post-intervention. Facilitators of progress included community support, effective leadership, and collective effort. Participants also indicated that trying to affect community change while simultaneously making personal health improvements likely stalled initial progress.

CONCLUSION

These findings highlight the potential and challenges associated with civic engagement within the context of rural lifestyle interventions. Future implementation efforts should focus on reframing civic engagement as an approach to support and maintain behavior change.

Trends in the rate of regular exercise among adults: results from chronic disease and risk factor surveillance from 2010 to 2018 in Jiangsu, China

Objective

The aims of this study were to estimate the rates of regular exercise and its trends among the adult population in Jiangsu, from 2010 to 2018, China, and to assess associations with sociodemographic factors.

Methods

Chronic disease and risk factor surveillance data from adults aged ≥18 years were gathered in Jiangsu Province from 2010 to 2018. Rates of regular exercise were calculated after post-stratification weighting, and time trends were compared among participants with different characteristics, including gender, age, urban-rural region, educational level, occupation, annual household income, body mass index (BMI), baseline self-reported chronic diseases, smoking status, alcohol consumption, and region. Multivariable logistic regression analyses were performed to assess the associations of sociodemographic characteristics with regular exercise.

Results

A total of 33,448 participants aged 54.05 ± 14.62 years and 55.4% female (8,374 in 2010, 8,302 in 2013, 8,372 in 2015, and 8,400 in 2018) were included in this study. The weighted rate of regular exercise was 12.28% (95% confidence interval [CI]: 9.11-15.45%) in 2010 and 21.47% (95% CI, 17.26-25.69%) in 2018, showing an overall increasing trend (P for trend = 0.009). Nevertheless, stratification analysis showed that the regular exercise rate decreased from 33.79% in 2010 to 29.78% in 2018 among retired adults. Significant associations were observed between regular exercise and age >45 years (45- < 60 years, odds ratio [OR]: 1.24, 95% CI: 1.14-1.34; ≥60 years, OR: 1.20, 95% CI: 1.08-1.34), urban residence (OR: 1.43, 95% CI: 1.32-1.54), higher education (primary, OR: 1.30, 95% CI: 1.16-1.46; secondary, OR: 2.00, 95% CI: 1.79-2.25; college or higher, OR: 3.21, 95% CI: 2.77-3.72), occupation (manual work, OR: 1.52, 95% CI: 1.33-1.73; non-manual work, OR: 1.69, 95% CI: 1.54-1.85; not working, OR: 1.22, 95% CI: 1.03-1.44; retired, OR: 2.94, 95% CI: 2.61-3.30), higher income (¥30,000- < ¥60,000, OR: 1.16, 95% CI: 1.06-1.28; ≥¥60,000, OR: 1.20, 95% CI: 1.10-1.32), higher BMI (overweight, OR: 1.12, 95% CI: 1.05-1.20), self-reported chronic disease at baseline (OR: 1.24, 95% CI:1.16-1.33), former smoking (OR: 1.15, 95% CI: 1.01-1.31) and ever (30 days ago) drinking (OR: 1.20, 95% CI: 1.11-1.29).

Conclusion

The rate of regular exercise among adults in Jiangsu Province was low, but this rate increased by 9.17% from 2010 to 2018, showing an upward trend. There were differences in the rate of regular exercise among different sociodemographic factors.

Barriers, facilitators, and opportunities to promote healthy weight behaviors among preschool-aged children in two rural U.S communities

BACKGROUND

Obesity levels are higher in rural versus urban children. Multi-level community-based interventions can be effective in promoting healthy child weight, but few of such interventions have focused on rural children. This formative study assessed barriers, facilitators, and opportunities to promote healthy child weight in two rural communities.

METHODS

Multiple data collection methods were used concurrently in two rural communities in Indiana and North Carolina. Focus groups and interviews were conducted with participants, including parents of children aged 2-5 years (n = 41), childcare providers (n = 13), and stakeholders from 23 community organizations. Observational audits were conducted at 19 food outlets (grocery stores) and 50 publicly-accessible physical activity resources. Focus groups/interviews were analyzed thematically. Surveys were analyzed using descriptive statistics, Fisher's exact test, and t-tests.

RESULTS

Family level barriers included limited financial resources and competing priorities, whereas parental role-modeling was perceived as a facilitator of healthy weight behaviors. At the organizational level, childcare providers and community stakeholders cited limited funding and poor parental engagement in health promotion programs as barriers. Childcare providers explained that they were required to comply with strict nutrition and physical activity guidelines, but expressed concerns that similar messages were not reinforced at home. Facilitators at the organizational level included healthy meals provided at no cost at childcare programs, and health promotion programs offered through community organizations. At the community level, lack of public transportation, and limited access to healthy food outlets and physical activity-promoting resources posed barriers, whereas existing physical activity resources (e.g., parks) and some ongoing investment to improve physical activity resources in the community were assets. In designing/implementing a potential child obesity prevention intervention, participants discussed the need to garner community trust, emphasize wellness instead of obesity prevention, establish community partnerships, and leverage existing community resources.

CONCLUSIONS

Rural areas experience multiple challenges that make it difficult for children/families to engage in healthy weight behaviors. This study highlights several assets (existing programs/resources, expertise within communities) that can be leveraged as facilitators. Findings will guide the study team in developing a child obesity prevention intervention for the two rural communities.

Urban-rural disparities in childhood obesogenic environments in the United States: Application of differing rural definitions

BACKGROUND

Research is needed that identifies environmental resource disparities and applies multiple rural definitions. Therefore, this study aims to examine urban-rural differences in food and physical activity (PA) environment resource availability by applying several commonly used rural definitions. We also examine differences in resource availability within urban-rural categories that are typically aggregated.

METHODS

Six food environment variables (access to grocery/superstores, farmers' markets, fast food, full-service restaurants, convenience stores, and breastfeeding-friendly facilities) and 4 PA environment variables (access to exercise opportunities and schools, walkability, and violent crimes) were included in the childhood obesogenic environment index (COEI). Total COEI, PA environment, and food environment index scores were generated by calculating the average percentile for related variables. US Department of Agriculture Urban Influence Codes, Office of Management and Budget codes, Rural-Urban Continuum Codes, Census Bureau Population Estimates for percent rural, and Rural Urban Commuting Area Codes were used. One-way ANOVA was used to detect urban-rural differences.

RESULTS

The greatest urban-rural disparities in COEI (F=310.2, P<.0001) and PA environment (F=562.5, P<.0001) were seen using RUCC codes. For food environments, the greatest urban-rural disparities were seen using Census Bureau percent rural categories (food: F=24.9, P<.0001). Comparing remote rural categories, differences were seen for food environments (F=3.1, P=.0270) and PA environments (F=10.2, P<.0001). Comparing metro-adjacent rural categories, differences were seen for PA environment (F=4.7, P=.0090).

CONCLUSION

Findings inform future research on urban and rural environments by outlining major differences between urban-rural classifications in identifying disparities in access to health-promoting resources.

A novel method to map community- and neighborhood-level access to rural physical activity built environments in the United States

Physical activity (PA) built environments may support PA among rural youth and families. In the United States (U.S.), differences between rural and urban PA built environments are assessed using coarse scale, county-level methods. However, this method insufficiently examines environmental differences within rural counties. The present study uses rural-specific geospatial mapping techniques and a fine scale, within-rural grouping strategy to identify differing levels of access to the PA built environment among a rural sample. First, PA infrastructure variables (parks, sidewalks) within a rural region of the Midwest U.S. were mapped. Then, households (N = 112) of participants in the NU-HOME study, a childhood obesity prevention trial, were categorized to community-level and neighborhood-level PA built environment groups using two access indicators; Rural-Urban Commuting Area (RUCA) codes and Walk Scores®, respectively. Finally, households were categorized to new groups that combined community-level RUCA codes and neighborhood-level Walk Scores® to indicate the diverse ways in which rural families might access PA built environments, including by vehicle travel and pedestrian commuting. Household access to PA infrastructure (per geospatial proximity and density analyses), parent perceptions of the PA environment, and child PA were examined across the new combined access groups. All measures of household access to PA infrastructure significantly differed by group (p <.0001). Several parent PA perceptions differed by group; child PA did not. The present study provides future researchers with innovative strategies to map and examine how access to the PA built environment differs within a rural area. Due to the public availability of the access indicators used (RUCA codes, Walk Scores®), study methods can be replicated.

Differences in Rural Built Environment Perceptions Across Demographic and Social Environment Characteristics

The benefits of physical activity to health and obesity prevention are well established. However, attributes of the built environment influence participation in physical activity. The purpose of this study is to assess differences in perceptions of neighborhood walkability across demographic characteristics and social environment factors among rural residents. In a telephone survey, adult respondents (N = 448) across nine rural counties in a southeastern state answered questions about perceived neighborhood walkability, demographic characteristics, and their neighborhood social environment. Study recruitment for a convenience sample occurred through collaborations with local community organizations. Prevalence of destinations and barriers were estimated according to demographic and neighborhood social environment characteristics. Multiple logistic regression models assessed the association of demographic and neighborhood social environment characteristics with neighborhood walkability and calculated adjusted prevalence. Relaxing places to walk were the most often reported destinations (62.0%), followed by retail destinations (45.7%), and communal destinations (42.6%). Traffic was the most reported barrier to safe walking (40.4%), followed by animals (37.5%), and crime (30.5%). Perceptions of retail and communal destinations varied by age and race. Perceptions of traffic and crime as barriers varied by race, weight status, and income. Community belonging and social cohesion were associated with lower perceptions of barriers. Study findings present demographic characteristics and social environment attributes as key factors that shape perceived neighborhood walkability. Findings can help inform programmatic efforts and environmental change strategies to improve walking in rural areas.

Psychosocial and environmental determinants of active transport to school in Austrian rural communities: a cross-sectional study among schoolchildren and their parents

Background

Active transport to school (ATS) is an effective health-promoting intervention to integrate physical activity into children’s everyday lives. While previous studies have examined environmental and behavioural determinants on ATS in urban areas, evidence on rural areas is rare.

Method

This study examined whether environmental and psychosocial characteristics are associated with ATS in two rural communities in Austria. Participants from four schools (two primary / two secondary schools) returned a self-reported questionnaire on individual and environmental determinants of ATS consisting of one section for parents and one for children, with 382 of the 467 total responses being included in the analysis.

Results

Bivariate analyses showed a significant association of psychosocial characteristics of parents and children (intention, attitude, social norm, perceived behavioural control: p < 0.001), one environmental item (walking and cycling network: p ≤ 0.001) as well as distance and duration for walking to/from school between ATS. In a multiple regression model, the chances of participating in ATS were higher among children who have higher perceived behavioural control, walk between 5 to 10 minutes to school, and whose parents have a higher commitment to ATS.

Conclusions

Future initiatives to enhance ATS in rural areas should focus on the control beliefs of parents and children, and should involve parents in order to increase parents’ commitment to ATS. Additionally, measures should explore the effects of active transport promotion in the context of public transport and school buses. Above all, further opportunities for ATS should be considered in spatial and community planning.

“Sympathy” vs.“Empathy”: Comparing experiences of I2Audits and disability simulations

People with disability often experience stigma and discrimination, and people with disability in rural areas may experience these at higher rates. Additionally, people with disability in rural areas may have fewer opportunities for physical and social participation due to barriers in the built environment. Activities such as disability simulations and inclusive, interdisciplinary community planning workshops (i.e., I2Audits) seek to draw awareness to and address these problematic experiences. The present study used thematic analysis from qualitative research to examine the advantages and disadvantages of using disability simulations and I2Audits in rural communities. Findings suggest that disability simulations increase stigmatization, lead to feelings of embarrassment and discomfort, and do not capture the experiences of people with disability. On the other hand, I2Audits lead to meaningful environmental changes, create feelings of empowerment, and center the lived experiences of people with disability within a bio-psycho-social model of disability. Results suggest that not only can I2Audits be a powerful tool to draw attention to physical barriers that people with disability face, but they also draw attention to the multi-level changes needed to increase opportunities for participation and address sources of stigma and discrimination in rural areas.

Evaluation of a civic engagement approach to catalyze built environment change and promote healthy eating and physical activity among rural residents: a cluster (community) randomized controlled trial

BACKGROUND

Prior studies demonstrate associations between risk factors for obesity and related chronic diseases (e.g., cardiovascular disease) and features of the built environment. This is particularly true for rural populations, who have higher rates of obesity, cancer, and other chronic diseases than urban residents. There is also evidence linking health behaviors and outcomes to social factors such as social support, opposition, and norms. Thus, overlapping social networks that have a high degree of social capital and community cohesion, such as those found in rural communities, may be effective targets for introducing and maintaining healthy behaviors.

METHODS

This study will evaluate the effectiveness of the Change Club (CC) intervention, a civic engagement intervention for built environment change to improve health behaviors and outcomes for residents of rural communities. The CC intervention provides small groups of community residents (approximately 10-14 people) with nutrition and physical activity lessons and stepwise built environment change planning workshops delivered by trained extension educators via in-person, virtual, or hybrid methods. We will conduct process, multilevel outcome, and cost evaluations of implementation of the CC intervention in a cluster randomized controlled trial in 10 communities across two states using a two-arm parallel design. Change in the primary outcome, American Heart Association's Life's Simple 7 composite cardiovascular health score, will be evaluated among CC members, their friends and family members, and other community residents and compared to comparable samples in control communities. We will also evaluate changes at the social/collective level (e.g., social cohesion, social trust) and examine costs as well as barriers and facilitators to implementation.

DISCUSSION

Our central hypothesis is the CC intervention will improve health behaviors and outcomes among engaged citizens and their family and friends within 24 months. Furthermore, we hypothesize that positive changes will catalyze critical steps in the pathway to improving longer-term health among community residents through improved healthy eating and physical activity opportunities. This study also represents a unique opportunity to evaluate process and cost-related data, which will provide key insights into the viability of this approach for widespread dissemination.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05002660 , Registered 12 August 2021.

Supporting Rehabilitation of Rural Patients Receiving Total Knee Arthroplasty Through Physical Activity: Perceptions of Stakeholder Groups

Objective

To identify how patients with osteoarthritis waiting for and recovering from total knee arthroplasty (TKA) conceptualized and participated in physical activity behaviors in their rural setting and to gather perceptions of health care professionals and rehabilitation decision‐makers on the feasibility of a remotely led physical activity coaching intervention.

Methods

Using a qualitative descriptive study, we collected data from three stakeholder groups: patients waiting for or recovering from TKA (interviews), health professionals delivering a physical activity intervention to patients in the recovering cohort (focus group), and rehabilitation leaders involved in decision‐making at the local or provincial level (interviews).

Results

A total of 38 individuals provided their perspectives (25 patients, five health professionals, eight decision‐makers). Patients waiting for and recovering from surgery described the attributes of their rural environment that supported and restricted their ability to participate in physical activities. Patients recovering from TKA appreciated support for goal‐setting and problem‐solving during their rehabilitation. Health care professionals and decision‐makers commented on the benefits of the program's innovative use of relatively simple technology to support remotely delivered, personalized rehabilitation in rural settings.

Conclusion

This study adds to the limited voice of and about patients living with osteoarthritis who reside in rural settings and identifies facilitators and barriers to TKA rehabilitation in this population. Our findings highlight that it is important to consider the local context and the resources available to patients as they navigate living well with osteoarthritis.

Driving Distance and Food Accessibility: A Geospatial Analysis of the Food Environment in the Navajo Nation and Border Towns

The Navajo Nation, an area home to approximately 173,000 people in the southwest United States, experiences the highest rates of food insecurity in the United States and is classified as a food desert. The present study assessed the accessibility to food outlets (grocery stores, convenience stores, and restaurants) as measured by driving time on the Navajo Nation and in selected surrounding border towns. Food outlets located in neighboring border towns were examined using network analysis tools in ArcGIS Pro to calculate driving distance and examine the potential impact of driving time within the Navajo Nation on accessibility to nutritious foods. There were 14 grocery stores, 21 convenience stores, and 65 restaurants identified in the Navajo Nation using Mergent Intellect, a proprietary database, as compared to border towns which had a total of 542 grocery stores, 762 convenience stores, and 3,329 restaurants equaling a ratio of about 50:1 (grocery, 39:1; convenience, 36:1; restaurants, 51:1) when comparing food outlets nearby versus on the Navajo Nation. This ecological study presents a visual representation of driving time and food accessibility, revealing geographic areas within the Navajo Nation where access to border town food stores is sparse, and food insecurity may be elevated.

Benchmarking the driver acceleration impact on vehicle energy consumption and CO2 emissions

The study proposes a methodology for quantifying the impact of real-world heterogeneous driving behavior on vehicle energy consumption, linking instantaneous acceleration heterogeneity and CO₂ emissions. Data recorded from 20 different drivers under real driving are benchmarked against the Worldwide Harmonized Light Vehicle Test Cycle (WLTC), first by correlating the speed cycle with individual driver behavior and then by quantifying the CO₂ emissions and consumption. The vehicle-Independent Driving Style metric (IDS) is used to quantify acceleration dynamicity, introducing driving style stochasticity by means of probability distribution functions. Results show that the WLTC cycle assumes a relatively smooth acceleration style compared to the observed ones. The method successfully associates acceleration dynamicity to CO₂ emissions. We observe a 5% difference in the CO₂ emissions between the most favourable and the least favourable case. The intra-driver variance reached 3%, while the inter-driver variance is below 2%. The approach can be used for quantifying the driving style induced emissions divergence.

Individual-Level and Neighborhood-Level Factors Associated with Longitudinal Changes in Cardiometabolic Measures in Participants of a Clinic-Based Care Coordination Program: A Secondary Data Analysis

Background: Identifying individual and neighborhood-level factors associated with worsening cardiometabolic risks despite clinic-based care coordination may help identify candidates for supplementary team-based care. Methods: Secondary data analysis of data from a two-year nurse-led care coordination program cohort of Medicare, Medicaid, dual-eligible adults, Leveraging Information Technology to Guide High Tech, High Touch Care (LIGHT2), from ten Midwestern primary care clinics in the U.S. Outcome Measures: Hemoglobin A1C, low-density-lipoprotein (LDL) cholesterol, and blood pressure. Multivariable generalized linear regression models assessed individual and neighborhood-level factors associated with changes in outcome measures from before to after completion of the LIGHT2 program. Results: 6378 participants had pre-and post-intervention levels reported for at least one outcome measure. In adjusted models, higher pre-intervention cardiometabolic measures were associated with worsening of all cardiometabolic measures. Women had worsening LDL-cholesterol compared with men. Women with pre-intervention HbA1c > 6.8% and systolic blood pressure > 131 mm of Hg had worse post-intervention HbA1c and systolic blood pressure compared with men. Adding individual’s neighborhood-level risks did not change effect sizes significantly. Conclusions: Increased cardiometabolic risks and gender were associated with worsening cardiometabolic outcomes. Understanding unresolved gender-specific needs and preferences of patients with increased cardiometabolic risks may aid in tailoring clinic-community-linked care planning.

In search of sustainable and inclusive mobility solutions for rural areas

Background

Despite emerging research on novel mobility solutions in urban areas, there have been few attempts to explore the relevance and sustainability of these solutions in rural contexts. Furthermore, existing research addressing rural mobility solutions typically focuses on a specific user group, such as local residents, second-home owners, or tourists. In this paper, we study the social inclusivity, economic viability, and environmental impacts of novel mobility solutions in rural contexts based on published scholarly literature. When doing so, we bring both permanent and temporary residents of rural areas under one research framework.

Methods

We used grey literature to identify and categorise novel mobility solutions, which have been applied in European rural areas and are suitable for travelling longer distances. By using six service flexibility variables, we reached four categories of novel mobility solutions: semi-flexible demand-responsive transport, flexible door-to-door demand-responsive transport, car-sharing, and ride-sharing. We analysed the social inclusivity, economic viability, and environmental impacts of those categories based on criteria and evidence identified from scholarly literature by including the perspectives of both permanent and temporary residents of rural areas.

Results

Our findings revealed that while single novel mobility solutions are seldom applicable for all rural travellers, strong spatial and temporal synergies exist when combining different solutions. The need for a connected and flexible set of mobility solutions sensitive to the temporal and spatial patterns of mobility needs is inevitable. Accessible and easily understandable information on routing, booking, and ticketing systems, as well as cooperation, shared values, and trust between various parties, are key success factors for sustainable rural mobility.

Conclusion

Integration of the needs of various user groups is essential when aiming to achieve the provision of environmentally, socially, and economically sustainable mobility solutions in rural areas.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12544-022-00536-3.

Play-Friendly Communities in Nova Scotia, Canada: A Content Analysis of Physical Activity and Active Transportation Strategies

The Play-Friendly Cities framework describes key municipal actions and indicators which support a community’s playability and can positively influence children’s health behaviors and quality of life. The purpose of this study was to conduct a content analysis of Nova Scotia physical activity (PA) and active transportation (AT) strategies by applying the playability criteria in the Play-Friendly Cities framework. Methods: PA and AT strategies from communities across Nova Scotia were assessed using the Play-Friendly Cities framework. Strategy content was analyzed based on indicators across four themes: participation of children in decision making, safe and active routes around the community, safe and accessible informal play environments, and evidence-informed design of formal play spaces. Results: Forty-two (28 PA,14 AT) strategies were reviewed and all included statements reflective of at least one indicator (8 ± 4; range: 1–14). Content about safe and active routes around the community was most prevalent (41 plans, 812 mentions), while participation of children in decision making was least frequently presented (18 plans, 39 mentions). Content about safe and accessible informal play environments (31 plans, 119 mentions) and evidence-informed design of formal play spaces (28 plans, 199 mentions) was also present. Conclusions: All PA and AT strategies included some content reflective of a Play-Friendly City; however, there was great variability in the number of included indicators. This summary provides key information on opportunities, such as increasing meaningful involvement of children in decision making, that can inform future municipal actions and policies to improve a community’s playability.

The Navajo Nation Healthy Diné Nation Act: A Description of Community Wellness Projects Funded by a 2% Tax on Minimal-to-No-Nutritious-Value Foods

CONTEXT

To promote the health of the Navajo people, the Navajo Nation passed the Healthy Diné Nation Act (HDNA) in 2014. The HDNA included a 2% tax on "minimal-to-no-nutritional-value" foods and waived 5% sales tax on healthy foods, the first such policy in the United States and any sovereign Tribal nation. Uniquely aligned with Tribal government structures, revenue was directly allocated to 110 small local government entities (Chapters) for self-determined wellness projects.

OBJECTIVE

To characterize HDNA-funded wellness projects, test for variation in project type, and funding amount over time by region and community size.

DESIGN

Longitudinal study assessing funded wellness projects from tax inception through 2019.

SETTING

The Navajo Nation.

PARTICIPANTS

One hundred ten Navajo Nation Chapters receiving funding for self-determined wellness projects.

OUTCOME MEASURES

The categories and specific types of wellness projects and funding over 4 years by region and community size.

RESULTS

Of revenue collected in 2015-2018, more than 99.1% was disbursed through 2019 ($4.6 million, $13 385 annually per community) across 1315 wellness projects (12 per community). The built recreational environment category received 38.6% of funds, equipment/supplies 16.5%, instruction 15.7%, food and water initiatives 14.0%, and social events 10.2%. Most common specific projects were walking trails ($648 470), exercise equipment ($585 675), food for events ($288 879), playgrounds ($287 471), and greenhouses ($275 554). Only the proportion allocated to instruction changed significantly over time (increased 2% annually, P = .02). Smaller communities (population <1000) allocated significantly higher proportions to traditional, agricultural, and intergenerational projects and less to the built environment.

CONCLUSIONS

Through 2019, more than 99% of HDNA revenue was successfully disbursed to 110 rural, Tribal communities. Communities chose projects related to promoting the built recreational environment, agriculture, and fitness/nutrition education, with smaller communities emphasizing cultural and intergenerational projects. These findings can inform other indigenous nations considering similar policies and funding distributions.

System Optimization of Shared Mobility in Suburban Contexts

Shared mobility is a viable choice to improve the connectivity of lower-density neighbourhoods or suburbs that lack high-frequency public transportation services. In addition, its integration with new forms of powertrain and autonomous technologies can achieve more sustainable and efficient transportation. This study compares four shared-mobility technologies in suburban areas: the Internal Combustion Engine, Battery Electric, and two Autonomous Electric Vehicle scenarios, for various passenger capacities ranging from three to fifteen. The study aims to provide policymakers, transportation planners, and transit providers with insights into the potential costs and benefits as well as system configurations of shared mobility in a suburban context. A vehicle routing problem with time windows was applied using the J-Horizon software to optimize the costs of serving existing intra-community demand. The results indicate a similar fleet composition for Battery Electric and Autonomous Electric fleets. Furthermore, the resulting fleet for all four technologies is dominated by larger vehicle capacities. Due to the large share of driver cost in the total cost, the savings using a fleet of Autonomous Electric Vehicles are predicted to be 68% and 70%, respectively, compared to Internal Combustion and Battery Electric fleets.

Supporting a rural wellness intervention through assessing and mapping rural physical activity environments

Rural residents are more likely to be physically inactive than their urban counterparts and are therefore at higher risk for obesity and cardiovascular disease. Research has shown that these disparities are driven in part by the physical environment, policies, and programming in rural communities. The purpose of this study was to use the Rural Active Living Assessment (RALA) to assess the physical activity environment of four Midwestern towns and to develop physical activity maps to support Enhanced Win With Wellness, a community-based cardiovascular risk reduction program. The RALA Town Wide (TWA) and Program and Policy (PPA) assessments were conducted in all four towns and are scored from (0–100). The TWA scores ranged from 69 to 96 (mean = 82.25) and the PPA scores ranged from 47 to 70 (mean = 59.75), indicating the towns had more amenities that supported physical activity than policies and programming. Using data gathered from the RALA assessments, digital physical activity maps were created for each town using the Google Maps platform and accessible through QR codes. The maps were advertised through Facebook and flyers to program participants and were viewed 3,073 times during the study period. Our study illustrates how the results from the TWA and PPA can be transformed into an easily accessible map that can used to reach populations residing in rural communities to increase awareness of physical activity amenities and improve engagement. It is also useful in helping identify gaps in recreational opportunities and to assist in developing policies or programs supporting physical activity.

Spatial clustering patterns and regional variations for food and physical activity environments across the United States

This study examined spatial patterns of obesogenic environments for US counties. We mapped the geographic dispersion of food and physical activity (PA) environments, assessed spatial clustering, and identified food and PA environment differences across U.S. regions and rurality categories. Substantial low food score clusters were located in the South and high score clusters in the Midwest and West. Low PA score clusters were located in the South and high score clusters in the Northeast and Midwest (p < .0001). For region, the South had significantly lower food and PA environment scores. For rurality, rural counties had significantly higher food environment scores and metropolitan counties had significantly higher PA environment scores (p < .0001). This study highlights geographic clustering and disparities in food and PA access nationwide. State and region-wide environmental inequalities may be targeted using structural interventions and policy initiatives to improve food and PA access.

Associations of neighborhood built, safety, and social environment with walking to and from school among elementary school-aged children in Chiba, Japan

BACKGROUND

Although it is globally known that Japan has high prevalence of active school travel among children, there are few international studies on Japanese children's school travel. Moreover, only few studies have focused on the differences in their mode of travel between to-school and from-school. This study examined the associations of neighborhood built, safety, and social environments with walking to/from school among elementary school-aged children in Chiba, Japan.

METHODS

We conducted an online survey with 1545 parents of children aged 6-12 years residing in Chiba between 25 and 27 November 2020 during the COVID-19 pandemic. A neighborhood was defined as the area of a postcode provided by the participants. Each neighborhood environment was assessed based on the built environment (new town designation, walkability, distance to school, population density), social environment (neighborhood cohesion and connection), and safety (CCTVs, a road section for walking alone, safety volunteers). Neighborhood walkability was measured using subscales of the Neighborhood Environment Walkability Scale (youth and abbreviated versions) including crime safety and traffic safety. Parents' perceived influence of COVID-19 on school commuting and after-school activities were also included in the model as covariates. Walking to and from school were separately analyzed using multinomial logistic regressions, where new towns and walkability were computed separately as explanatory variables.

RESULTS

Four fifths of children walked to and from school daily. Walking to school was positively associated with crime safety, neighborhood connections, and schools sited in new towns. Walking from school had positive associations with traffic safety, neighborhood cohesion, and CCTVs, but negative associations with safety volunteers and after-school activities. The presence of a section for walking alone and perceived influence of COVID-19 had negative associations with walking to and from school.

CONCLUSIONS

Recent social changes such as declining birthrate, decline in public elementary schools, and increasing after-school activities may change parental attitudes toward children's walking to/from school, and subsequently, their mode of school travel over time. To maintain the high prevalence of walking to/from school in Japan, multidisciplinary approaches involving different stakeholders from education, public health, and urban planning are required to overcome sectionalism and support this behavior in the long term.

Do State Comprehensive Planning Statutes Address Physical Activity?: Implications for Rural Communities

Less than one-quarter of U.S. adults meet physical activity (PA) recommendations, with rural residents less likely to be active than urban residents. The built environment has been identified as a potential facilitator of PA and local comprehensive plans are a foundational tool for guiding the development of the built environment. The purpose of this study was therefore to understand the current landscape of comprehensive planning state statutes related to PA and rural communities. We used primary legal research methods to identify, compile, and evaluate all 50 state comprehensive planning statutes for items related to PA and conditional mandates based on population size of local jurisdictions. The presence of population-conditional planning mandates and the inclusion of PA-related items was analyzed by state-level rurality using Fisher's exact tests. Our analyses demonstrated that (1) broader PA-related items were addressed in state statutes more often than more specific PA-related items; (2) when PA-related items were addressed, they were most likely to be mandated, subsumed elements; (3) several PA-related items were less likely to be addressed in the most rural states and/or conditionally mandated for jurisdictions meeting minimum population requirements; and (4) only two states addressed PA directly and explicitly in their comprehensive planning statutes.

The significant places of African American adults and their perceived influence on cardiovascular disease risk behaviors

BACKGROUND

AA living in rural areas of the southeastern U.S. experience a disproportionate burden of cardiovascular disease (CVD) morbidity and mortality. Neighborhood environmental factors contribute to this disparity and may decrease the effectiveness of lifestyle interventions aimed at preventing CVD. Furthermore, the influence of neighborhood factors on AA CVD risk behaviors (i.e. physical activity) may be obscured by the use of researcher-defined neighborhoods and researcher-defined healthy and unhealthy places. The objective of this study was to elucidate the effects of neighborhood environments on AA CVD risk behaviors among AA adults who recently completed a lifestyle intervention. We specifically sought to identify AA adults' self-perceived places of significance and their perceptions of how these places impact CVD risk behaviors including diet, physical activity and smoking.

METHODS

We conducted semi-structured interviews with AA adults (N = 26) living in two rural North Carolina counties (Edgecombe and Nash, North Carolina, USA). Participants were recruited from a community-based behavioral CVD risk reduction intervention. All had at least one risk factor for CVD. Participants identified significant places including where they spent the most time, meaningful places, and healthy and unhealthy places on local maps. Using these maps as a reference, participants described the impact of each location on their CVD risk behaviors. Data were transcribed verbatim and coded using NVivo 12.

RESULTS

The average age of participants was 63 (SD = 10) and 92% were female. Places participants defined as meaningful and places where they spent the most time included churches and relatives' homes. Healthy places included gyms and parks. Unhealthy places included fast food restaurants and relatives' homes where unhealthy food was served. Place influenced CVD risk behaviors in multiple ways including through degree of perceived control over the environment, emotional attachment and loneliness, caretaking responsibilities, social pressures and social support.

CONCLUSIONS

As we seek to improve cardiovascular interventions for rural AA in the American South, it will be important to further assess the effect of significant places beyond place of residence. Strategies which leverage or modify behavioral influences within person-defined significant places may improve the reach and effectiveness of behavioral lifestyle interventions.

Participation and engagement of a rural community in Ciclovía: progressing from research intervention to community adoption

Background

Open streets events, where roads are temporarily closed to motorized vehicles, can provide safe spaces for physical activity (PA) and become sustainable community infrastructure. Since 2016, we have collaborated with a rural community to implement an open streets event, named ciclovía. In 2019, ciclovía was adopted as a community-wide program. This paper describes the process of building and progressing a ciclovía from a research intervention to a community-adopted program and participation of a rural community in ciclovía.

Methods

We used community-based participatory research to foster bidirectional learning on how to optimize the content and implementation of ciclovía to be feasible and acceptable for rural communities. The community-academic partnership focused on: 1) understanding the science of ciclovía; 2) learning the implementation process; 3) creating tools to facilitate planning, implementation, and evaluation of ciclovía; and 4) developing transition steps from a research intervention to a community-adopted program.

Results

The progression of the research intervention to community adoption spanned 2 years. First, the partnership met quarterly to discuss the science of ciclovía, its utility, and its adaptation for rural communities. Second, the partnership studied processes that facilitated ciclovía implementation. Third, the partnership created the ciclovía planning guide and tools for communities to establish their own ciclovía. The guide included forming a planning committee, setting meeting and communication plans, marketing and promotion, and selecting evaluation tools. Fourth, the transition steps from research intervention to community adoption included creating roles and responsibilities, implementing ciclovía using the planning guide, and convening listening sessions for improvement on implementation. Community attendance at ciclovía doubled from 189 individuals (126 children and 63 adults) when it was a research intervention to 394 individuals (277 children and 117 adults) when it was a community program.

Conclusions

The progression from a research intervention to a community-adopted program encompasses multiple steps that involve bidirectional learning and partnership with the community. Lessons learned from this study are integrated into a disseminatable ciclovía planning guide.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11980-6.

Using a Socio-Environmental Approach to Explore the Determinants for Meeting the Recommended Physical Activity among Adults at Risk of Diabetes in Rural Indonesia

Moderate-to-vigorous physical activity (PA) is recommended to mitigate the risk of diabetes. This study explored the PA of adults at risk for diabetes in rural Indonesia and determined the requirements for meeting the recommended PA level. In total, 842 adults were screened using a diabetes risk test in a rural health centre; among them, 342 were at risk of diabetes. The level of PA was assessed using the International Physical Activity Questionnaire, whereas the associated factors underlying the three domains -individual, support, and environment-were determined by the Influences on Physical Activity Instrument. The data analysis included a three-step multiple linear regression (MLR) and logistic regression (LR). Overall, 40.6% of the participants met the recommended PA. According to the MLR analysis, among males, individuals who gave PA a higher priority and had enough time to perform PA were predicted to have a higher activity energy expenditure (MET-minutes per week). According to the LR analysis, men were more likely to meet the recommended PA, and people who gave PA a lower priority and had less access to space for PA were less likely to meet the recommended PA level. Strategies for promoting PA in rural Indonesia include focusing on women, people who prioritize PA less, and those who have less time and space in which to be physically active.

Parent Preferences for Physical Activity in Before and After School Programs in Rural and Suburban Communities: A Discrete Choice Experiment

BACKGROUND

The purpose of this study was to examine and compare parent preferences of before and after school physical activity program components in rural and suburban elementary schools.

METHODS

A discrete choice experiment was conducted to measure parent preferences for components of before/after school programs. A total of 183 parents (age = 37.2 [8.2] y, 155 females) sampled from 15 elementary schools (K-6 grades) in the Western United States took part in the study, half of which were from a rural community (n = 93, 50.8%). Results from the discrete choice experiment were analyzed using hierarchic Bayesian methodology, which estimated utility scores and was used to calculate important scores for program components.

RESULTS

The specific goal of the before/after school program was the strongest determinant of parents' stated choice overall, followed by leaders, time of day, length, and main focus. Learning sports as the physical activity goal was the top-rated attribute. Subgroup analyses revealed discrepancies between suburban and rural parents and parents of boys and girls.

CONCLUSION

This study extends the application of discrete choice experiments to school-based programming, providing a unique way to design empirically based, stakeholder informed school programs, specifically within before and after school settings.

What Sets Physically Active Rural Communities Apart from Less Active Ones? A Comparative Case Study of Three US Counties

BACKGROUND

Rural US communities experience health disparities, including a lower prevalence of physical activity (PA). However, "Positive Deviants"-rural communities with greater PA than their peers-exist. The purpose of this study was to identify the factors that help create physically active rural US communities.

METHODS

Stakeholder interviews, on-site intercept interviews, and in-person observations were used to form a comparative case study of two rural counties with high PA prevalence (HPAs) and one with low PA prevalence (LPA) from a southern US state, selected based on rurality and adult PA prevalence. Interview transcripts were inductively coded by three readers, resulting in a thematic structure that aligned with a Community Capital Framework, which was then used for deductive coding and analysis.

RESULTS

Fifteen stakeholder interviews, nine intercept interviews, and on-site observations were conducted. Human and Organizational Capital differed between the HPAs and LPA, manifesting as Social, Built, Financial, and Political Capital differences and a possible "spiraling-up" or cyclical effect through increasing PA and health (Human Capital), highlighting a potential causal model for future study.

CONCLUSIONS

Multi-organizational PA coalitions may hold promise for rural PA by directly influencing Human and Organizational Capital in the short term and the other forms of capital in the long term.

The Effects of Play Streets on Social and Community Connectedness in Rural Communities

Promoting physical activity (PA) is a long-standing public health initiative to improve overall health and wellbeing. Innovative strategies such as Play Streets, temporary activation of public spaces to provide safe places for active play, are being adopted in urban and rural communities to increase PA among children. As part of these strategies, aspects of social and community connectedness may be strengthened. This study analyzes focus groups and interviews from rural Play Street implementation team members (n = 14) as well as adults (n = 7) and children (n = 25) who attended Play Streets hosted in rural North Carolina, Maryland, Oklahoma, and Texas to better understand the added benefits of Play Streets in community connectedness. Overall, elements of social support and social cohesion are mentioned most frequently with instrumental and conditional support; however, concepts of social capital, collective-efficacy, and social identification are also presented. Participants expressed that Play Streets provided more than just PA; they provided opportunities to access and share resources, build perceptions of safety and trust in the community, and develop relationships with others. Fostering community connection through Play Streets may reduce health inequities in rural communities by building community resilience. Community-based PA programming that enhance and capitalize on community connectedness could be effective ways to improving the overall health and wellbeing of residents.

School-based physical activity interventions in rural and urban/suburban communities: A systematic review and meta-analysis

Disparities in physical activity and health outcomes exist between urban and rural youth. School settings can be utilized to promote physical activity in youth regardless of urban-rural status. This systematic review and meta-analysis aimed to assess and compare the effect of rural and urban/suburban school-based physical activity programs on total physical activity in youth. A search of five databases was conducted. A total of 33 studies remained after the exclusion process, 28 of which took place in urban/suburban schools and five of which took place in rural schools. The DerSimonian and Laird random effects model was employed with the estimates of heterogeneity taken from the inverse-variance fixed-effect model. For rural studies, the Hartung-Knapp-Sidak-Jonkman method was used to obtain error estimates. Results from the total sample indicated a significant but small pooled increase in daily physical activity (Hedge's g = 0.12, 95% confidence interval [CI]: 0.06-0.18), which held for interventions conducted in urban/suburban schools (Hedge's g = 0.12, 95% CI: 0.06-0.19). For rural school-based interventions, there was no significant pooled effect (Hedge's g = 0.06, 95% CI: -0.50 to 0.61). This meta-analysis provides evidence that school-based interventions can be marginally effective for increasing daily physical activity in children and adolescents; however, no effect was observed for interventions implemented in rural settings.

"You're Going to Have to Think a Little Bit Different" Barriers and Facilitators to Using mHealth to Increase Physical Activity among Older, Rural Cancer Survivors

Wearable activity trackers (WATs) hold great promise in increasing physical activity among older cancer survivors. However, older cancer survivors who reside in rural regions are at increased risk of being digitally marginalized. The goal of this study was to learn about WATs adoption motivation and needs of rural older cancer survivors who live in New Mexico, one of the most rural states with the lowest broadband Internet connectivity in the United States. We conducted six key informant interviews and recruited 31 older cancer survivors from rural counties statewide who participated in interviews and focus groups. Our results show great interest in using WATs as part of an intervention to alleviate barriers associated with the digital divide. Participants were offered diverse modalities to support them in adoption of the trackers. These results will be used to inform future interventions and policies focusing on increasing physical activity in older cancer survivors who reside in rural communities.

Factors That Influence Walking Intervention Adherence for Older Adults Living in Retirement Communities

Walking interventions improve health outcomes among older adults. However, few clinical trials evaluate long-term behavior change adherence. The authors explored factors that influence walking adherence in older adults following their participation in a clinical trial. They conducted n = 7 focus groups with n = 23 participants enrolled in the parent study (ClinicalTrials.gov number: NCT03654807). The authors used content analysis to code data according to the social-ecological model. They found that supportive services (exercise classes) in retirement communities have multilevel impacts on adherence to walking activity. Residents from communities offering services continued walking because of increased confidence gained in the parent trial, while residents in communities without services were motivated by their functional improvements. Residents voiced frustration with retirement community physical activity programs that did not address the full spectrum of physical functioning. Findings support the need for retirement communities to account for various motivational factors in tailoring programs to promote increased physical activity for older adults.

Environmental Factors Associated with Physical Activity in Rural U.S. Counties

Background: Rural U.S. adults’ prevalence of meeting physical activity (PA) guidelines is lower than urban adults, yet rural-urban differences in environmental influences of adults’ PA are largely unknown. The study’s objective was to identify rural-urban variations in environmental factors associated with the prevalence of adults meeting PA guidelines. Methods: County-level data for non-frontier counties (n = 2697) were used. A five-category rurality variable was created using the percentage of a county’s population living in a rural area. Factor scores from Factor Analyses (FA) were used in subsequent Multiple Linear Regression (MLR) analyses stratified by rurality to identify associations between environmental factor scores and the prevalence of males and females meeting PA guidelines. Results: FA revealed a 13-variable, four-factor structure of natural, social, recreation, and transportation environments. MLR revealed that natural, social, and recreation environments were associated with PA for males and females, with variation by sex for social environment. The natural environment was associated with PA in all but urban counties; the recreation environment was associated with PA in the urban counties and the two most rural counties. Conclusions: Variations across the rural-urban continuum in environmental factors associated with adults’ PA, highlight the uniqueness of rural PA and the need to further study what succeeds in creating active rural places.

Prevalence and differences of ideal cardiovascular health in urban and rural adolescents in the Region of Tyrol: results from the EVA Tyrol study

Purpose

Early adoption of a healthy lifestyle has positive effects on cardiovascular health (CVH) in adulthood. In this study, we aimed to assess CVH metrics in a cohort of healthy teenagers with focus on differences between rural and urban areas.

Methods

The Early Vascular Aging (EVA) Tyrol study is a population-based non-randomized controlled trial, which prospectively enrolled 14- to 19-year-old adolescents in North Tyrol, Austria and South Tyrol, Italy between 2015 and 2018. Data from the baseline and control group (prior to health intervention) are included in the current analysis. CVH determinants (smoking, body mass index, physical activity, dietary patterns, systolic and diastolic blood pressure, total cholesterol and fasting blood glucose) were assessed and analyzed for urban and rural subgroups separately by univariate testing. Significant variables were added in a generalized linear model adjusted for living in urban or rural area with age and sex as covariates. Ideal CVH is defined according to the guidelines of the American Heart Association.

Results

2031 healthy adolescents were enrolled in the present study (56.2% female, mean age 16.5 years). 792 adolescents (39.0%) were from urban and 1239 (61.0%) from rural areas. In 1.3% of adolescents living in urban vs. 1.7% living in rural areas all CVH determinants were in an ideal range. Compared to the rural group, urban adolescents reported significantly longer periods of moderate to vigorous-intensive activity (median 50.0 min/day (interquartile range 30–80) vs. median 40.0 min/day (interquartile range 25–60), p < 0.01). This observation remained significant in a generalized linear model (p < 0.01). There were no significant differences between the study groups regarding all other CVH metrics.

Conclusion

The low prevalence of ideal CVH for adolescents living in urban as well as rural areas highlights the need for early health intervention. Geographic differences must be taken into account when defining targeted subgroups for health intervention programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02156-6.