What Rural Women Want the Public Health Community to Know About Access to Healthful Food: A Qualitative Study, 2011

Planting Seeds for Food Is Medicine: Pre-Implementation Planning Methods and Formative Evaluation Findings From a Multi-Clinic Initiative in the Midwest

Food is medicine (FIM) initiatives are an emerging strategy for addressing nutrition-related health disparities increasingly endorsed by providers, payers, and policymakers. However, food insecurity screening protocols and oversight of medically-tailored food assistance programs are novel for many healthcare settings. Here, we describe the pre-implementation planning processes used to successfully engage federally-qualified health centers (FQHCs) across Kansas to develop new FIM initiatives. A Kansas-based philanthropic foundation facilitated pre-implementation planning for FQHCs over 17 months across 3 stages: 1) Community inquiry, 2) FIM learning event with invitation for FQHC attendees to request pre-implementation funding, and 3) Pre-implementation planning workshops and application assignments for FQHC grantees to develop a FIM implementation grant proposal. We evaluated satisfaction and perceived utility of these pre-implementation planning activities via post-workshop surveys and qualitative comparisons of FIM design components from pre-implementation and implementation grant applications. All 7 FQHCs attending the learning event applied for and were awarded pre-implementation planning grants; 6 submitted an implementation grant application following workshop completion. FQHCs rated pre-implementation support activities favorably; however, most clinics cited limited staff as a barrier to effective planning. As compared to pre-implementation planning grant proposals, all FQHCs elected to narrow their priority population to people with pre-diabetes or diabetes with better articulation of evidence-based nutrition prescriptions and intervention models in their final program designs. In the midst of a nationwide FIM groundswell, we recommend that funders, clinic stakeholders, and evaluators work together to devise and financially support appropriate pre-implementation planning activities prior to launching new FIM initiatives.

Communicating about the social determinants of health: development of a local brand

BACKGROUND

Successful comprehensive population-based approaches to chronic disease prevention leverage mass media to amplify messages and support a culture of health. We report on a community-engaged formative evaluation to segment audiences and identify major themes to guide campaign message development for a transformative health communication campaign.

METHODS

Four key phases of campaign development: (I) Formative evaluation to identify priorities, guiding themes, and audience segments (interviews/focus groups with residents, N = 85; representatives of community-based partner organizations, N = 10); (II) Brand development (focus groups and closed-ended surveys; N = 56); (III) Message testing approaches to verbal and visual appeals (N = 50 resident intercept interviews); (IV) Workshop (N = 26 participants representing 15 organizations).

RESULTS

Residents were engaged throughout campaign development and the resulting campaign materials, including the campaign name and visual aesthetic (logo, color schemes, overall look and feel) reflect the diversity of the community and were accepted and valued by diverse groups in the community. Campaign materials featuring photos of county residents were created in English, Spanish, and Hmong. Plain language messages on social determinants of health resonate with residents. The county was described as a sort of idyllic environment burdened by inequality and structural challenges. Residents demonstrated enthusiasm for the campaign and provided specific suggestions for content (education about disease risks, prevention, management; information about accessing resources; testimonials from similar people) and tone.

CONCLUSIONS

Communication to support a policy, systems, and environmental change approach to chronic disease prevention must carefully match messages with appropriate audiences. We discuss challenges in such messaging and effectiveness across multiple, diverse audiences.

“Nobody talks about it”: Preconception health and care among women in the rural, Midwestern United States

Introduction:

Good preconception and interconception health are fundamental to optimizing women’s health and reducing risk factors for adverse maternal–infant outcomes. Although rural women in the United States tend to experience health disparities, no published qualitative studies have focused on their preconception/interconception health. The purpose of this study was to determine what rural, Midwestern women perceive to be their most pressing health needs and effective ways to provide outreach and education regarding preconception/interconception health and care.

Methods:

Non-pregnant, reproductive-age women in Hardin County, Ohio, regardless of parity, were recruited through convenience sampling. Semi-structured interviews with four domains (beliefs and behaviors; perceived needs; knowledge and information sources; barriers to care) were conducted in May–June 2021 until saturation was reached. Qualitative methods were used to analyze data and determine themes. Binomial tests were used to compare selected demographic characteristics of participants to the county’s reproductive-age residential female population.

Results:

Nineteen women aged 20–44 years were individually interviewed. Comparing race/ethnicity, education, and insurance status, participants appeared to be representative of the county population. Four themes were identified: (1) needs regarding healthcare and other resources; (2) lack of preconception/interconception care and perceived unimportance due to intergenerational knowledge transfer and paucity of healthcare providers; (3) difference in understanding of the term “women’s health” and low health literacy; and (4) suggested interventions including education and outreach.

Conclusion:

Interviews with rural Midwestern women revealed needs regarding preconception/interconception health and care and potential ways to raise awareness. These findings can inform strategies to improve rural women’s health and birth outcomes.

Comparison of barriers and facilitators of MIND diet uptake among adults from Northern Ireland and Italy

Background

The aim of the study was to identify and compare components of the COM-B (capability, opportunity, motivation and behaviour) model, that influences behaviour to modify dietary patterns in 40–55-year olds living in Northern Ireland (NI) and Italy, in order to reduce the risk of cognitive decline in later life.

Methods

This was a qualitative study examining factors influencing Mediterranean-DASH (Dietary Approaches to Stop Hypertension) Intervention for Neurodegenerative Delay (MIND) diet behaviour. This study further elaborated the COM-B components into the 14 domains of the Theoretical Domains Framework to further understand behaviour. Twenty-five Northern Irish and Italian participants were recruited onto the study, to take part in either a focus group or an interview. Participants were both male and female aged between 40 and 55 years.

Results

Thematic analysis revealed that the main barriers to the uptake of the MIND diet were; time, work environment (opportunity), taste preference and convenience (motivation). Culture (motivation), seasonal foods and lack of family support (opportunity) to be a barrier to the Italian sample only. The main facilitators reported were; improved health, memory, planning and organisation (motivation) and access to good quality food (opportunity). Cooking skills, knowledge (capability) and heathy work lunch (opportunity) reported as a facilitator to the Italian sample only.

Conclusions

Cross-cultural differences in relation to psychosocial barriers and facilitators were found in both samples. More barriers than facilitators towards uptake of the MIND diet were found. There is a need for interventions that increase capability, opportunity, and motivation to aid behaviour change. The findings from this study will be used to design a behaviour change intervention using the subsequent steps from the Behaviour Change Wheel.

Back in the Day: Nostalgia Frames Rural Residents' Perspectives on Diet and Physical Activity

OBJECTIVE

To observe and interpret cultural influences on health behaviors in a rural area with a high prevalence of obesity.

DESIGN

Descriptive, qualitative study.

SETTING

Lenoir County, NC, US.

PARTICIPANTS

Four focus groups (n = 33) were conducted. Participants were 76% African American and with an average of 25 years of county residence.

PHENOMENON OF INTEREST

Diet, physical activity, environment ANALYSIS: Content analysis and thematic data analysis to identify key themes using qualitative analysis software.

RESULTS

Participants frequently evoked nostalgia to frame recurrent themes including decreased opportunities for physical activity and changing food access and preparation in the community, contrasting with memories of enjoying local produce and safe outdoor recreation. They interpreted present health behaviors in the context of these past losses.

CONCLUSIONS AND IMPLICATIONS

Nostalgia is an important element in our participants' cultural repertoires, revealing elements of place-based culture. Nostalgic narratives may foster a sense of reduced options for healthy eating and exercise by over-emphasizing loss. The incorporation of place-specific obesogenic cultural factors, including the way residents juxtapose past and present, may improve obesity interventions in rural settings.

Store patterns of availability and price of food and beverage products across a rural region of Newfoundland and Labrador

OBJECTIVES

Rural populations bear a disproportionate burden of diet-related risk, and one important explanation is retail food access disparities. Much existing literature has focused on subjective measures of the rural retail food environment, as well as urban-rural differences. The purpose of this paper is to examine how objectively measured food availability and prices vary within a rural region, and to explore how store features predict rural food availability and prices.

METHODS

We conducted an observational audit of a census of rural food stores (n = 78) using a modified Nutrition Environment Measures Survey instrument. The study was conducted on the Avalon Peninsula in Newfoundland and Labrador. Observed prices in-store were matched to nutrient composition data and converted to three units of measure for all analyses: unit price ($/kg), serving price ($/serving), and energy price ($/kcal). We examined average availability and prices across the region, and how store features were associated with prices.

RESULTS

Healthy food options were generally less available across the stores than regular items. However, with few exceptions, there were no clear or consistent patterns of difference in availability or pricing between stores of different types. No single product category stood out in terms of a clear price pattern. Store characteristics (including store type, size, ownership, or rurality) did not predict food prices.

CONCLUSIONS

Food availability and prices varied in this rural region, but with limited differences between stores of different types. More research is needed on measuring rural environmental determinants of diet in Canada.

Beyond fatalism: Information overload as a mechanism to understand health disparities

BACKGROUND

Fatalism - beliefs about the causes and controllability of disease - has been negatively associated with prevention behaviors. Fatalism has been suggested as a mechanism for health disparities because ethnic minorities are especially likely to hold fatalistic beliefs. However, the construct has been criticized: Fatalism fails to account for structural barriers to health faced by vulnerable populations that also score highly on measures of fatalism. Another critique suggests that operationalizations of fatalism expose communication failures: "Fatalism" rather reflects information overload from an environment riddled with misinformation and contradictions. This study aimed to expand understanding of one mechanism through which communication may contribute to disparities by considering the context of nutrition among bicultural Latinas, who face increased risk from dietary acculturation.

METHOD

Mixed-methods (semi-structured in-depth interview, survey) with Mexican-American women ages 18-29 (n = 24) in rural California.

RESULTS

Contrary to previous studies, the majority of this sample of Mexican-American women did not endorse fatalistic beliefs; most demonstrated clear understanding of the link between diet and risk of diseases: Diabetes and heart disease were understood to result from behaviors within one's control. Yet despite articulating links between diet and disease, participants felt overloaded and confused about conflicting information from public and interpersonal sources. Moreover, despite reporting feeling inundated with information, participants noted critical information gaps, distinguishing between information available and information needed.

CONCLUSIONS

We found minimal support for fatalistic beliefs among a sample of Mexican-American women, but considerable information overload and confusion, together with a desire for specific knowledge and skills. Results extend understanding of how communication may influence disparities: Information overload may be conflated with fatalism, challenging the notion that fatalism is a cultural belief. Moreover, inequalities in access to and ability to process information compound overload effects. We discuss opportunities to improve the clarity of communication about nutrition science and dietary recommendations.

Development of a Participatory Health Communication Intervention: An Ecological Approach to Reducing Rural Information Inequality and Health Disparities

A strong and diverse communication infrastructure is essential for communication to improve health. When that infrastructure is weak, health information fails to reach appropriate audiences; this is a component of information inequality that contributes to health disparities. Approaches to addressing information inequality have either focused on individual-level barriers or exclusively on changing the information environment. Largely missing from information inequality interventions is a multilevel, ecological approach consistent with the ways in which information inequality affects health. This study addresses that gap by describing a participatory intervention in a rural, majority-Latino community. Previous work identified a weak information infrastructure as a major barrier to health: Residents struggled to find timely, relevant information, while stakeholders faced challenges knowing how to reach diverse audiences with critical health-related information. We employed participatory health communication asset mapping to identify health communication resources - safe, trusted spaces, and places - that served three distinct communication functions: informational (i.e., where health information can be provided), conversational (i.e., where residents feel comfortable discussing health issues), and connection (i.e., where a relationship exists). Through a six-step process, community leaders and residents identified communication resources and collaborated to create a communication resource map. We discuss how this study advances the theoretical understanding of integration of culture-centered and ecological approaches for communication to reduce health disparities.

Rural Women's Perceptions About Cancer Disparities and Contributing Factors: a Call to Communication

Rural cancer disparities are increasingly documented in the USA. Research has identified and begun to address rural residents' cancer knowledge and behaviors, especially among women. Little, however, is known about rural female residents' awareness of cancer inequities and perceived contributing factors affecting them and their families. The purpose of this study was to address these gaps in the literature via a secondary analysis of qualitative needs assessment in Illinois' rural southernmost seven counties, a geographic region with relatively high rates of cancer incidence, morbidity, and mortality. A convenience sample of 202 rural adult female residents was recruited and participated in 26 focus groups, with 3-13 women per group. Inductive content analysis, guided by the principle of constant comparison, was used to analyze the qualitative data. Most respondents indicated their awareness of disproportionate cancer burden in their communities. Individual-level behaviors and environmental toxins were identified as contributing factors. Interestingly, however, environmental toxins were more often discussed as factors contributing to geographic differences, whereas individual-level behaviors were noted as important for overall cancer prevention and control. This study provides important insight into female rural residents' perspectives and offers novel venues for educational programs and research in the context of communication to eliminate disparities.

Feasibility and outcomes of an out-of-school and home-based obesity prevention pilot study for rural children on an American Indian reservation

BACKGROUND

Children living in rural areas are at higher risk for obesity compared to urban children, and Native American (NA) children have the highest prevalence of overweight/obesity for all races combined. Out-of-school programs (OOSPs) are a promising setting to improve children's health. Parents are important in supporting their child's obesity-related behaviors, yet it remains unclear what combination and dose of parent engagement strategies is feasible and optimal. This study's primary objective was to assess the feasibility of an OOSP and home-based obesity prevention intervention for rural NA and non-NA children.

METHODS

This was an 11-week, two group, randomized feasibility study. Participants were children and their parents at one OOSP on a rural American Indian reservation. Children, ages 6-9, were randomized to receive the Generations Health (GH) intervention or comparison condition. The GH group received daily activities focused on physical activity (PA), nutrition, sleep, and reducing TV/screen time, and frequently engaged parents. The comparison group received usual OOSP activities. To assess intervention feasibility, we measured recruitment and participation rates and program satisfaction. We assessed pre- to posttest changes in body composition, PA and sleep patterns, dietary intake and Healthy Eating Index-2010 (HEI-2010) scores, TV/screen time, and nutrition knowledge. We report recruitment and participation rates as percentages and participants' program satisfaction as means. Two-tailed paired t tests and 95% confidence intervals were used to detect changes in behavioral and health outcome variables.

RESULTS

Forty-six children met age eligibility criteria; following screening, 52% (24/46) met the inclusion criteria and 96% (23/24) were randomized to the study. Overall, 91% of the children participated in the intervention and 100% participated in at least some of the posttest assessments. Parents reported high program satisfaction (mean rating of 4, on a 1-5 scale). Our outcome measure for child adiposity, zBMI, was reduced by 0.15 in the GH group, but increased by 0.13 in the comparison condition. Meaningful changes were evident for total kilocalories, HEI-2010 scores, PA, TV/screen time, and nutrition knowledge.

CONCLUSIONS

High recruitment, participation and program satisfaction and positive health and behavioral outcomes at 11 weeks provide encouraging indications of the feasibility and potential effectiveness of the intervention.

TRIAL REGISTRATION

ISRCTN24274245.

Fast-food, everyday life and health: A qualitative study of 'chicken shops' in East London

The higher prevalence of fast food outlets in deprived areas has been associated with the production and maintenance of geographical inequalities in diet. In the UK one type of fast food outlet - the 'chicken shop' - has been the focus of intense public health and media interest. Despite ongoing concerns and initiatives around regulating these establishments, the 'chicken shop' is both a commercially successful and ubiquitous feature of disadvantaged urban neighbourhoods. However, little is known about how they are perceived by local residents. We report data from a qualitative study of neighbourhood perceptions in a low SES urban setting. Narrative family interviews, go-along interviews and school video focus group workshops with 66 residents of East London were conducted over two waves. The topic of chicken shops was a prolific theme and a narrative analysis of these accounts revealed that local perceptions of chicken shops are complex and contradictory. Chicken shops were depicted as both potentially damaging for the health of local residents and, at the same time, as valued community spaces. This contradiction was discursively addressed in narrative via a series of rhetorical rebuttals that negated their potential to damage health on the grounds of concepts such as trust, choice, balance, food hygiene and compensatory physical activity. In some instances, chicken shops were described as 'healthy' and patronising them constructed as part of a healthy lifestyle. Chicken shops are embedded in the social fabric of neighbourhoods. Successful strategies to improve diet therefore requires context-sensitive environmental interventions.

Physical activity and masculinity in rural men: a qualitative study of men recruited from churches

The majority of rural US men fail to meet physical activity (PA) guidelines and are at risk for chronic diseases. This study sought to understand rural men's perceptions about PA and PA engagement and the influence of masculinity and social norms. From 2011 to 2014, 12 focus groups were conducted with men prior to a church-based health promotion intervention. Men were recruited from Illinois' rural, southernmost seven counties, where 40% of men report no exercise in the past 30 days. We used inductive content analysis methods to identify PA-related themes, and subsequently used elements of the Health, Illness, Men, and Masculinities framework as a lens to explore subthemes. We identified four themes: (i) knowledge of the positive impact of PA on health, (ii) perceptions of appropriate types of PA for men, (iii) the importance of purposeful PA and (iv) the desire to remain strong and active, particularly during aging. These findings can inform strategies for messaging and interventions to promote PA among rural men. Health promotion efforts should consider the intersections between rurality and masculinity as it relates to rural men's perceptions of PA, include information about purposeful PA and encourage them to engage in PA with a support person.

Community Perspectives on Access to and Availability of Healthy Food in Rural, Low-Resource, Latino Communities

INTRODUCTION

Attention has focused on the food environment as a result of the growing concern with obesity rates among Latinos in rural areas. Researchers have observed associations between a lack of physical access to affordable produce in areas where supermarkets and grocery stores are limited and poor dietary intake and obesity; these associations are high in rural, low-resource neighborhoods with a high population of Latino residents. We aimed to engage residents of low-resource, Latino-majority neighborhoods in discussions of food access in a rural yet agricultural community setting, which is typically described as a "food desert."

METHODS

We used a mixed-methods approach and conducted 3 focus groups (n = 20) and in-depth interviews (n = 59) and surveys (n = 79) with residents of a rural yet agricultural community. We used thematic analysis to explore residents' perceptions of access to healthy foods.

RESULTS

Residents (n = 79; mean age, 41.6 y; 72% female; 79% Latino; 53% Spanish-speaking) reported that dollar and discount stores in this agricultural area provided access to produce; however, produce at retail stores was less affordable than produce at nonretail outlets such as fruit and vegetable stands. Gifts and trades of fruits and vegetables from neighbors and community organizations supplied no-cost or low-cost healthy foods. Residents' suggestions to improve food access centered on lowering the cost of produce in existing retail outlets and seeking out nonretail outlets.

CONCLUSION

Our findings contribute to understanding of the food environment in low-resource, rural yet agricultural areas. Although such areas are characterized as "food deserts," residents identified nonretail outlets as a viable source of affordable produce, while indicating that the cost of retail produce was a concern. Innovative policy solutions to increase healthy food consumption must focus on affordability as well as accessibility, and consider alternate, nonretail food outlets in agricultural areas.