Community Coalitions for Change and the Policy, Systems, and Environment Model: A Community-Based Participatory Approach to Addressing Obesity in Rural Tennessee

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.

Participants' Experiences With a Community Based Participatory Research Produce Prescription Program: Findings From a Qualitative Study

PURPOSE

The purpose of this study was to explore a food-insecure, low income, predominantly African American community's experiences with a produce prescription program (PPP).

DESIGN

Researchers conducted 3 focus groups and 4 individual interviews with Maywood Veggie Rx (VRxM) participants asking questions about the logistics of the program while also exploring ideas around health, food, and community.

SETTING

This produce prescription program took place in Maywood, Illinois which is an urban underserved community with 23.5 K people, most of whom are Black/African American (61%) and Hispanic (32%).

PARTICIPANTS

The 24 participants interviewed through focus groups and individual interviews were enrolled in the 2021-2022 VRxM program. Participants were mainly female, with only three participants being males. Ages ranged between 34 and 74 years of age with a mean age of 56.3.

METHOD

Qualitative data from transcripts were then coded via a grounded theory approach to identify common themes.

RESULTS

A research team of seven including the two Co-PIs, three medical students and two dietetic interns identified 278 codes which were then condensed into 117 codes and then placed into 9 categories. Researchers identified three recurrent themes among the experiences of VRxM participants: (1) trust building, (2) culturally relevant and adaptive nutrition education, and (3) bidirectional feedback. These three themes mirror many of the principles of Community Based Participatory Research (CBPR).

CONCLUSION

The study findings identify common themes among the experiences of VRxM which are in line with the collaborative approach of CBPR principles. Produce Prescription Programs should utilize CBPR principles in the creation and implementation of programming to improve the participant experience. Future research should include additional focus groups on new iterations of VRxM and should also include those people who chose not to participate in VRxM to explore barriers to participation.

Partnerships and Community Engagement Key to Policy, Systems, and Environmental Achievements for Healthy Eating and Active Living: a Systematic Mapping Review

INTRODUCTION

Policy, systems, and environmental (PSE) change approaches frequently address healthy eating and active living (HEAL) priorities. However, the health effects of PSE HEAL initiatives are not well known because of their design complexity and short duration. Planning and evaluation frameworks can guide PSE activities to generate collective impact. We applied a systematic mapping review to the Individual plus PSE Conceptual Framework for Action (I+PSE) to describe characteristics, achievements, challenges, and evaluation strategies of PSE HEAL initiatives.

METHODS

We identified peer-reviewed articles published from January 2009 through January 2021 by using CINAHL, Web of Science, MEDLINE, PsycINFO, and CAB Abstracts databases. Articles describing implementation and results of PSE HEAL initiatives were included. Activities were mapped against I+PSE components to identify gaps in evaluation efforts.

RESULTS

Independent reviewers examined 437 titles and abstracts; 52 peer-reviewed articles met all inclusion criteria. Twenty-four focused on healthy eating, 5 on active living, and 23 on HEAL. Descriptive analyses identified federal funding of initiatives (typically 1-3 years), multisector settings, and mixed-methods evaluation strategies as dominant characteristics. Only 11 articles reported on initiatives that used a formal planning and evaluation framework. Achievements focused on partnership development, individual behavior, environmental or policy changes, and provision of technical assistance. Challenges included lack of local coalition and community engagement in initiatives and evaluation activities and insufficient time and resources to accomplish objectives. The review team noted vague or absent descriptions of evaluation activities, resulting in questionable characterizations of processes and outcomes. Although formation of partnerships was the most commonly reported accomplishment, I+PSE mapping revealed a lack of engagement assessment and its contributions toward initiative impact.

CONCLUSION

PSE HEAL initiatives reported successes in multiple areas but also challenges related to partnership engagement and community buy-in. These 2 areas are essential for the success of PSE HEAL initiatives and need to be adequately evaluated so improvements can be made.

Forms of Community Engagement in Neighborhood Food Retail: Healthy Community Stores Case Study Project

Community engagement is well established as a key to improving public health. Prior food environment research has largely studied community engagement as an intervention component, leaving much unknown about how food retailers may already engage in this work. The purpose of this study was to explore the community engagement activities employed by neighborhood food retailers located in lower-income communities with explicit health missions to understand the ways stores involve and work with their communities. A multiple case study methodology was utilized among seven retailers in urban U.S. settings, which collected multiple sources of data at each retailer, including in-depth interviews, store manager sales reports, store observations using the Nutrition Environment Measures Survey for Stores, public documents, and websites. Across-case analysis was performed following Stake's multiple case study approach. Results indicated that retailers employed a wide variety of forms of community engagement within their communities, including Outreach, Building Relationships through Customer Relations, Giving Back, Partnering with Community Coalitions, and Promoting Community Representation and Inclusiveness. Strategies that built relationships through customer relations were most common across stores; whereas few stores demonstrated community inclusiveness where members participated in store decision making. Findings provide a more comprehensive view of the ways local food retailers aim to develop and sustain authentic community relationships. Additional research is needed to evaluate the impact of community engagement activities on improving community health.

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.

Development of a School-Based Physical Activity Intervention Using an Integrated Approach: Project SMART

Physical activity (PA) is a health-protective factor with multiple benefits for school-age children, yet only 22% of children and adolescents living in the United States (United States) accrue the recommended amount of moderate to vigorous PA. Given the prevalence of insufficient PA among children, promoting and providing PA opportunities during the school day, especially when integrated into the curriculum and linked to the learning standards, is essential for children. The purpose of this paper is to describe the procedure for the development of a school-based PA program using an integrated approach through the modified intervention mapping protocol (IMP). A total of 22 physical education teachers and 167 children from five different elementary schools were involved in the process. The procedure includes the Self-Determination Theory (SDT) that provides a theoretical framework that plays a vital role in motivating students to have a physically active lifestyle. This study applied SDT and IMP to develop and pilot a PA intervention called Project SMART using an integrative community participatory approach. As a pilot PA intervention, Project SMART is an online educational game where the students navigate a virtual journey across the United States A class’s aggregate PA propels the students on their journey, where standards-based modules are unlocked to achieve STEM (science, technology, engineering, and math) and social-emotional learning outcomes while gaining an understanding of the importance of health behaviors and opportunities to habitually engage in healthy decision-making with the support of their peers. Although initially labor intensive for the researchers, the process of tailoring the intervention to the children’s contextual and cultural needs has implications for all theoretically grounded and evidence-based PA interventions.

Overcoming barriers to physical activity in underserved populations

There is compelling evidence suggesting underserved populations, including racial/ethnic minorities and individuals with low socioeconomic status, are less likely to partake in sufficient amounts of physical activity (PA) at recommended levels. Communities of color and low-income individuals face institutional, societal, and environmental barriers that may prevent them from achieving adequate levels of PA. However, these communities also possess a wealth of knowledge, assets, and support that can be harnessed to help individuals meet PA guidelines. This paper outlines the barriers to PA and explores how to overcome them, drawing from case studies of successful, evidence-based interventions that use culturally- and linguistically- appropriate approaches to increase PA in underserved populations.

Rural SNAP Participants and Food Insecurity: How Can Communities Leverage Resources to Meet the Growing Food Insecurity Status of Rural and Low-Income Residents?

The burden of obesity disproportionately influences poor health outcomes in rural communities in the United States. Various social and environmental factors contribute to inadequate food access and availability in rural areas, influencing dietary intakes and food insecurity rates. This study aims to identify patterns related to food insecurity and fruit and vegetable consumption within a SNAP-eligible and low-income, highly obese rural Appalachian community. A prospective cohort was implemented to identify gaps in resources addressing obesity and food insecurity challenges. SAS 9.4 software was used to examine differences in dietary intakes and shopping practices among SNAP participants. Among participants (n = 152), most reported an annual household income less than USD 20,000 (n = 90, 60.4%), 29.1% reported food insecurity, and 39.5% reported receiving SNAP benefits within the last month. The overall mean FV intake was 3.46 daily servings (95% CI: 3.06–3.91) among all participants. SNAP participation was associated with food insecurity (p = 0.007) and those participating in SNAP were two times more likely to report being food insecure (OR = 2.707, 95% CI: 1.317, 5.563), relative to non-participants. These findings further depict the need for intervention, as the burden of food insecurity persists. Tailoring health-promoting initiatives to consider rurality and SNAP participation is vital for sustainable success among these populations.