Research Brief An Ecological Approach to Exploring Rural Food Access and Active Living for Families With Preschoolers* Brandy Buro, MS, RD1; Abby Gold, PhD, MPH, RD2; Dawn Contreras, PhD3; Ann L. Keim, PhD4; Amy R. Mobley, PhD, RD5; Renee Oscarson, PhD, RD, LN, BCC6; Paula Peters, PhD7; Sandy Procter, PhD, RD, LD8; Carol Smathers, MS, MPH9 ABSTRACT Objective: To identify factors using the Ecological Model of Childhood Overweight related to accessing nutritious foods and physical activity opportunities from the perspectives of rural parents of preschoolers. Methods: A mixed-methods study using a quantitative survey (Active Where?) and qualitative interviews. Analyzed interview themes provided context to the survey results. The setting was Head Start centers, county human service offices, and Women, Infants, and Children Program sites in rural counties in the Midwest. Rural parents (n ¼ 377) of preschoolers took part in the survey in 7 Midwestern states; 15 similar participants were interviewed from 1 of the states. Transcribed interviews were coded. Frequencies and chi-square tests were computed; significance was set at P < .05. Results: The Active Where? survey and interviews revealed that close proximity to recreation spaces and traffic safety issues influenced physical activity. For food access, close proximity to full service grocery stores did not influence access to healthy foods because respondents traveled to urban communities to purchase healthy foods. Conclusions and Implications: Public transportation solutions and enhanced neighborhood safety are potential community-wide obesity prevention strategies in rural communities. However, interventions should be tailored to the community’s stage of readiness. Strong social networks should be considered an asset for community change in these regions. Key Words: preschool children, obesity, rural communities, environment, ecological model (J Nutr Educ Behav. 2015;47:548-554.) Accepted August 24, 2015.
INTRODUCTION Childhood obesity disproportionately affects low-income, minority, and rural children.1-3 Children living in 1
rural areas in the US are about 25% more likely to be overweight or obese than their urban counterparts.4 Some argue that the reason children in rural areas are more obese is because fewer
Center for Family Development, University of Minnesota Extension, St Paul, MN Department of Public Health, North Dakota State University, Fargo, ND 3 Health and Nutrition Institute, Michigan State University Extension, East Lansing, MI 4 Family Living Programs, University of Wisconsin-Extension, Madison, WI 5 Department of Nutritional Sciences, University of Connecticut, Storrs, CT 6 Department of Counseling and Human Development, South Dakota State University, Brookings, SD 7 Department of Family and Consumer Sciences, K-State Research and Extension, Kansas State University, Manhattan, KS 8 Department of Human Nutrition, Kansas State University, Manhattan, KS 9 Family and Consumer Sciences, Ohio State University Extension, Columbus, OH * This online article was corrected after publication to include Carol Smathers in the author list. Conflict of Interest Disclosure: The authors’ conflict of interest disclosures can be found online with this article on www.jneb.org. Address for correspondence: Abby Gold, PhD, MPH, RD, Department of Public Health, North Dakota State University, PO Box 6050, Dept 2662, Fargo, ND 58108-6050; Phone: (701) 231-7478; Fax: (701) 231-8872; E-mail: [email protected] Ó2015 Society for Nutrition Education and Behavior. Published by Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.jneb.2015.08.020 2
548
opportunities exist for urban children to exercise.4 The geography and infrastructure (built environment) of rural areas make residents especially prone to obesity. Built environmental factors for physical activity include safe playground equipment, sidewalks or safe streets, green spaces, and accessible indoor gym facilities. Built environmental factors for healthy eating include access to healthy foods in rural grocery stores where food deserts are commonly found.5 The availability of conveniently located retail food outlets that sell nutritious foods at affordable prices is an important factor in providing individuals with healthy food choices that reduce their risk for obesity.6,7 The purposes of this study were to understand the rural built environment from the perspectives of parents with preschoolers and to identify barriers to providing nutritious foods and physical activity opportunities. The researchers used the Ecological
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Buro et al 549
Figure. Ecological Model of Predictors of Childhood Overweight. (Reprinted with permission from Davison and Birch 2001.) Model of Childhood Overweight8 (Figure) to illustrate how community characteristics such as the built environment affected multiple aspects of a child's environment. Although it is a popular tool in emerging obesity prevention research, its application in rural settings has been limited.9 This study aimed to discover how the community portion of the ecological model affected the barriers and facilitators for accessing fruit, vegetables, and physical activity opportunities for rural parents with preschoolers.
METHODS This study used mixed methods in a developmental approach with complementary intent.10 The Active Where? Parent Survey provided a quantitative, descriptive assessment of participants' perceptions. Qualitative interviews provided themes and added context to the Active Where? survey responses. Research participants for both the survey and interviews were rural parents and caregivers with children
aged 3–5 years. Rural status was defined as an area with a population density < 1,000 people per square mile.9 Participants were asked to consider how questions applied to the preschooler(s) in their households. All procedures were approved by the North Dakota State University Institutional Review Board.
Active Where? Parent Survey This survey was a sub-study of the Communities Preventing Childhood Obesity (CPCO) study examining the influence of coalition building on policy, systems, and environments of preschool children to prevent childhood obesity.11 A convenience sample of 377 individuals was recruited from 14 rural communities in 7 Midwestern states at local Head Start programs, county human services offices, and Special Supplemental Nutrition Program for Women, Infants, and Children clinics. Surveys were administered by researchers in an
interview format at recruitment sites in fall, 2012. A consent statement was read aloud before administering the survey. Participants received $30 after completing the survey, which took approximately 45–60 minutes. The survey was adapted, with permission, from the Active Where? Parent–Child Survey developed by Grow et al.12 The Active Where? survey measures parental perceptions of how the built and physical environment affects the physical activity and eating behaviors of their children. The adapted version included a parent demographic section and 11 sections assessing home and neighborhood environment characteristics. Three sections were included in this CPCO sub-study: recreation places and sports facilities where your child plays (a ¼ .81), barriers to activity in the local neighborhood (a ¼ .88), and a brief food frequency questionnaire (a ¼ .70). Descriptive and nonparametric statistics (frequencies and chisquare tests) were conducted in SAS
550 Buro et al version 9.4 (SAS Institute, Cary, NC, 2013). Significance for chi-square tests was set at P < .01.
Semistructured Interview Interview participants were recruited through a network sampling method using word of mouth or a flier sent home with children enrolled in Head Start sites located in rural eastern North Dakota. Interview participants were communities different from the Active Where? survey participants to prevent site contamination. Participant recruitment continued until data saturation was achieved (ie, when responses were repeated and no new information was heard).13 After the researchers obtaining consent, 45-minute interviews took place between November, 2013 and January, 2014 at a convenient time and location for participants. Participants received a $25 gift card at the beginning of each interview. Interview questions were modeled after the Ecological Model of Childhood Overweight. Questions inquired about the participant's community, home environment, and beliefs related to nutrition and physical activity. Questions were peer-reviewed by the 7 CPCO program directors and then pilot-tested with 3 rural parents of preschoolers in eastern North Dakota (Table 1).
Journal of Nutrition Education and Behavior Volume 47, Number 6, 2015 Constant comparison, or simultaneous data collection and analysis, was exercised to enhance trustworthiness.14 Transcribed interviews were organized and coded with qualitative data analysis software (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany, 2012). Codes were examined for relationships and patterns. Themes were generated by observing which codes occurred together frequently across all participants. One researcher coded the transcripts and a second researcher reviewed the coded interviews to look for consistency in coding technique. Coding issues were discussed and consensus was reached between the 2 researchers. The query tool, an ATLAS.ti software feature, extracted exemplary quotes corresponding to code relationships and themes.
RESULTS A total of 377 survey participants and 15 interview participants provided demographic information and were included in the analysis. The majority of participants in both samples were female (87.0% [n ¼ 328] of survey participants and 100.0% [n ¼ 15] of interview participants) and white (96.7% [n ¼ 365] of survey participants and 100.0% [n ¼ 15] of interview participants). Approximately 70.0% of survey participants (n ¼ 263) lived in
Table 1. List of Semistructured Conversational Interview Questions Used With Rural Parents 1. What do you believe a healthy lifestyle consists of for your child/children? 2. Where do you purchase food? a. Why do you choose to shop at those establishments? b. How would you describe the quality and variety of the food available in these establishments? 3. How do you decide what food to buy for you and your family? 4. Could you give me examples of what you consider nutritious or healthy food? 5. What kinds of activities do you and your family do together? 6. What activities does your child engage on his or her own with or without your supervision? 7. Do you have access to physical activity equipment? 8. Where do you purchase physical activity equipment? 9. Is there anything you would change about your community that you believe could help improve the health of your family? 10. What are ways you believe your community can provide more opportunities for recreational activities or physical activity for your family?
town (within city limits), whereas 40.0% of interview participants (n ¼ 6) lived in town vs out of town (outside city limits). Mean age of participants' preschool-aged children was 3.91 years (SD, 0.91 years) for survey participants and 3.6 years (SD, 0.74 years) for interview participants. Table 2 presents additional demographics.
Active Where? Parent Survey Results For the section on recreation places and sports facilities where your child plays, proximity to convenient recreation/play spaces was an important factor for determining level of use. Chi-square tests for independence indicated that there was a significant relationship between neighborhood type (town or rural), which was used as a proxy for distance, and how frequently children were active at small public parks (c2 [3; n ¼ 371] ¼ 16.57; P < .01), large public parks (c2 [3; n ¼ 366] ¼ 13.09; P < .01), and public playgrounds with equipment (c2 [3; n ¼ 371] ¼ 15.53; P < .01). No significant relationships were found between neighborhood type and the remaining 13 recreation places (Table 3). Frequencies were computed for all 22 items in the section on barriers to activity in the local neighborhood to identify major barriers to being active in the local park and streets or roads in the local neighborhood. Nearly one third (n ¼ 104; 27.6%) of participants somewhat agreed or strongly agreed that no adult supervision was a barrier to being active at the local park. Traffic was the most frequently reported barrier to being active on the local street on road, with the majority (n ¼ 232; 61.5%) somewhat agreeing or strongly agreeing. For the sections on food frequency and barriers to activity in the local neighborhood sections, chi-square tests for independence indicated that there was no significant relationship between ease of walking to stores and how often fresh fruit was available in the home (c2 [9; n ¼ 375] ¼ 3.97; P ¼ .94) or how often fresh vegetables were available in the home (c2 [12; n ¼ 375] ¼ 6.60; P ¼ .88).
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Table 2. Combined Demographic Characteristics of Survey and Interview Participants Survey Participants
Interview Participants
Characteristic Age, y
n 372
% 98.7
Mean 30.9
SD 6.9
n 15
% 100.0
Mean 32.7
SD 4.1
Household size
376
99.7
4.5
1.3
15
100.0
4.8
1.7
Children, n
376
99.7
2.6
1.2
15
100.0
3.2
1.5
Drivable motor vehicles, n
363
96.3
2.0
1.1
14
100.0
2.2
0.7
Level of education Less than high school High school/general equivalency diploma Some college Associate’s degree Bachelor’s degree or more
377 28 116 111 48 74
100.0 7.4 30.8 29.4 12.7 19.6
14 0 2 1 6 5
93.3 0.0 13.3 6.7 40.0 33.3
Marital status Single, never married Married Widowed, divorced, or separated Living with partner Other
377 67 224 48 35 3
100.0 17.8 59.4 12.7 9.3 0.8
15 0 13 1 0 1
100.0 0.0 86.7 6.7 0.0 6.7
Themes: Semistructured Interview Results The theme of accessibility and use of resources categorized barriers to ac-
cessing food and physical activity opportunities. Convenience of accessing resources, knowledge of resources, and perceived value all influenced how parents used available resources.
Table 3. Chi-Square Test Results for Recreation Place Use, by Neighborhood Type Degrees of Freedom 3
n 370
c2 0.28
P .96
Beach, lake, river, or creek
3
365
4.42
.22
Biking/hiking/walking trails
3
369
0.76
.89
Basketball court
3
368
1.39
.71
Other playing fields/courts (football, softball, ot tennis)
3
369
2.62
.45
Recreation Place Indoor recreation or exercise facility (public or private)
YMCA
3
369
0.28
.96
Boys and girls club
3
367
2.00
.57
Swimming pool
3
369
7.15
.07
Walking/running track
3
371
2.75
.43
Small public park
3
371
16.57*
School with recreational facilities open to public
3
365
2.39
< .01 .50
Large public park
3
366
13.09*
< .01
Public playground with equipment
3
371
15.50*
< .01
Public open space (grass or sand/dirt) that is not a park
3
372
0.77
.86
Shopping mall or plaza
3
369
7.28
.06
Friend/relative’s house
3
371
1.29
.73
*P < .01.
For food, parents had access to a local grocery store, but not everyone chose to shop there. Participants preferred shopping in urban communities to receive the best value, often coordinating trips with another errand to justify the time and costs of travel and buying in bulk to last until the next trip. Ashley (a pseudonym) said, Some nights after work you stop [at the local store] and you get food, but it's rotten. And by the time you get home, or a day or two later it's mushy. So I think living in a rural community, people probably do give up quality fruits and vegetables. It's convenience. It's just that you pay for the convenience, too. And you pay as far as losing quality. For accessing physical activity opportunities, seasonality influenced patterns and use of indoor and outdoor recreational spaces. Recreational programs available for preschoolers were offered in the summer. Outdoor recreational facilities (parks and swimming pools) were also used more often in the summer. Children engaged in indoor activities during the winter because it could be too cold to play outside regularly or for extended periods of time. Indoor activities were typically sedentary, such as crafts and gaming. Limited indoor space
552 Buro et al restricted children's ability to stay active in the winter months. Holly, who recently relocated from an urban community, shared her ideas: We used to go to the mall in [urban town] a lot because they had this little brand-new indoor play area. There's nothing really like that indoors around here . like, a play place for kids, you know? . I feel like there are a lot of open places in [rural town] that you could fit something like that in. Factors contributing to neighborhood safety influenced how or whether resources were used. For instance, families reported being most active outdoors, but only when parents thought it was safe enough to do so. Although parents believed their local neighborhood was generally safe for preschoolers, they repeatedly mentioned several threats to safety that merited the need for supervision and enforcement of rules and boundaries for outdoor play. Briana explained her rules for play on their farm: ‘‘They know their boundaries. . The garden—that's their stopping point.’’ Participants identified traffic as the major threat to safety. Pedestrian and biking trails were viewed as a component of the built environment that would enhance safety of outdoor play, creating safe routes to other outdoor recreational spaces and providing some protection from highway traffic and alleviating the need to bike or walk on the road. Parents who lived near a highway without sidewalks admitted that their family would walk or bike more if a trail were available, but they sometimes believed their community lacked financial resources to develop trails. Although not included as a part of the Active Where? survey, a family's social network could be considered as either a barrier or a facilitator to accessing healthy food and physical activity opportunities in rural communities. Formal methods of informing the public of available resources or programs and upcoming community events were rarely identified. Information was communicated through word of mouth. Participants without a strong local social network (for instance, those new to the community) described difficulty in knowing about available programs or recreational fa-
Journal of Nutrition Education and Behavior Volume 47, Number 6, 2015 cilities. Even parents who described themselves as well-established in the community were sometimes unaware of how to access some resources, and relied on social ties to obtain needed information. Participants clearly valued developing interpersonal relationships. Parents expressed the need for more community events or programs to connect them with other families, fostering social development among their children. Enrolling children in early child care programs was recognized as another method to establish interpersonal relationships. Interpersonal relationships also promoted food access. Participants obtained affordable produce through friends' garden surplus. Other food access options included communitysupported agriculture programs and food delivery services.
DISCUSSION Current approaches to childhood obesity prevention focus on altering community-wide factors of the built environment and encompassing policy and physical aspects of the places where children live, learn, and play.9,15 Community-based interventions have potentially more impact compared with the limitations of behavior change interventions directed toward individuals as implied by the ecological model.16 This study identified built environmental factors important for promoting or preventing rural preschool children's healthy eating and physical activity levels.
Physical Activity Access Distance to public parks and playgrounds was related to how frequently children were active in those places; specifically, survey participants living in town used parks more frequently than did those living out of town. Social influences were identified as facilitators of physical activity. Relationships create opportunities for unstructured play, which ultimately supported development of children's social skills.17 Interview participants in this study valued interpersonal relationships for seeking information about recreation, whereas survey participants identified local friends' and
neighbors' homes as important recreation places. Focus groups conducted by Moore et al17 revealed a desire for improved public transportation systems in rural communities to alleviate individual costs associated with traveling to recreation places when distance was a major barrier to being active. Traffic was identified as the major barrier to being active near local streets and roads among survey participants, but it was also a prominent concern of neighborhood safety for interview participants. Consequently, interview participants' rules and boundaries for outdoor play prohibited their children from being active near streets and roads. Supporting this notion, Grow et al12 found perceived traffic safety to be the strongest correlate with whether or not children walked or biked to parks.
Healthy Food Access Survey results indicated no relationship between ease of walking to stores and how often fruits and vegetables were available within the home. Rural Arkansas residents were willing to drive further than necessary to obtain what they sought in terms of affordability, quality, and selection, because local stores within close proximity rarely offered food meeting this criteria.18 In addition, Krukowski et al19 reported that participants acknowledged that supporting local businesses would benefit the community, but they chose to shop elsewhere to access greater value—a reaction to barriers of food access apparent among the current study's participants. Rural residents who value certain aspects of larger grocery stores are willing to travel further to shop and therefore accumulate more total shopping miles each week.20,21 The perception of decreased number of quality foods also exists in low–food access communities.21 Community food system approaches such as mobile food markets and community gardens may be a strategy to increase healthy food access and quality in rural communities.22 The survey did not assess the consumer food environment, characteristics discovered to be influential in where and how interview participants obtained food. Overall descriptions of
Journal of Nutrition Education and Behavior Volume 47, Number 6, 2015 barriers related to accessing fruits and vegetables using the mixed-method approach might be lacking for this reason. When using a mixed-method approach, it would have been more desirable to survey and interview participants from the same community. However, the authors decided to avoid contaminating the CPCO communities with unintentional information. To minimize demographic characteristic differences between interview and survey participants, similar types of communities and sites were chosen for recruitment (primarily rural and low-income sites). Finally, only 3 survey sections were used in this study. However, for the purpose of this mixed-methods study, themes revealed from the qualitative data were matched with the 3 most relevant survey sections.
IMPLICATIONS FOR RESEARCH AND PRACTICE This mixed-methods study identified community-level factors of the SocioEcological Model of Childhood Obesity involved with accessing fruits and vegetables and physical activity opportunities in rural communities. Proximity and traffic safety were 2 important areas of focus for enhancing use of public recreation spaces. Creative solutions to public transportation options for families and preschoolers in rural areas should be investigated further. Installing sidewalks and traffic-calming techniques in residential areas near highways could enhance neighborhood safety and promote active transportation to recreation places.23 Finally, an assessment of the local consumer food environment should be included in the design of future community-wide interventions, because quality and affordability of foods available rurally sometimes prohibited families from using local food access options. Social networks, illustrated by the theme of interpersonal relationships in the current study, should be considered an asset for community change in rural regions. Social capital, or interpersonal and organizational connections, is an essential component of community action, and its value should be realized in
future research endeavors and intervention strategies.24,25
ACKNOWLEDGMENTS This project was supported by the Agriculture and Food Research Initiative, Grant 2011-68001-30100, from the US Department of Agriculture, National Institute of Food and Agriculture, Childhood Obesity Prevention: Integrated Research, Education and Extension to Prevent Childhood Obesity, Program Code A2101. The authors extend appreciation to the parents who made this study possible.
REFERENCES 1. Wang Y, Beydoun MA. The obesity epidemic in the United States—gender, age, socioeconomic, racial/ethnic, and geographic characteristics: a systematic review and meta-regression analysis. Am J Epidemiol. 2007;29:6-28. 2. Joens-Matre RR, Welk GJ, Calabro MA, Russell DW, Nicklay E, Hensley LD. Rural-urban difference in physical activity, physical fitness, and overweight prevalence of children. J Rural Health. 2008;24:49-54. 3. Centers for Disease Control. Obesity prevalence among low-income, preschool-aged children—United States, 1998-2008. In: Services DoHaH, ed. Vol. 58. 2009:769–773. 4. Lutfiyya MN, Lipsky MS, WisdomBehounek J, Inpanbutr-Martinkus M. Is rural residence a risk factor of overweight and obesity for US children? Obesity (Silver Spring). 2007;15:2348-2356. 5. Hendrickson D, Smith C, Eikenberry N. Fruit and vegetable access in four low-income food deserts communities in Minnesota. Agric Human Values. 2006;23:371-383. 6. Flourney R, Treuhaft S. Healthy food, healthy communities: improving access and opportunities through food retailing. http://www.policylink.org/ sites/default/files/HEALTHYFOOD. pdf. Accessed September 28, 2015. 7. Wrigley N, Warm D, Margetts B. Deprivation, diet and food-retail access: findings from the Leeds ‘‘food deserts’’ study. Environ Plan A. 2003;35:151-188. 8. Davison KK, Birch LL. Childhood overweight: a contextual model and recommendations for future research. Obes Rev. 2001;2:159-171.
Buro et al 553 9. Yousefian A, Ziller E, Swartz J, Hartley D. Active living for rural youth: addressing physical inactivity in rural communities. J Public Health Manag Pract. 2009;15:223-231. 10. Greene JC. Mixed Methods in Social Inquiry. San Francisco, CA: Jossey-Bass; 2007. 11. Communities Preventing Childhood Obesity. http://www.prevchildobesity .org. Accessed June 21, 2015. 12. Grow HM, Saelens BE, Kerr J, Durant NH, Norman GJ, Sallis JF. Where are youth active? Roles of proximity, active transport, and built environments. Med Sci Sports Exerc. 2008; 40:2071-2079. 13. Creswell JW. Qualitative Inquiry and Research D: Choosing among Five Approaches. Thousand Oaks, CA: Sage; 2013. 14. Hays DG, Singh AA. Qualitative Inquiry in Clinical and Educational Settings. New York, NY: Guilford Press; 2012. 15. Davison KK, Lawson CT. Do attributes in the physical activity environment influence children’s physical activity? A review of the literature. Int J Behav Nutr Phys Act. 2006;3:1-17. 16. Sallis JF, Cervero RB, Ascher W, Henderson KA, Kraft MK, Keff J. An ecological approach to creating active living communities. Annu Rev Public Health. 2006;27:297-322. 17. Moore JB, Jilcott SB, Shores KA, Evenson KR, Brownson RC, Novick LF. A qualitative examination of perceived barriers and facilitators of physical activity for urban and rural youth. Health Educ Res. 2010;25: 355-367. 18. Krukowski RA, McSweeney J, Sparks C, West DS. Qualitative study of influences on food store choice. Appetite. 2012;59:510-516. 19. Krukowski RA, Sparks C, DiCarlo M, McSweeney J, West DS. There’s more to food store choice than proximity: a questionnaire development study. BMC Public Health. 2013;13:1-8. 20. Jilcott SB, Moore JB, WallBassett ED, Lui H, Saelens BE. Association between travel times and food procurement practices among female Supplemental Nutrition Assistance Program participants in eastern North Carolina. J Nutr Educ Behav. 2011;43: 385-389. 21. Sohi I, Bell BA, Liu J, Battersby SE, Liese AD. Differences in food environment perceptions and spatial attributes of food shopping between residents of
554 Buro et al low and high food access areas. J Nutr Educ Behav. 2014;46:241-249. 22. Haynes-Maslow L, Auvergne L, Mark B, Ammerman A, Weiner BJ. Low-income individuals’ perceptions about fruit and vegetable access programs: a qualitative study. J Nutr Educ Behav. 2015;47:317-324.
Journal of Nutrition Education and Behavior Volume 47, Number 6, 2015 23. Committee on Environmental Health. The built environment: designing communities to promote physical activity in children. Pediatrics. 2009; 123:1591-1598. 24. Agnitsch K, Flora J, Ryan V. Bonding and bridging social capital: the interactive effects on community
action. J Community Dev Soc. 2006; 37:36-51. 25. Lu AH, Dickin K, Dollahite J. Development and application of a framework to assess community nutritionists’ use of environmental strategies to prevent obesity. J Nutr Educ Behav. 2014;46: 475-483.
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CONFLICT OF INTEREST The authors have not stated any conflicts of interest.
Buro et al 554.e1
INTRODUCTION Childhood obesity disproportionately affects low-income, minority, and rural children.1-3 Children living in 1
rural areas in the US are about 25% more likely to be overweight or obese than their urban counterparts.4 Some argue that the reason children in rural areas are more obese is because fewer
Center for Family Development, University of Minnesota Extension, St Paul, MN Department of Public Health, North Dakota State University, Fargo, ND 3 Health and Nutrition Institute, Michigan State University Extension, East Lansing, MI 4 Family Living Programs, University of Wisconsin-Extension, Madison, WI 5 Department of Nutritional Sciences, University of Connecticut, Storrs, CT 6 Department of Counseling and Human Development, South Dakota State University, Brookings, SD 7 Department of Family and Consumer Sciences, K-State Research and Extension, Kansas State University, Manhattan, KS 8 Department of Human Nutrition, Kansas State University, Manhattan, KS 9 Family and Consumer Sciences, Ohio State University Extension, Columbus, OH * This online article was corrected after publication to include Carol Smathers in the author list. Conflict of Interest Disclosure: The authors’ conflict of interest disclosures can be found online with this article on www.jneb.org. Address for correspondence: Abby Gold, PhD, MPH, RD, Department of Public Health, North Dakota State University, PO Box 6050, Dept 2662, Fargo, ND 58108-6050; Phone: (701) 231-7478; Fax: (701) 231-8872; E-mail: [email protected] Ó2015 Society for Nutrition Education and Behavior. Published by Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.jneb.2015.08.020 2
548
opportunities exist for urban children to exercise.4 The geography and infrastructure (built environment) of rural areas make residents especially prone to obesity. Built environmental factors for physical activity include safe playground equipment, sidewalks or safe streets, green spaces, and accessible indoor gym facilities. Built environmental factors for healthy eating include access to healthy foods in rural grocery stores where food deserts are commonly found.5 The availability of conveniently located retail food outlets that sell nutritious foods at affordable prices is an important factor in providing individuals with healthy food choices that reduce their risk for obesity.6,7 The purposes of this study were to understand the rural built environment from the perspectives of parents with preschoolers and to identify barriers to providing nutritious foods and physical activity opportunities. The researchers used the Ecological
Journal of Nutrition Education and Behavior Volume 47, Number 6, 2015
Journal of Nutrition Education and Behavior Volume 47, Number 6, 2015
Buro et al 549
Figure. Ecological Model of Predictors of Childhood Overweight. (Reprinted with permission from Davison and Birch 2001.) Model of Childhood Overweight8 (Figure) to illustrate how community characteristics such as the built environment affected multiple aspects of a child's environment. Although it is a popular tool in emerging obesity prevention research, its application in rural settings has been limited.9 This study aimed to discover how the community portion of the ecological model affected the barriers and facilitators for accessing fruit, vegetables, and physical activity opportunities for rural parents with preschoolers.
METHODS This study used mixed methods in a developmental approach with complementary intent.10 The Active Where? Parent Survey provided a quantitative, descriptive assessment of participants' perceptions. Qualitative interviews provided themes and added context to the Active Where? survey responses. Research participants for both the survey and interviews were rural parents and caregivers with children
aged 3–5 years. Rural status was defined as an area with a population density < 1,000 people per square mile.9 Participants were asked to consider how questions applied to the preschooler(s) in their households. All procedures were approved by the North Dakota State University Institutional Review Board.
Active Where? Parent Survey This survey was a sub-study of the Communities Preventing Childhood Obesity (CPCO) study examining the influence of coalition building on policy, systems, and environments of preschool children to prevent childhood obesity.11 A convenience sample of 377 individuals was recruited from 14 rural communities in 7 Midwestern states at local Head Start programs, county human services offices, and Special Supplemental Nutrition Program for Women, Infants, and Children clinics. Surveys were administered by researchers in an
interview format at recruitment sites in fall, 2012. A consent statement was read aloud before administering the survey. Participants received $30 after completing the survey, which took approximately 45–60 minutes. The survey was adapted, with permission, from the Active Where? Parent–Child Survey developed by Grow et al.12 The Active Where? survey measures parental perceptions of how the built and physical environment affects the physical activity and eating behaviors of their children. The adapted version included a parent demographic section and 11 sections assessing home and neighborhood environment characteristics. Three sections were included in this CPCO sub-study: recreation places and sports facilities where your child plays (a ¼ .81), barriers to activity in the local neighborhood (a ¼ .88), and a brief food frequency questionnaire (a ¼ .70). Descriptive and nonparametric statistics (frequencies and chisquare tests) were conducted in SAS
550 Buro et al version 9.4 (SAS Institute, Cary, NC, 2013). Significance for chi-square tests was set at P < .01.
Semistructured Interview Interview participants were recruited through a network sampling method using word of mouth or a flier sent home with children enrolled in Head Start sites located in rural eastern North Dakota. Interview participants were communities different from the Active Where? survey participants to prevent site contamination. Participant recruitment continued until data saturation was achieved (ie, when responses were repeated and no new information was heard).13 After the researchers obtaining consent, 45-minute interviews took place between November, 2013 and January, 2014 at a convenient time and location for participants. Participants received a $25 gift card at the beginning of each interview. Interview questions were modeled after the Ecological Model of Childhood Overweight. Questions inquired about the participant's community, home environment, and beliefs related to nutrition and physical activity. Questions were peer-reviewed by the 7 CPCO program directors and then pilot-tested with 3 rural parents of preschoolers in eastern North Dakota (Table 1).
Journal of Nutrition Education and Behavior Volume 47, Number 6, 2015 Constant comparison, or simultaneous data collection and analysis, was exercised to enhance trustworthiness.14 Transcribed interviews were organized and coded with qualitative data analysis software (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany, 2012). Codes were examined for relationships and patterns. Themes were generated by observing which codes occurred together frequently across all participants. One researcher coded the transcripts and a second researcher reviewed the coded interviews to look for consistency in coding technique. Coding issues were discussed and consensus was reached between the 2 researchers. The query tool, an ATLAS.ti software feature, extracted exemplary quotes corresponding to code relationships and themes.
RESULTS A total of 377 survey participants and 15 interview participants provided demographic information and were included in the analysis. The majority of participants in both samples were female (87.0% [n ¼ 328] of survey participants and 100.0% [n ¼ 15] of interview participants) and white (96.7% [n ¼ 365] of survey participants and 100.0% [n ¼ 15] of interview participants). Approximately 70.0% of survey participants (n ¼ 263) lived in
Table 1. List of Semistructured Conversational Interview Questions Used With Rural Parents 1. What do you believe a healthy lifestyle consists of for your child/children? 2. Where do you purchase food? a. Why do you choose to shop at those establishments? b. How would you describe the quality and variety of the food available in these establishments? 3. How do you decide what food to buy for you and your family? 4. Could you give me examples of what you consider nutritious or healthy food? 5. What kinds of activities do you and your family do together? 6. What activities does your child engage on his or her own with or without your supervision? 7. Do you have access to physical activity equipment? 8. Where do you purchase physical activity equipment? 9. Is there anything you would change about your community that you believe could help improve the health of your family? 10. What are ways you believe your community can provide more opportunities for recreational activities or physical activity for your family?
town (within city limits), whereas 40.0% of interview participants (n ¼ 6) lived in town vs out of town (outside city limits). Mean age of participants' preschool-aged children was 3.91 years (SD, 0.91 years) for survey participants and 3.6 years (SD, 0.74 years) for interview participants. Table 2 presents additional demographics.
Active Where? Parent Survey Results For the section on recreation places and sports facilities where your child plays, proximity to convenient recreation/play spaces was an important factor for determining level of use. Chi-square tests for independence indicated that there was a significant relationship between neighborhood type (town or rural), which was used as a proxy for distance, and how frequently children were active at small public parks (c2 [3; n ¼ 371] ¼ 16.57; P < .01), large public parks (c2 [3; n ¼ 366] ¼ 13.09; P < .01), and public playgrounds with equipment (c2 [3; n ¼ 371] ¼ 15.53; P < .01). No significant relationships were found between neighborhood type and the remaining 13 recreation places (Table 3). Frequencies were computed for all 22 items in the section on barriers to activity in the local neighborhood to identify major barriers to being active in the local park and streets or roads in the local neighborhood. Nearly one third (n ¼ 104; 27.6%) of participants somewhat agreed or strongly agreed that no adult supervision was a barrier to being active at the local park. Traffic was the most frequently reported barrier to being active on the local street on road, with the majority (n ¼ 232; 61.5%) somewhat agreeing or strongly agreeing. For the sections on food frequency and barriers to activity in the local neighborhood sections, chi-square tests for independence indicated that there was no significant relationship between ease of walking to stores and how often fresh fruit was available in the home (c2 [9; n ¼ 375] ¼ 3.97; P ¼ .94) or how often fresh vegetables were available in the home (c2 [12; n ¼ 375] ¼ 6.60; P ¼ .88).
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Table 2. Combined Demographic Characteristics of Survey and Interview Participants Survey Participants
Interview Participants
Characteristic Age, y
n 372
% 98.7
Mean 30.9
SD 6.9
n 15
% 100.0
Mean 32.7
SD 4.1
Household size
376
99.7
4.5
1.3
15
100.0
4.8
1.7
Children, n
376
99.7
2.6
1.2
15
100.0
3.2
1.5
Drivable motor vehicles, n
363
96.3
2.0
1.1
14
100.0
2.2
0.7
Level of education Less than high school High school/general equivalency diploma Some college Associate’s degree Bachelor’s degree or more
377 28 116 111 48 74
100.0 7.4 30.8 29.4 12.7 19.6
14 0 2 1 6 5
93.3 0.0 13.3 6.7 40.0 33.3
Marital status Single, never married Married Widowed, divorced, or separated Living with partner Other
377 67 224 48 35 3
100.0 17.8 59.4 12.7 9.3 0.8
15 0 13 1 0 1
100.0 0.0 86.7 6.7 0.0 6.7
Themes: Semistructured Interview Results The theme of accessibility and use of resources categorized barriers to ac-
cessing food and physical activity opportunities. Convenience of accessing resources, knowledge of resources, and perceived value all influenced how parents used available resources.
Table 3. Chi-Square Test Results for Recreation Place Use, by Neighborhood Type Degrees of Freedom 3
n 370
c2 0.28
P .96
Beach, lake, river, or creek
3
365
4.42
.22
Biking/hiking/walking trails
3
369
0.76
.89
Basketball court
3
368
1.39
.71
Other playing fields/courts (football, softball, ot tennis)
3
369
2.62
.45
Recreation Place Indoor recreation or exercise facility (public or private)
YMCA
3
369
0.28
.96
Boys and girls club
3
367
2.00
.57
Swimming pool
3
369
7.15
.07
Walking/running track
3
371
2.75
.43
Small public park
3
371
16.57*
School with recreational facilities open to public
3
365
2.39
< .01 .50
Large public park
3
366
13.09*
< .01
Public playground with equipment
3
371
15.50*
< .01
Public open space (grass or sand/dirt) that is not a park
3
372
0.77
.86
Shopping mall or plaza
3
369
7.28
.06
Friend/relative’s house
3
371
1.29
.73
*P < .01.
For food, parents had access to a local grocery store, but not everyone chose to shop there. Participants preferred shopping in urban communities to receive the best value, often coordinating trips with another errand to justify the time and costs of travel and buying in bulk to last until the next trip. Ashley (a pseudonym) said, Some nights after work you stop [at the local store] and you get food, but it's rotten. And by the time you get home, or a day or two later it's mushy. So I think living in a rural community, people probably do give up quality fruits and vegetables. It's convenience. It's just that you pay for the convenience, too. And you pay as far as losing quality. For accessing physical activity opportunities, seasonality influenced patterns and use of indoor and outdoor recreational spaces. Recreational programs available for preschoolers were offered in the summer. Outdoor recreational facilities (parks and swimming pools) were also used more often in the summer. Children engaged in indoor activities during the winter because it could be too cold to play outside regularly or for extended periods of time. Indoor activities were typically sedentary, such as crafts and gaming. Limited indoor space
552 Buro et al restricted children's ability to stay active in the winter months. Holly, who recently relocated from an urban community, shared her ideas: We used to go to the mall in [urban town] a lot because they had this little brand-new indoor play area. There's nothing really like that indoors around here . like, a play place for kids, you know? . I feel like there are a lot of open places in [rural town] that you could fit something like that in. Factors contributing to neighborhood safety influenced how or whether resources were used. For instance, families reported being most active outdoors, but only when parents thought it was safe enough to do so. Although parents believed their local neighborhood was generally safe for preschoolers, they repeatedly mentioned several threats to safety that merited the need for supervision and enforcement of rules and boundaries for outdoor play. Briana explained her rules for play on their farm: ‘‘They know their boundaries. . The garden—that's their stopping point.’’ Participants identified traffic as the major threat to safety. Pedestrian and biking trails were viewed as a component of the built environment that would enhance safety of outdoor play, creating safe routes to other outdoor recreational spaces and providing some protection from highway traffic and alleviating the need to bike or walk on the road. Parents who lived near a highway without sidewalks admitted that their family would walk or bike more if a trail were available, but they sometimes believed their community lacked financial resources to develop trails. Although not included as a part of the Active Where? survey, a family's social network could be considered as either a barrier or a facilitator to accessing healthy food and physical activity opportunities in rural communities. Formal methods of informing the public of available resources or programs and upcoming community events were rarely identified. Information was communicated through word of mouth. Participants without a strong local social network (for instance, those new to the community) described difficulty in knowing about available programs or recreational fa-
Journal of Nutrition Education and Behavior Volume 47, Number 6, 2015 cilities. Even parents who described themselves as well-established in the community were sometimes unaware of how to access some resources, and relied on social ties to obtain needed information. Participants clearly valued developing interpersonal relationships. Parents expressed the need for more community events or programs to connect them with other families, fostering social development among their children. Enrolling children in early child care programs was recognized as another method to establish interpersonal relationships. Interpersonal relationships also promoted food access. Participants obtained affordable produce through friends' garden surplus. Other food access options included communitysupported agriculture programs and food delivery services.
DISCUSSION Current approaches to childhood obesity prevention focus on altering community-wide factors of the built environment and encompassing policy and physical aspects of the places where children live, learn, and play.9,15 Community-based interventions have potentially more impact compared with the limitations of behavior change interventions directed toward individuals as implied by the ecological model.16 This study identified built environmental factors important for promoting or preventing rural preschool children's healthy eating and physical activity levels.
Physical Activity Access Distance to public parks and playgrounds was related to how frequently children were active in those places; specifically, survey participants living in town used parks more frequently than did those living out of town. Social influences were identified as facilitators of physical activity. Relationships create opportunities for unstructured play, which ultimately supported development of children's social skills.17 Interview participants in this study valued interpersonal relationships for seeking information about recreation, whereas survey participants identified local friends' and
neighbors' homes as important recreation places. Focus groups conducted by Moore et al17 revealed a desire for improved public transportation systems in rural communities to alleviate individual costs associated with traveling to recreation places when distance was a major barrier to being active. Traffic was identified as the major barrier to being active near local streets and roads among survey participants, but it was also a prominent concern of neighborhood safety for interview participants. Consequently, interview participants' rules and boundaries for outdoor play prohibited their children from being active near streets and roads. Supporting this notion, Grow et al12 found perceived traffic safety to be the strongest correlate with whether or not children walked or biked to parks.
Healthy Food Access Survey results indicated no relationship between ease of walking to stores and how often fruits and vegetables were available within the home. Rural Arkansas residents were willing to drive further than necessary to obtain what they sought in terms of affordability, quality, and selection, because local stores within close proximity rarely offered food meeting this criteria.18 In addition, Krukowski et al19 reported that participants acknowledged that supporting local businesses would benefit the community, but they chose to shop elsewhere to access greater value—a reaction to barriers of food access apparent among the current study's participants. Rural residents who value certain aspects of larger grocery stores are willing to travel further to shop and therefore accumulate more total shopping miles each week.20,21 The perception of decreased number of quality foods also exists in low–food access communities.21 Community food system approaches such as mobile food markets and community gardens may be a strategy to increase healthy food access and quality in rural communities.22 The survey did not assess the consumer food environment, characteristics discovered to be influential in where and how interview participants obtained food. Overall descriptions of
Journal of Nutrition Education and Behavior Volume 47, Number 6, 2015 barriers related to accessing fruits and vegetables using the mixed-method approach might be lacking for this reason. When using a mixed-method approach, it would have been more desirable to survey and interview participants from the same community. However, the authors decided to avoid contaminating the CPCO communities with unintentional information. To minimize demographic characteristic differences between interview and survey participants, similar types of communities and sites were chosen for recruitment (primarily rural and low-income sites). Finally, only 3 survey sections were used in this study. However, for the purpose of this mixed-methods study, themes revealed from the qualitative data were matched with the 3 most relevant survey sections.
IMPLICATIONS FOR RESEARCH AND PRACTICE This mixed-methods study identified community-level factors of the SocioEcological Model of Childhood Obesity involved with accessing fruits and vegetables and physical activity opportunities in rural communities. Proximity and traffic safety were 2 important areas of focus for enhancing use of public recreation spaces. Creative solutions to public transportation options for families and preschoolers in rural areas should be investigated further. Installing sidewalks and traffic-calming techniques in residential areas near highways could enhance neighborhood safety and promote active transportation to recreation places.23 Finally, an assessment of the local consumer food environment should be included in the design of future community-wide interventions, because quality and affordability of foods available rurally sometimes prohibited families from using local food access options. Social networks, illustrated by the theme of interpersonal relationships in the current study, should be considered an asset for community change in rural regions. Social capital, or interpersonal and organizational connections, is an essential component of community action, and its value should be realized in
future research endeavors and intervention strategies.24,25
ACKNOWLEDGMENTS This project was supported by the Agriculture and Food Research Initiative, Grant 2011-68001-30100, from the US Department of Agriculture, National Institute of Food and Agriculture, Childhood Obesity Prevention: Integrated Research, Education and Extension to Prevent Childhood Obesity, Program Code A2101. The authors extend appreciation to the parents who made this study possible.
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CONFLICT OF INTEREST The authors have not stated any conflicts of interest.
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