Table 4 Barriers to healthy eating and physical activity in preschool-aged children in two rural communities

Family level

Unhealthy nutrition practices

Parental lack of cooking skills

“People don't know how to cook anymore. They just don't know how to cook, and they don't believe even if they do know how to cook, they don't believe they have the time to cook.” (Stakeholder)

Parental lack of nutrition knowledge

“There's definitely a lot of ignorance about nutrition in general, where like ‘Juicy Juice’ says the word juice in it, therefore it’s fruit, this counts. And it’s not understanding how nutrition actually works. And therefore, thinking that they are getting fruits and vegetables when they aren't.” (Parent)

Limited financial resources within families

Perception that healthy foods are expensive

“Cost is a huge barrier to healthy food choices. And then the lack of where you would even go to get it outside of traveling farther away… People are compartmentalized, but there's one overarching thing and that is: how can I survive. Period. And so, these decisions about better foods as opposed to less expensive foods… what's going to win is always going to be less expensive foods.” (Stakeholder)

Other priorities competing with eating healthy and being active

"A lot of these parents are doing everything they can just to get food on the table. If they're having trouble with food, having their kid go out and exercise is not a priority.” (Parent)

“Looking at the expenses that you have, healthy food is going to go below rent. So as long as you have any kind of food, that is going to be your priority.” (Stakeholder)

Organization level:

Limited availability/access to health programs

Limited access to childcare programs

“Childcare is definitely a huge barrier. If you don't have an immediate family member who can stay with your kids, then, your options are pretty limited.” (Parent)

Perception that practices at childcare are not reinforced at home

“We follow food programs, so we follow more strict nutritious guidelines. But you know, if they leave and go straight through Wendy's drive-thru, all my work is for naught. And I know there's not anything you can do about that. You can't force a parent to treat them differently.” (Childcare provider)

Poor parental engagement in health programs

“It’s hard. Parent involvement, getting parents involved, is our biggest downfall.” (Stakeholder)

Community level:

Limited access to community resources

Limited access to healthy foods (and beverages) and healthy food outlets

“It's the access. So, we tend to go to Dollar General like in a pinch. Like we need peanut butter, and we just need to get it right away for a recipe or something. But it’s nice to go there when we don’t feel like cooking, or we just want to get something for the kids. I would like to have a little farmers’ market or something there that we could, where we could get fresh fruits and vegetables. And so quick access, I would say is tough.” (Parent)

“I mean we have clean water, there are parts of our county that don’t probably have running water. And I say that’s not a majority, but then again there definitely are pockets of the county that are in such poverty conditions that. That is part of being so spread out. So, there’s pockets here where there is just not access.” (Stakeholder)

Limited access to physical activity resources

“We don't have a park. That's one thing that has really bothered me a lot. The only park in eastern [county] is the playground at the school… we can go there as long as school’s out. Of course, all the kids who are schooling remotely can't go there during the day… It's kind of hard. Especially we've got … essentially just the eastern third of the county: the only park is at the school.” (Parent)

“There are things there that the children can use… There's a walking track and there's swimming but you have to pay to swim. Now, you know, we…. the county does try, but not for the preschoolers, of course, to have sports, basketball, football, soccer, things like that, and they may even have some for five-year-olds, but that would probably be the youngest. But we don't really have child-friendly or toddler-friendly places here.” (Stakeholder)

Safety concerns within neighborhoods

“There is a basketball court in the park, but you never see kids there. You never see anybody at the park, and I just don’t know that it’s—it’s perhaps not safe or the kids are doing other things. But the town is not as safe as it used to be.” (Stakeholder)

Lack of public transportation

“We don't have any public transportation… So, if folks don't have their own transportation, they would have to rely on a support system. You know grandma or neighbor whatever.” (Stakeholder)