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

BMC Public Health volume 24, Article number: 2160 (2024) Cite this article

Abstract

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.

Peer Review reports

Background

Rates of chronic disease among Americans are high [1,2,3] and projected to increase over time [4]. This is important, since living with multiple chronic diseases is associated with greater health care use and cost (e.g., doctor office visits, prescriptions) [1]. For example, 90% of health care spending is accounted for by the 60% of Americans with at least one chronic disease and 41% accounted for by the 12% of Americans with five or more chronic diseases [1]. Additionally, experiencing multiple chronic conditions leads to increased risk of mortality [5]. Disparities also exist with respect to chronic disease morality. Rural compared to urban residents in the United States (U.S.) have higher mortality rates from all five leading causes of death, including cancer, heart disease, unintentional injury, chronic lower respiratory disease, and stroke [6, 7].

To address high rates of chronic disease and related disparities, chronic disease prevention must address behavioral risk factors on multiple levels of influence and across the entire lifespan [8]. National guidelines for the promotion of breastfeeding [9], healthy eating [10, 11], and physical activity (PA) [10, 12] indicate areas for improvement regarding U.S. population health behaviors for chronic disease prevention. However, education approaches alone are unlikely to favorably impact rural Americans’ health practices [13]. As such, concerted policy, systems, and environmental (PSE) changes to improve breastfeeding, healthy eating, and PA practices in alignment with guidelines in settings where Americans “live, learn work, shop, and play” are needed [14,15,16,17,18].

PSE changes may be especially impactful for rural U.S. populations who experience a higher burden of diet and PA related chronic disease, due to infrastructure, resource, and economic challenges [19,20,21,22,23,24,25,26,27,28]. For example, rural Americans are less likely than urban counterparts to initiate and sustain breastfeeding [29], to choose foods and beverages aligned with 2015–2020 Dietary Guidelines for Americans [11], or to meet PA guidelines [19, 20, 30, 31]. To mitigate rural health disparities, an understanding of PSE factors related to promoting breastfeeding, healthy eating, and/or PA in rural communities is needed. Further, understanding opportunities to track such factors over time can help move public health surveillance beyond individual-level behaviors to monitor PSE factors more likely to influence populations’ health-related choices [15].

Researchers applying PSE approaches have called for additional investigation and analysis of policy approaches surrounding the allocation of resources and funding to high-risk populations [14, 15]. Indeed, policy approaches to improve health behaviors among rural populations are studied as a means to implement empirically supported strategies on the national, state, county, or organizational levels [16,17,18]. While many systematic reviews have compiled evidence-based environmental approaches to health promotion [19,20,21,22,23,24,25, 32,33,34,35,36,37], fewer recent reviews have compiled evidence-based policy approaches to address low rates of breastfeeding, healthy eating, and PA that may have profound implications for population health outcomes [38]. Lastly, to our knowledge, no scoping reviews have been published on rural behavior change policy approaches that may be included within less formal channels, such as grey literature reports and theses.

There is a need to comprehensively review and compile existing policy approaches to address low rates of breastfeeding, healthy eating, and PA in rural areas. Scoping reviews can provide information for effective implementation and evidence-based policy strategies as chronic disease prevention strategies [39], and be important tools for compiling academic and non-academic sources to understand the breadth of policies that have been implemented in rural areas [39]. Given the above considerations, the purpose of this scoping review was to identify policy supports that encourage breastfeeding, healthy eating, and/or PA practices among rural American communities. A secondary aim was to assess policy measurement approaches used to collect data in rural communities.

Methods

Design

A broad scoping review was conducted in 2020 as part of a large project to inform PSE surveillance indicators for breastfeeding, healthy eating, and PA promotion among U.S. rural people and places. This project was contracted by the Division of Nutrition, PA, and Obesity Centers for Disease Control and Prevention (CDC). CDC partners aided in developing the review focus and provided feedback, although were not responsible for synthesizing results or drawing conclusions. Notably, the below methods section details the approach used for the entire review, although only the results pertaining to policy are presented here. Carrying out the scoping review procedures, as detailed below, resulted in the inclusion of over 300 sources that were described in an internal-facing report to CDC. To facilitate the reporting of results to a wider audience and improve the ability to offer specific recommendations, authors split results for breastfeeding, healthy eating, and PA by policy, systems, or environmental strategies.

Both the 2018 Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [40] and guidance published by Arksey and O’Malley [41] were used to inform the review strategy and reporting.

The review team included scholars with expertise in rural health and PSE change strategies to improve breastfeeding, healthy eating, and PA patterns/practices. A library partner, a team of graduate research assistants, and an expert advisory board were also involved. Advisory board members (n = 6) included well-established researchers in the areas of PSE and breastfeeding (n = 2), healthy eating (n = 2), or PA (n = 2), with experience working with rural communities when possible. Training was arranged for graduate research assistants at the start of the review process, covering topics including literature review methods, PSE examples, and data extraction. Findings related to policies to encourage/support rural breastfeeding, healthy eating, and PA patterns/practices are reported here and other results (i.e., systems, environments, and qualitative case studies) are reported separately (forthcoming). A review protocol was pre-registered using Open Science Framework (OSF; https://doi.org/10.17605/OSF.IO/VXMDC [42].

Search strategy

A science librarian tested and selected the search strategy used to identify sources, designed to broadly capture policy, systems, and environmental strategies for breastfeeding, healthy eating, and PA promotion occurring in rural settings. Grey literature, graduate research (including thesis and dissertation work), and peer-reviewed scientific literature were all of interest. Searches occurred over a 5-month period between February and July 2020. The procedures for searches are described below by source type.

Peer-reviewed scientific articles and graduate research

Four academic databases – Medline, PubMed, Web of Science, and Agricola – were selected to identify peer-reviewed research across the three discipline areas and ProQuest was used to identify graduate research. Given the broad focus of the scoping review, key terms were tested to select words that most accurately captured relevant sources without overly restricting search databases. Key terms were applied to databases between March and June of 2020 by one researcher with terms focused on topic area (e.g., breastfeed*, diet*, “physical activity*”), geography (e.g., rural*, “United States”), and setting (e.g., policy, environment*) (see https://doi.org/10.17605/OSF.IO/VXMDC for the full search strategy) [42].

The year 2000 was used as a search restriction for peer-reviewed research given PSE strategies for breastfeeding, healthy eating, and PA were less of a focus among the scientific community prior to this year [43]. ProQuest searchers were limited by topic area. For example, search restrictions for healthy eating and PA included only dissertation research and the year 2018 and, for breastfeeding, only the year 2015 was used due to fewer retrieved results compared to the other topic areas. Graduate research prior to these years were assumed to be published and thus would have been identified through the peer-reviewed literature searches. The complete search strategy is available at https://doi.org/10.17605/OSF.IO/VXMDC [42].

All search results were downloaded to an EndNote X9 file for title and abstract review. Due to the large scope of the review, full text reviewing occurred independently among project team members. Figure 1 provides a PRISMA diagram of included and excluded studies related to all three PSE approaches, with reasons for exclusion. This process was iterative. Trained research team members (HD, SE, CM, RSW) completed abstract review, full text review, and extraction, with liberal inclusion of source materials, and then three project leads (BH, KJK, and MRUM) and trained research team members (KHK, MEW) checked eligibility of all extracted full text articles. The flow diagram regarding academic and ProQuest sources reviewed and included in our synthesis among all behaviors and PSE areas is shown in Fig. 1.

Fig. 1
figure 1

PRISMA diagram of included and excluded studies related to policy, systems, and environmental change approaches for breastfeeding, healthy eating, and physical activity promotion

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To supplement the systematic search, literature recommendations were solicited from the advisory group, including both original research and related systematic/scoping reviews. Research team members reviewed and determined if advisory group recommendations met inclusion criteria.

Grey literature

Grey literature searches spanned Google, Google Scholar, Google government pages (inurl:gov) and public health, federal nutrition assistance program, Cooperative Extension Services (Extension – a nationwide educational network that addresses public needs by providing non-formal higher education and learning activities to farmers, ranchers, communities, youth, and families) [44], and other webpages (see https://doi.org/10.17605/OSF.IO/VXMDC) [42]. Search lists were generated for breastfeeding, healthy eating, and PA topic areas with some overlap as appropriate.

Graduate research assistants visited webpages, identified grey literature documents, and reviewed sources for relevant information. Using an iterative process, trained research team members (HD, SE, CM, RSW) completed a review of all grey literature sources (with liberal inclusion of source materials) and then three project leads (BH, KJK, and MRUM) and trained research team members (KHK, MEW) checked these standardized Excel spreadsheets for clarity/completeness and inclusion eligibility.

Inclusion and exclusion criteria

All sources were required to meet five criteria for inclusion. Specifically: (1) a focus on at least one of three topic areas (breastfeeding, healthy eating, and/or PA); (2) about PSE factors (rather than individual behavioral or interpersonal-level approaches); (3) results specific to rural U.S. populations or places; and (4) English language publication. There were no restrictions on research design which resulted in the inclusion of both objective and subjective data. Given the number of sources identified, social environment factors were excluded after the search to narrow the review focus, as social factors (e.g., peer support, social marketing) were considered less consistent indicators for potential public health surveillance [45].

Rural definition

Several definitions of “rural” are used in the literature and across organizations. For this review, rural settings were determined using the source description. For grey literature sources, the “Am I Rural” search tool was used to determine source inclusion if there was no clear description/classification of rural and a location (town, county) was reported. The “Am I Rural” search tool, which uses common rural definitions to provide rural classifications for certain locations, including Census definition (designating Urbanized areas and Urban Clusters), Core Based Statistical Areas, Federal Office of Rural Health Policy defined rural areas, Frontier and Remote Area (FAR) codes by census tract defined rural areas, Rural Urban Commuting Areas (RUCA) codes by census tract, Rural-Urban Continuum Codes (RUCC), and Urban Influence Codes (UIC) [46]. To reflect the heterogeneity of rural people and places and to address the inadequacy of standard rural definitions in capturing sociodemographic and cultural variations, study sites were characterized, when possible (county or town information listed), using a rural–urban typology for rural spaces, including: African American South; Aging Farmlands; Evangelical Hubs; Graying America; Hispanic Centers; Latter Day Saints Enclaves; Native American Lands; Rural Middle America; and Working Class Country [47, 48].

Scoping review outcomes and results synthesis

Outcomes were extracted to standardized Excel sheets designed by study leads and reviewed by CDC partners and advisors, including the study or source design and objective, setting or sector, population characteristics, behavioral focus, and results specific to rural PSE factors. PSE change definitions were sourced from Supplemental Nutrition Assistance Program Education (SNAP-Ed, a federally-funded grant program that supports evidence-based nutrition and obesity prevention interventions and projects for those eligible for SNAP) [49] guidance due to the large organizational emphasis on using these types of strategies to improve community health outcomes. Thus, a “policy” was considered a “written statement of an organizational position, decision, or course of action”. All outcomes were extracted by multiple researchers using an iterative process.

Results

Results from this scoping review include 122 total sources focused on policy, which are compiled in Table 1. Table 2 presents detailed information about original research (n = 73 sources: 8 breastfeeding, 41 healthy eating, and 41 PA, where n = 17 included 2 behaviors). Table 3 presents results specific to grey literature (n = 45 sources: 15 breastfeeding, 16 healthy eating, and 28 PA, where n = 12 included 2 behaviors and n = 1 included all 3). Table 4 presents results specific to graduate research (n = 3 sources: 1 breastfeeding, 2 healthy eating, and 1 PA, where n = 1 included 2 behaviors).

Breastfeeding

Rural settings which cited breastfeeding policy in grey literature, graduate research, and peer-reviewed sources focused on initiatives in hospital/healthcare settings [50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68], workplaces [68,69,70,71,72,73], schools [68], food assistance programs [29, 74], libraries [72], and/or local business settings [72].

Breastfeeding policies in rural hospital and healthcare settings mainly focused on the implementation of the Baby-Friendly Hospital Initiative, CDC’s Ten Steps to Successful breastfeeding, High 5 for Mom & Baby, or similar practices to create healthcare norms and environments supportive of breastfeeding initiation after birth [51,52,53,54,55, 57, 59, 61, 62, 64,65,66,67]. A specific policy to encourage maternal-infant skin-on-skin contact immediately postpartum was found promising for encouraging rural breastfeeding initiation and duration. [60, 61, 63] Another study found rural hospitals could improve the implementation of policies to support breastfeeding compared to more urban settings, and higher breastfeeding rates were found among hospitals implementing several steps of Baby-Friendly Hospital Initiative Ten Steps in both urban and rural settings [62].

Policy initiatives were similar among rural workplaces, schools, libraries, and local business setting, and included leadership decisions that increase support and resources [70,71,72,73], and provide protocols for breastfeeding [69]. Examples of food assistance program policy changes included addressing inconsistency of breastfeeding promotion and practices [29]. and included benefits for breastfeeding women using food assistance (e.g., Special Supplemental Nutrition Program for Women, Infants, and Children) [29, 74].

Methods and tools used to assess rural breastfeeding policies included data from Baby Friendly USA [61, 64], surveys or questionnaires (e.g., Maternity Practices in Infant Nutrition and Care survey) [60, 62, 63, 70], and interviews (Table 5) [29, 71].

Healthy eating

Rural settings focused on healthy eating policy involved initiatives in schools [75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106], food assistance programs [97, 101, 102, 107,108,109,110,111,112,113,114], food retail [98, 99, 101,102,103, 107, 109, 113, 115,116,117,118,119,120,121], childcare settings [122,123,124,125], healthcare settings [119, 121, 126, 127], local food producers [83, 109, 118, 121, 128], churches [91, 129], community gardens [130], neighborhoods [110, 131], health departments [132], local government [133], and workplaces [73, 95, 130, 133].

Policy initiatives in rural schools and childcare settings included promoting healthy food (e.g., advertisement, cafeteria monitors encouraging healthy choices) [82, 86, 88, 95, 103], adopting federal or state level child nutrition programs (e.g., farm to school programs, U.S. Department of Agriculture school meal programs) [78, 79, 83, 90, 93], prohibiting or limiting access to unhealthy foods at schools [76, 80, 87, 89, 95, 104,105,106, 115], allowing students to bring water bottles to school [91], enacting school breakfast programs [75, 81, 84, 86, 90, 100], increasing healthy food availability [75, 82, 85, 91, 94, 95, 100, 123], reversing lunch and recess [104,105,106], requiring health education (e.g. education in diabetes best practices) [76, 80], and adopting school nutrition standards [75, 76, 85, 92, 93, 125]. Barriers cited in school and childcare settings include lack of capacity or training to implement food programming [88, 105, 124], federally mandated academic testing requirements [80], lack of nutrition standards or ability to influence cafeteria foods [80], lack of access to healthy food outlets [94], cost of healthy foods or funding for healthy eating policy [87, 94, 98, 124], use of unhealthy foods as rewards [91], and inability of food service directors to implement healthy food policy [87].

Food assistance programs, such as the Federal Distribution Program for Indian Reservations, SNAP, and Women Infants and Children (WIC), promote health eating by addressing food insecurity, financial stress, and healthy food access in rural and urban communities. Food assistance programs were highlighted as vital for rural communities given higher rates of food insecurity and financial stress, and low access to healthy food among rural populations [97, 101, 102, 107,108,109,110,111,112,113,114]. Food assistance program policies that restrict the amount of and access to benefits [110], or those that do not improve access to healthy foods [111], were identified as potential barriers.

Rural food retail policy initiatives included promoting local produce using vouchers [119], food prescriptions [119], or advertisements [115, 116, 118, 120], reducing costs at healthy food stores [116], providing incentives for small, healthful food stores [117], creating co-operative services [107, 120], and changing healthful food store zoning [99]. Barriers to promoting healthy eating using food retail policy included food systems issues [98, 118], low access to healthy food stores [116], and low enforcement and implementation [99].

Healthcare setting policy initiatives in rural areas included sodium reduction policies (e.g., lower sodium options, fast food free zones) [127] and farmers market prescriptions/vouchers from physicians [119, 126, 127]. Barriers in healthcare settings included low implementation of or adherence to new policies among physicians [119], and lack of funding for new policy initiatives [127].

Additionally, policy initiatives for rural food producers, churches, community gardens, neighborhoods, health departments, local governments, and workplaces similarly focused on increasing access to healthy foods, increasing access to food preparation equipment, developing nutrition standards, garnering political support, implementing shared use agreements, and disseminating health promotion materials [73, 83, 91, 95, 109, 110, 118, 128,129,130,131,132,133].

Methods and tools used to assess rural healthy eating policies included interviews and/or focus groups [80, 87, 88, 98, 105, 109, 112, 119, 128,129,130, 132], surveys [83, 89, 91, 105, 106, 109, 113, 118, 127, 133, 134], assessment tools [82, 96, 98, 122,123,124, 131], administrative data [79, 84, 90, 116], policy coding forms [99], workshops [110], observational tools [92], photovoice [94], and process evaluation measures [86] (Table 5).

Physical activity

Rural settings for identified policy results for PA included schools [75,76,77, 80, 82, 87, 88, 91, 93,94,95, 98, 100,101,102,103,104, 106, 107, 120, 125, 135,136,137,138,139,140,141,142,143,144,145,146,147,148,149,150,151,152,153,154,155,156], trails/sidewalks/paths [115, 130, 138, 149, 154, 155, 157,158,159,160,161,162,163], streets [100, 102, 103, 113, 125, 136,137,138,139,140,141,142,143,144,145, 155,156,157,158,159, 161, 162, 164,165,166,167,168,169], childcare [122,123,124,125, 162], recreation facilities [98, 101, 107, 113, 114, 134, 138, 140, 141, 144, 170, 171], churches [91, 129, 172], parks/playgrounds [75, 95, 98, 102, 103, 113, 114, 134, 141, 161], healthcare settings [126], county fairgrounds [95], workplaces [73, 95, 149, 161, 162], neighborhoods [110, 131, 163], commercial/retail outlets [141], and community gardens [130]. In addition, many studies noted PA policies that were not setting specific [94, 115, 131]. Policy initiatives for PA focused on Complete Streets efforts (i.e., an approach to planning, designing and building streets that enables safe access for all users) [103, 125, 164, 165, 167, 168], joint or shared use efforts with schools [75, 101, 120, 146] or churches [172], Safe Routes to Schools efforts [100, 125, 136, 137], and coordinated plans or master plans for the community or county (greenway, trail, town, pedestrian, bicycle, transportation) [100, 136, 141, 157, 160], a coordinated school health plan [100] or childcare PA standards [125].

In rural schools or childcare settings, policy supports for PA included joint/shared use efforts [75, 101, 120, 138, 139, 146,147,148, 152], designated walk/bike to school days or programs [100, 103, 125, 136, 137, 143, 144, 154], PA breaks during the school day (e.g., brain breaks, mini field trips, outside time) [123, 147, 150], after-school PA programming [107, 155], making changes to the recess period [104], integrating PA into classroom activities [80], PA curriculum [104], PA standards [125], supporting or requiring physical education (PE) in schools [76, 80, 98, 100, 150], and increasing PE time [104]. Policy barriers at schools included insufficient time for recess or PA [87, 88], teachers withholding PA as punishment [88], federally mandated academic testing requirements [80, 135], low population sizes in rural areas, distance to schools [153, 155], community perceptions that schools are “off limits” during after hours [148], limited recreational facilities [94, 153], lack of trained personnel/staff for implementation [124, 153], limited funding [87, 124, 135], absence of political support (from administrators or policymakers) [150], conflicts with other school activities [153], and limited formal PE requirements [87].

Policy supports for PA focused on rural streets, trails, sidewalks, and paths included bicycle and pedestrian plans [113, 125, 136, 138, 139, 141, 144, 145, 156, 159, 163,164,165, 167,168,169], ensuring compliance with the American Disabilities Act [161], enhancing or adding PA infrastructure [158, 163], which included ecotourism (e.g., facilitating connections with historical resources), pedestrian centered street improvements [113], maintenance of PA infrastructure [158], and addressed parks, schools, farmlands, and commercial/retail areas as part of the plan [100, 103, 113, 130, 136,137,138,139,140,141,142,143,144,145, 157,158,159, 162, 164,165,166,167,168,169]. In addition, one study specifically noted policies to address the needs of rural, diverse populations, such as minority groups, low-income groups, elderly, and people with disabilities [141]. Barriers to policy changes in streets include lack of or inadequately maintained sidewalks [140, 145, 162], lack of awareness of existing policies [169], conflicting evidence informing policy, absence of political support [130, 140], limited funding [115, 130], safety concerns (e.g., stray animals, lack of safety features, traffic) [115, 155, 162], and graffiti [100, 103, 113, 136,137,138,139,140,141,142,143,144,145, 157,158,159, 162, 164,165,166,167,168,169].

Policies in rural parks or recreational facilities included improving or maintaining PA environments [103], ensuring PA programming is available year-round [107], addressing the needs of diverse populations (e.g., minority groups, lower income groups, the elderly, and persons with disabilities) [141, 161], implementing shared use agreements [113, 170, 171], developing land use plans, and allowing public use of PA resources [114]. Potential barriers to PA policies included lack of funding, lack of availability of coalition members and zoning, more mixed-use zoning needed [140], tending to public and outdoor spaces (e.g., litter, issues with grass) [170], and differences in political agendas as a possible reason for varying priorities in PA-supportive environmental change (e.g., recreational facilities, sidewalks, mixed-use school athletic spaces) [113, 140, 141, 149, 170]. Park-specific barriers include distance to parks and inadequately maintained park amenities [113, 134, 140, 141, 161].

Finally, policy changes across rural faith-based organizations (churches), healthcare settings, county fairgrounds, workplaces, neighborhoods, commercial/retail outlets, and community gardens included requirement of social events to include youth PA opportunities, subsidizing gym memberships, and joint use agreements [73, 91, 95, 110, 126, 129,130,131, 162, 163, 172]. Barriers across other settings included lack of access to or absence of PA resources, funding instability, safety concerns, existing organizational practices, and distance to PA opportunities [91, 95, 126, 129,130,131, 172].

Methods and tools used to assess rural PA policies included interviews and/or focus groups [80, 87, 88, 104, 115, 129, 130, 135, 147, 150, 151, 155, 162, 171], surveys [104, 106, 113, 117, 131, 135, 149, 152, 153, 158, 159, 169, 170], assessment tools [122,123,124, 138, 139, 142, 144, 145, 155, 161], administrative data [93, 141], workshops [110], and photovoice [94] (see Table 5).

Table 1 Source Characteristics of breastfeeding, healthy eating, and physical activity policy efforts in rural U.S. settings (n = 122)
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Table 2 Original research about breastfeeding, healthy eating, and physical activity policies in rural U.S. settings (n=73)
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Table 3 Grey literature about breastfeeding, healthy eating, and physical activity policies in rural U.S. settings (n = 46)
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Table 4 Graduate Research about Breastfeeding, Healthy Eating, and Physical Activity Policies in Rural U.S. Settings (n = 3)
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Table 5 Methods and Tools for Assessing Breastfeeding, Healthy Eating, and PA Policy Factors in Rural Communities
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Discussion

Summary of findings

This scoping review identified policy supports for breastfeeding, healthy eating, and/or PA in rural areas of the U.S., as part of a larger project to compile information on existing PSE change approaches encompassing these behaviors. Results show that policy initiatives for breastfeeding included changes to implement certain standards or practices, increase access to resources, and improve culture or norms mainly in hospitals and workplaces. Policy initiatives for healthy eating included increasing access to healthy foods, reducing the financial burden of purchasing healthier foods, requiring programs or initiatives to promote healthy eating, and improving food assistance programs. Policy initiatives for PA focused on joint or shared use agreements, Safe Routes to Schools efforts, coordinated plans or master plans for the community or county to implement or improve greenways, trails, and transportation options, coordinated school health plans, and childcare or school PA standards. Methods and tools to assess policy changes related to breastfeeding, healthy eating, and PA mostly included interviews or focus groups, surveys, assessment tools, or administrative data. Findings from this scoping review can be used to develop policy and surveillance recommendations to promote breastfeeding, healthy eating, and PA in rural communities that have been historically under-resourced.

Contributions to current literature

This scoping review adds to existing research which compiles and reviews policy approaches to improve rates of breastfeeding [34, 173,174,175,176,177], healthy eating [24, 178,179,180,181,182,183,184,185], and PA [21, 186,187,188,189,190,191,192,193,194]. For breastfeeding promotion policies, our findings align with existing reviews that demonstrate the need for tracking policies to protect, promote, and support breastfeeding in hospital, workplace, and community settings [34, 173,174,175,176]. For healthy eating promotion policies, our results confirmed findings from past reviews showing that policies addressing transportation and access barriers and bridging partnerships between retail outlets or schools and local food producers may be effective for improving healthy eating among rural residents [24, 178,179,180,181,182,183,184,185]. Schools were also identified as important settings for healthy eating promotion, and many sources cited policies to increase access to federal or state level child nutrition programs [78, 79, 83, 90, 93], or to include nutrition standards on the school level that increase availability of healthy foods [75, 76, 85, 92, 93]. Despite these findings, existing literature points to a lack of policy examples and related literature in small or isolated rural areas experiencing the greatest healthy eating disparities [178, 183]. For PA promotion policies, our results aligned with findings from past reviews showing that existing policy approaches to improve PA are being implemented in rural areas but additional research is needed to demonstrate their effectiveness, especially when considering the lag that often exists between implementation and research and the impracticality of randomized control trials in these settings [21, 186,187,188,189,190,191,192,193,194]. Nonetheless, existing research supports the implementation of PA policy in school/childcare, workplace, and community (e.g., parks, recreational facilities, streets) settings to address barriers related to PA resource access and safety within PA environments [21, 186,187,188,189,190,191,192,193,194]. This often included policies to ensure pedestrian and bike infrastructure plans were developed and implemented [113, 136, 138, 139, 141, 144, 145, 156, 159, 163,164,165, 167,168,169], and that policies existed to ensure active transportation to school was possible [100, 103, 136, 137, 143, 144, 154]. Despite alignment with past reviews focused explicitly on policy approaches for breastfeeding, healthy eating, or PA promotion, existing reviews do not specifically focus on rural environments, explore multiple behavioral settings, or include grey literature sources. Therefore, our results fill an important gap in the literature by compiling policy-focused health promotion strategies in under-resourced, rural areas [195].

Implications for policy, practice, and research

Results from this scoping review have several implications for policy, practice, and research. To start, healthy eating [75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98, 104,105,106, 122,123,124], and PA [75, 82, 87, 88, 91, 93, 98, 100, 101, 104, 106, 113, 120, 122,123,124, 135,136,137,138,139,140,141,142,143,144,145,146,147,148,149,150,151,152,153, 155, 162] policies were often implemented in schools and childcare settings. Given schools and childcare centers are critical resources for rural communities and the number of healthy eating and PA policies in these settings, researchers and practitioners should explore potential policy surveillance mechanisms on the district/administrative level and track their effectiveness [196]. Rural schools and childcare settings may also benefit from partnerships with local health departments, Extension offices, and research institutions due to reduced capacity for dissemination, implementation, and evaluation of policy approaches.

For breastfeeding, results show that policies in hospitals and workplace settings are most common to encourage rural breastfeeding rates [50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65, 68,69,70,71,72]. Hospital adoption and implementation of breastfeeding-supportive policies was the most common factor related to breastfeeding [51,52,53,54,55, 57, 59, 61, 62, 64,65,66,67,68], although declines in the number of rural hospitals and healthcare workers may pose a unique challenge for rural hospital maintenance of these policy strategies. [50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65] Annual assessments in rural areas may be beneficial, and it is recommended that terminology captures the variety in strategy names identified in this review in addition to “Baby-Friendly” (e.g., “The Gift”,“High 5 for Mom & Baby”) and the level of progress in adopting full policy strategies (e.g., 8 out of 10 steps) [53, 55, 59, 61, 62, 64]. Policies to support breastfeeding in workplace settings could be a focus of surveillance efforts, since barriers exist for breastfeeding among lower income and impoverished workers [197, 198]. Moreover, existing information in support of this recommendation is primarily qualitative so additional quantitative assessments are needed [69,70,71,72].

For healthy eating, food assistance programs and food retail settings were identified as important for policy implementation [97,98,99, 102, 107,108,109,110,111,112,113, 115,116,117,118,119]. In response to these findings, we recommend that rural policy data collected by food assistance programs (e.g., SNAP-Ed, WIC) be leveraged for surveillance purposes. One potential solution is to use existing evaluation and data systems within state and local-level SNAP-Ed and Extension offices to monitor healthy eating promotion policy efforts that are not consistently published in peer-reviewed sources [199, 200]. Given the presence of both SNAP-Ed and Extension across rural America, tracking combined efforts is important and should be explored as a surveillance data source.

For PA, public settings like trails/paths [130, 149, 157,158,159,160], streets [100, 103, 113, 136,137,138,139,140,141,142,143,144,145, 157,158,159, 162, 164,165,166,167, 169], recreational facilities [140, 141, 149, 170], neighborhoods [131], and parks [113, 141] were found to be particularly important for policy efforts in rural areas. We recommend increased monitoring of policy implementation efforts and related adaptations in rural towns, including Safe Routes Partnerships, Complete Streets, shared or joint use, and town-level or school plans (e.g., trails, bike, pedestrian, transportation, master, coordinated school health plans) [137, 164, 167,168,169]. Additional school-based policy recommendations include tailoring policy work to each school, gaining support from policy makers and school administrators, and recognizing that schools located closer to the downtown areas have increased access to after school programming and activities [75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106, 135, 156]. In order to gain support of school administrators, it is evident that we need to do a better job sharing evidence with them on the academic benefits of PA, as is demonstrated through one quote by a superintendent, “What we continue to hear is ‘No Child Left Behind.’ I haven’t heard ‘Don’t leave fat kids behind.’ It’s about keeping kids academically fit.” (pg. S155) [135].

Overall, for policy initiatives across all three targeted behaviors of this review, there is a need to create infrastructure for data sharing across rural communities that includes open-source access, easy-to-use visualizations, and raw data. Rural organizations and stakeholders often lack capacity to access and analyze existing data to inform their work regarding breastfeeding, healthy eating, and PA. Providing easily accessible, publicly available data can enable local rural organizations to access relevant and actionable information to support and implement policy efforts [201,202,203,204]. Next, an open-source platform would allow stakeholders to easily share data and results given the difficulty in capturing this data independent of a system [205, 206]. This would in turn allow for improved surveillance of policy efforts in settings that are often overlooked in existing publications and reports, such as libraries, community gardens, health departments, local government, and faith-based organizations. Finally, many classification systems and definitions of “rural” are used in the sources identified for this scoping review. This ranged from standardized rural classification systems (e.g., RUCA, RUCC) to somewhat arbitrary descriptions (e.g., smaller population sizes, authors describing the study site as “rural”). Moreover, some sources met criteria for “rural” using the “Am I Rural?” tool, and did not meet criteria for rural a using a rural–urban typology (e.g., big cities; college towns; exurbs; middle suburbs; military posts; urban suburbs) [48]. Future research should employ more standardized rural definitions, and report the rural definition used.

Strengths and limitations

This scoping review presents rural policy strategies used to encourage breastfeeding, healthy eating, and PA over a twenty-year period to inform public health approaches and has several strengths. First, this scoping review employed a scientific librarian to ensure our search terms were comprehensive, included training for those carrying out our screening efforts using strict protocols, and engaged multiple reviewers to identify review articles. Adding to this, we made sure to conduct our review using a pre-existing theoretical framework that allowed the research team to accurately review the body of literature and compile information on each article that related to PSE change approaches [207, 208]. The PSE change framework is increasingly used to address health behavior and outcome disparities and this review synthesizes the growing body of literature on this topic [207, 208]. Next, this scoping review provides a holistic understanding of rural-specific policy change approaches for improving breastfeeding, healthy eating, and PA from academic and non-academic sources. While some past research has conducted systematic reviews of peer-reviewed original research on rural policy regarding breastfeeding [34, 173,174,175,176], healthy eating [24, 178,179,180,181,182,183,184,185], and PA [21, 186,187,188,189,190,191,192,193,194], promotion, it is important to incorporate distinct findings from grey literature and dissertation research about rural health promotion policies.

This study also has limitations. First, the scoping review search is a bit dated, being carried out in 2020. However, as the data for this review were pulled from a comprehensive review (resulting from a comprehensive search strategy) that encompassed PSE approaches (rather than only policy), carrying out an updated search requires substantial resources for which the study team no longer has funding. Additionally, there were likely changes to the nature of the literature published post-2020, due to the COVID-19 pandemic and numerous federal approaches to improve food and nutrition outcomes, in particular. Updated reviews can be carried out for strategic purposes (e.g., to compare pre- and post-pandemic policy for breastfeeding, healthy eating, and PA promotion in rural areas); however, authors do not consider this limitation to threaten the value of the 122 studies synthesized here. Second, it should be acknowledged that PSE approaches were often overlapping and not necessarily distinct. As an example, many policy changes are related to the environment (e.g., establishing pedestrian master plans), required the implementation of the policy on a systems or organizational level (e.g., tracking of Complete Streets implementation), and then resulted in increased environmental supports (e.g., number of greenways/trails in the community) [209]. Despite this limitation, publishing separate scoping review papers that describe PSEs independently across the target behaviors (in preparation) is important for compiling PSE change approaches to promote health in rural America without overwhelming readers with the breadth of existing knowledge. Third, we did not integrate formal reliability checking during article selection or results synthesis phases or provide ratings of bias for selected articles. The scope and size of the project, combined with an expedited timeline during the early months of the COVID-19 pandemic, limited our ability to report these types of metrics; however, we adhered to a rigorous protocol for scoping reviews and held regular search and extraction meetings to ensure consistent adherence to the inclusion/exclusion criteria and results synthesis process across all team members [39]. Fourth, many articles did not list a clear rural definition or failed to designate study settings as rural, which may have limited our ability to include all existing research relevant to this scoping review. Despite this, we employed methods (e.g., using the “Am I Rural” tool for grey literature sources) to ensure as much existing knowledge on policy approaches relevant in rural areas were captured.

Conclusions

This scoping review identified policy supports that encourage breastfeeding, healthy eating, and/or PA practices in rural American communities. Results from this comprehensive review of effective and empirically supported policy strategies can be used to inform future efforts to address low rates of breastfeeding, healthy eating, and PA in rural areas to address chronic disease disparities [39]. Given the identified policy strategies are already occurring in under-resourced rural settings, we recommend opportunities for novel surveillance of these indicators that move beyond individual behavior statistics to identify structural changes to make healthier choices the easier choices in the rural U.S.

Availability of data and materials

The complete search strategy and all data generated or analyzed from articles meeting inclusion criteria for this study as it pertains to this manuscript are included in this published article.

Abbreviations

BF:

Breastfeeding

CDC:

Centers for Disease Control and Prevention

FAR:

Frontier and Remote Area

HE:

Healthy Eating

PA:

Physical Activity

PRISMA-ScR:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews

RUCA:

Rural Urban Commuting Area

RUCC:

Rural-Urban Continuum Codes

SNAP:

Supplemental Nutrition Assistance Program

SNAP-Ed:

Supplemental Nutrition Assistance Program - Education

U.S.:

United States

UICs:

Urban Influence Codes

WIC:

Women, Infants, and Children

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Acknowledgements

As with all research, the success of this project would not have been possible without the dedication and efforts of many team members serving in different capacities. We thank each of our team members who made this project possible, our CDC Division of Nutrition, Physical Activity, and Obesity partners, and our Chickasaw Nation Industries, Inc. (CNI) Project Manager. We would also like to thank and acknowledge the Expert Advisors who provided us guidance and feedback throughout this project.

Funding

This project was supported through Centers for Disease Control and Prevention (CDC) Division of Nutrition, PA, and Obesity, dispersed through Chickasaw Nation Industries (2020; Prime Contract #: 75D30119C06517, Subaward Contract #: 782–01528-000–02).

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Authors and Affiliations

  1. Department of Public Health, Robbins College of Health and Human Sciences, Baylor University, Waco, TX, USA

    M. Renée Umstattd Meyer, Haley Delgado, Stephanie A. Eze, Cassady Mecate & Rebekah Summerall Woodward

  2. Gretchen Swanson Center for Nutrition, Omaha, NE, USA

    Bailey Houghtaling

  3. Department of Health Education and Behavior, College of Health and Human Performance University of Florida, Gainesville, FL, USA

    Marilyn E. Wende

  4. School of Nutrition and Food Science, Louisiana State University Agricultural Center, Louisiana State University, Baton Rouge, LA, USA

    Khawlah H. Kheshaifaty

  5. LSU Libraries, Louisiana State University, Baton Rouge, LA, USA

    Randa Lopez Morgan

  6. School of Education, Baylor University, Waco, TX, USA

    Kathy J. Krey

Authors
  1. M. Renée Umstattd Meyer
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  2. Bailey Houghtaling
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  3. Marilyn E. Wende
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  4. Khawlah H. Kheshaifaty
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  5. Haley Delgado
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  6. Stephanie A. Eze
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  7. Cassady Mecate
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  9. Randa Lopez Morgan
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  10. Kathy J. Krey
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Contributions

MRUM contributed to the conceptualization and design of the study methodology, interpreted study findings, drafted results, and edited, finalized, and approved the submitted manuscript. BH contributed to the conceptualization and design of the study methodology, interpreted study findings, drafted results, and edited, finalized, and approved the submitted manuscript. MEW synthesized review articles, drafted results, and edited, finalized, and approved the submitted manuscript. KHK synthesized review articles and reviewed and approved the submitted manuscript. HD assisted with the acquisition and interpretation of data, and reviewed and approved the submitted manuscript. SAE assisted with the acquisition and interpretation of data, and reviewed and approved the submitted manuscript. CM assisted with the acquisition and interpretation of data, and reviewed and approved the submitted manuscript. RSW assisted with the acquisition and interpretation of data, and reviewed and approved the submitted manuscript. RLM contributed to the design of the study methodology, acquisition of data, and reviewed and approved the submitted manuscript. KJK contributed to the conceptualization and design of the study methodology, interpreted study findings, drafted results, and reviewed and approved the submitted manuscript.

Corresponding author

Correspondence to M. Renée Umstattd Meyer.

Ethics declarations

Ethics approval and consent to participate

Not applicable in this study. This review has been registered in the Open Science Framework Registration https://doi.org/10.17605/OSF.IO/VXMDC [42].

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Not applicable in this study.

Competing interests

The authors declare no competing interests.

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Umstattd Meyer, M.R., Houghtaling, B., Wende, M.E. et al. A scoping review of policies to encourage breastfeeding, healthy eating, and physical activity among rural people and places in the United States. BMC Public Health 24, 2160 (2024). https://doi.org/10.1186/s12889-024-19173-7

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Keywords

BMC Public Health

ISSN: 1471-2458

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