Ellen Barnidge

The association of sidewalk walkability and physical disorder with area-level race and poverty

Introduction: There are significant differences in physical inactivity in various geographical areas and among demographic groups. Previous research suggests that walking is the most common form of physical activity; however, not all built environments support walking for recreational or transportation purposes. Objective: The purpose of this study was to assess the extent to which area-level factors, poverty rate and racial distribution, are associated with aspects of the street-scale environment (i.e. sidewalk walkability and physical disorder) using community audits. Methods: Street segments were randomly selected from 210 block groups. Pairs of trained auditors walked each street segment using an audit tool designed to capture aspects of the street environment. Multilevel logistic regression was used to assess the degree of neighborhood (i.e. block group) variation in sidewalk unevenness, sidewalk obstruction and the presence of physical disorder and the association with area-level characteristics. Results: 1780 street segments were audited. Block groups that were predominantly African–American were 38 times more likely to have a lot of unevenness, 15 times more likely to have many obstructions, and 12 times more likely to have physical disorder. Poverty rate was not independently associated with sidewalk walkability; however, block groups with the highest poverty rates were 21 times more likely to have physical disorder. Conclusion: The results indicate that aspects of the built environment vary by characteristics of the neighborhood. This suggests that there is a differential investment in community infrastructures and resources in neighborhoods that are mostly African–American. This differential investment is likely to influence disparities in rates of physical activity.

Understanding and Addressing Barriers to Implementation of Environmental and Policy Interventions to Support Physical Activity and Healthy Eating in Rural Communities

PURPOSE Rural residents are at greater risk of obesity than urban and suburban residents. Failure to meet physical activity and healthy eating recommendations play a role. Emerging evidence shows the effectiveness of environmental and policy interventions to promote physical activity and healthy eating. Yet most of the evidence comes from urban and suburban communities. The objectives of this study were to (1) identify types of environmental and policy interventions being implemented in rural communities to promote physical activity or healthy eating, (2) identify barriers to the implementation of environmental or policy interventions, and (3) identify strategies rural communities have employed to overcome these barriers. METHODS Key informant interviews with public health professionals working in rural areas in the United States were conducted in 2010. A purposive sample included 15 practitioners engaged in planning, implementing, or evaluating environmental or policy interventions to promote physical activity or healthy eating. FINDINGS Our findings reveal that barriers in rural communities include cultural differences, population size, limited human capital, and difficulty demonstrating the connection between social and economic policy and health outcomes. Key informants identified a number of strategies to overcome these barriers such as developing broad-based partnerships and building on the existing infrastructure. CONCLUSION Recent evidence suggests that environmental and policy interventions have potential to promote physical activity and healthy eating at the population level. To realize positive outcomes, it is important to provide opportunities to implement these types of interventions and document their effectiveness in rural communities.

The Garden of Eden: Acknowledging the Impact of Race and Class in Efforts to Decrease Obesity Rates

Geographic assessments indicate that the selection of produce in local supermarkets varies by both area-level income and racial composition. These differences make it particularly difficult for low-income African American families to make healthy dietary choices. The Garden of Eden produce market was created to improve access to high-quality, affordable produce for these communities. The Garden of Eden is housed in a church in an economically depressed African American community in St Louis, Mo, that has less access to fresh produce than surrounding communities. All staff are from the community and are paid a living wage. The market is run with an eye toward sustainability, with partners from academia, a local faith-based community organization, businesses, and community members collaborating to make all program decisions.

Association between community garden participation and fruit and vegetable consumption in rural Missouri

BackgroundFruit and vegetable consumption reduces chronic disease risk, yet the majority of Americans consume fewer than recommended. Inadequate access to fruits and vegetables is increasingly recognized as a significant contributor to low consumption of healthy foods. Emerging evidence shows the effectiveness of community gardens in increasing access to, and consumption of, fruits and vegetables.MethodsTwo complementary studies explored the association of community garden participation and fruit and vegetable consumption in rural communities in Missouri. The first was with a convenience sample of participants in a rural community garden intervention who completed self-administered surveys. The second was a population-based survey conducted with a random sample of 1,000 residents in the intervention catchment area.ResultsParticipation in a community garden was associated with higher fruit and vegetable consumption. The first study found that individuals who worked in a community garden at least once a week were more likely to report eating fruits and vegetables because of their community garden work (X2 (125) = 7.78, p = .0088). Population-based survey results show that 5% of rural residents reported participating in a community garden. Those who reported community garden participation were more likely to report eating fruits 2 or more times per day and vegetables 3 or more times per day than those who did not report community garden participation, even after adjusting for covariates (Odds Ratio [OR] = 2.76, 95% Confidence Interval [CI] = 1.35 to 5.65).ConclusionThese complementary studies provide evidence that community gardens are a promising strategy for promoting fruit and vegetable consumption in rural communities.

Exploring Community Health Through the Sustainable Livelihoods Framework

Health disparities are a major concern in the United States. Research suggests that inequitable distribution of money, power, and resources shape the circumstances for daily life and create and exacerbate health disparities. In rural communities, inequitable distribution of these structural factors seems to limit employment opportunities. The Sustainable Livelihoods framework, an economic development model, provides a conceptual framework to understand how distribution of these social, economic, and political structural factors affect employment opportunities and community health in rural America. This study uses photo-elicitation interviews, a qualitative, participatory method, to understand community members’ perceptions of how distribution of structural factors through creation and maintenance of institutional practices and policies influence employment opportunities and, ultimately, community health for African Americans living in rural Missouri.

Children Receiving Free or Reduced-Price School Lunch Have Higher Food Insufficiency Rates in Summer

BACKGROUND In 2012, 20% of households in the United States with children lacked consistent access to adequate food. Food insufficiency has significant implications for children, including poor physical and mental health outcomes, behavior problems, and low educational achievements. The National School Lunch Program (NSLP) is one policy solution to reduce food insufficiency among children from low-income families. OBJECTIVE The objective of this project was to evaluate the association between NSLP participation and household food insufficiency by examining trajectories of food insufficiency over 10 calendar months. The calendar months included both nonsummer months when school is in session and summer months when school is out of session. METHODS The study used the data from the Survey of Income and Program Participation and conducted linear growth curve analyses in the multilevel modeling context. Comparisons were made between the trajectories of food insufficiencies among recipients of free or reduced-price lunch and their counterparts who are eligible but choose not to participate in the program. RESULTS Heads of households that included children receiving free or reduced-price lunch (n = 6867) were more likely to be female, black, unmarried, and unemployed, and have a lower educational attainment than those whose children were eligible but did not receive free or reduced-price lunch (n = 11,396). For households participating in the NSLP, the food insufficiency rate was consistent from January to May at ∼4%, and then increased in June and July to >5%. Meanwhile, food insufficiency among eligible nonrecipients was constant throughout the year at nearly 2%. CONCLUSIONS The NSLP protects households from food insufficiency. Policies should be instituted to make enrollment easier for households.

Low-income Children's participation in the National School Lunch Program and household food insufficiency.

Assessing the impact of the National School Lunch Program (NSLP) on household food insufficiency is critical to improve the implementation of public food assistance and to improve the nutrition intake of low-income children and their families. To examine the association of receiving free/reduced-price lunch from the NSLP with household food insufficiency among low-income children and their families in the United States, the study used data from four longitudinal panels of the Survey of Income and Program Participation (SIPP; 1996, 2001, 2004, and 2008), which collected information on household food insufficiency covering both summer and non-summer months. The sample included 15, 241 households with at least one child (aged 5-18) receiving free/reduced-price lunch from the NSLP. A dichotomous measure describes whether households have sufficient food to eat in the observed months. Fixed-effects regression analysis suggests that the food insufficiency rate is .7 (95%CI: .1, 1.2) percentage points higher in summer months among NSLP recipients. Since low-income families cannot participate in the NSLP in summer when the school is not in session, the result indicates the NSLP participation is associated with a reduction of food insufficiency risk by nearly 14%. The NSLP plays a significant role to protect low-income children and their families from food insufficiency. It is important to increase access to school meal programs among children at risk of food insufficiency in order to ensure adequate nutrition and to mitigate the health problems associated with malnourishment among children.

A Participatory Regional Partnership Approach to Promote Nutrition and Physical Activity Through Environmental and Policy Change in Rural Missouri.

Background Rural residents are less likely than urban and suburban residents to meet recommendations for nutrition and physical activity. Interventions at the environmental and policy level create environments that support healthy eating and physical activity. Community Context Healthier Missouri Communities (Healthier MO) is a community-based research project conducted by the Prevention Research Center in St. Louis with community partners from 12 counties in rural southeast Missouri. We created a regional partnership to leverage resources and enhance environmental and policy interventions to improve nutrition and physical activity in rural southeast Missouri. Methods Partners were engaged in a participatory action planning process that included prioritizing, implementing, and evaluating promising evidence-based interventions to promote nutrition and physical activity. Group interviews were conducted with Healthier MO community partners post intervention to evaluate resource sharing and sustainability efforts of the regional partnership. Outcome Community partners identified the benefits and challenges of resource sharing within the regional partnership as well as the opportunities and threats to long-term partnership sustainability. The partners noted that the regional participatory process was difficult, but the benefits outweighed the challenges. Interpretation Regional rural partnerships may be an effective way to leverage relationships to increase the capacity of rural communities to implement environmental and policy interventions to promote nutrition and physical activity.

A Participatory Method to Identify Root Determinants of Health: The Heart of the Matter

Background: Co-learning is one of the core principles of community-based participatory research (CBPR). Often, it is difficult to engage community members beyond those involved in the formal partnership in co-learning processes. However, to understand and address locally relevant root factors of health, it is essential to engage the broader community in participatory dialogues around these factors.Objective: This article provides a glimpse into how using a photo-elicitation process allowed a community–academic partnership to engage community members in a participatory dialogue about root factors influencing health. The article details the decision to use photo-elicitation and describes the photo-elicitation method.Method: Similar to a focus group process, photo-elicitation uses photographs and questions to prompt reflection and dialogue. Used in conjunction with an economic development framework, this method allows participants to discuss underlying, or root, community processes and structures that influence health.Conclusion: Photo-elicitation is one way to engage community members in a participatory dialogue that stimulates action around root factors of health. To use this method successfully within a CBPR approach, it is important to build on existing relationships of trust among community and academic partners and create opportunities for community partners to determine the issues for discussion.

Clinic-to-Community Models to Address Food Insecurity

Overview Food insecurity (FI)—unreliable access to a sufficient quantity of affordable, nutritious food—is a social and economic condition with direct and indirect consequences, including poor dietary intake, poor physical and mental health, hospitalizations, stress, reduced academic achievement, and fetal epigenetic changes.1-3 Food insecurity affects 16.6% of US households with children.4 Centers for Medicare and Medicaid Services, the American Academy of Pediatrics, and the American Diabetes Association have each recently highlighted the clinical relevance of FI through funding initiatives, screening recommendations for children, or treatment recommendations. Food insecurity is assessed in clinical settings using a sensitive and specific 2-item screener.5 The screener asks an individual whether each of the following statements were often true, sometimes true, or never true for his or her household in the last 12 months: (1) “We worried whether our food would run out before we got money to buy more,” and (2) “The food that we bought just didn’t last and we didn’t have money to get more.” “Often” or “sometimes true” responses to either question indicate a positive screen result. Screening success hinges on linking FI households to community resources tailored to household needs and delivered outside of the practice setting.6 Such linkages demand coordination among clinicians, administrators, policy makers, and community providers. Clinic-to-community models for addressing FI are emerging. This Viewpoint reviews 2 initial models, translational challenges, and opportunities for clinical settings to better support patients living in FI households.