Subjectively-measured Environmental Support for Physical Activity, Healthy Eating, and Breastfeeding in the Rural United States: A Scoping Review to Inform Opportunities for Public Health Surveillance.

The purpose of this scoping review was to identify subjectively-measured environmental initiatives or factors that influence PA, HE, and/or breastfeeding practices within rural U.S. communities. Guided by a scientific research librarian, searches occurred February through July 2020. Grey literature searches spanned Google, Google Scholar, government pages, and public health, federal nutrition assistance program, Cooperative Extension Services, and related webpages. Four academic databases (Medline, PubMed, Web of Science, Agricola) were selected to identify peer-reviewed research and ProQuest Dissertations and Theses Global were used to identify dissertation research. Inclusion criteria included: (1) breastfeeding, HE, and/or PA focus; (2) environmental factors assessed using subjective measures; (3) specific to U.S. rural populations/contexts; and (4) English language. PA environment results focused on initiatives or factors in recreation (parks, playgrounds, facilities; n=54), street/sidewalk (n=44), or school (n=33) settings. PA environmental initiatives/factors included increasing transport/accessibility or addressing geographic disparities for recreation settings, improving/installing walkability features for streets/sidewalks, integrating PA into lessons, or improving PA equipment/spaces for school settings. HE environment results focused on initiatives in retail (n=65) and schools/childcare (n=33) settings. HE environment change initiatives/factors in retail settings included increasing the availability of fruits/vegetables in existing establishments or the prevalence of healthy food outlets. In schools, HE environmental initiatives/factors increased fruits/vegetables served and/or reduced unhealthy foods. Breastfeeding environment results focused on workplace settings (n=3). Breastfeeding environment initiatives/recommendations in workplaces included increasing compatibility for breastfeeding by addressing environmental and cultural barriers. Results from this scoping review were used to create recommendations to improve PA, HE, or breastfeeding environments in rural U.S. settings.