Objectively-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 objectively-measured environmental initiatives or features that impact physical activity (PA), healthy eating (HE), and/or breastfeeding practices among rural communities in the United States. A secondary aim was to assess measurement approaches for assessing rural environments and resources. Searches, informed by a scientific librarian, occurred from February to July 2020. Grey literature was identified using Google, Google Scholar, Google government pages, public health, federal nutrition assistance program, Cooperative Extension Services, and related webpages. Medline, PubMed, Web of Science, and Agricola academic databases were selected to identify peer-reviewed research. ProQuest Global was used to identify dissertation/thesis research. Inclusion criteria included: (1) focus on PA, HE, and/or breastfeeding; (2) environmental features assessed using objective measures; (3) specific to U.S. rural populations/contexts; and (4) English language. PA environment results (n=49) focused on initiatives in parks and recreational settings, streets or sidewalks, schools, trails and greenways, workplaces, and churches. HE environment results (n=84) focused on retail environments, schools/childcare settings, food assistance programs, local food producers, and hospital or healthcare settings. Breastfeeding environment results (n=11) focused on healthcare settings, workplace settings, and food retail settings. To measure PA, HE, and breastfeeding environments, audits, scans, and administrative data were mostly used. Results from this scoping review were used to create recommendations for environmental interventions related to PA, HE, and breastfeeding in under-resourced, rural communities. Researchers and practitioners can also use findings from this study to understand best practices for objectively measuring environmental resources in rural contexts.