Suggestions for Future Research
Explicitly Compare the Effectiveness of Interventions in Urban and Suburban Settings Versus Rural Settings. None of the studies included in the review explicitly compared the effectiveness of policy changes in rural and urban communities. Future investigations should report observed differences in rural settings compared with other settings to inform future research aiming to reduce health disparities in rural areas. Only 14 of the 29 studies identified in this study assessed intervention outcomes at the environmental, policy, or individual level. Therefore, more work is needed to assess policy and environmental, social, psychosocial, behavioral, and biological outcomes associated with nutrition-related policy and environmental strategies.
Experiment With a Variety of Intervention Settings. Among the studies reviewed, the most common settings were schools, small retail food outlets, and worksites. Additional research is needed to explore the feasibility and effectiveness of nutrition-related policy and environmental strategies in other rural settings, such as parks and recreational sites and hospitals, to identify the mix of settings that will yield the greatest population-level reach and effects.
Explore the Possibility of Aligning Federal Food and Nutrition Assistance Programs With Efforts to Increase Access to Local Foods. The limited research to date on COCOMO strategy 5, "improve availability of mechanisms for purchasing foods from farms," has focused on examining the effectiveness of voucher or coupon programs through USDA. This aligns with a study conducted by the NOPREN Rural Food Access Working Group (RFAWG), examining rural stakeholders' views about the most promising strategies for improving healthy food access in rural areas, finding that one of the highest ranked policy and research priorities included improving access to federal food and nutrition assistance programs.
Report Costs Associated With Implementing Intervention Strategies. Decision-makers often need information about costs as well as effectiveness when deciding whether to invest in evidence-based nutrition-related policy and environmental strategies. Unfortunately, cost and cost effectiveness data are often not reported in scientific articles. In this review, 3 articles included some type of implementation cost information. Conrey et al reported the cost for implementing Women, Infants, and Children (WIC) Farmers' Market Nutrition Program (FMNP) enhancements across New York State for one year; Saksvig et al mentioned that the cost of their school-based intervention was low, but did not provide specific costs; and Ruelle et al calculated cost distance, which is a spatial analysis technique that measures costs associated with moving across a landscape to help planners identify potential locations for farmers markets. When authors report cost or cost effectiveness information, decision-makers are granted important information from scientific studies that could influence their decision to adopt promising nutrition-related policy and environmental strategies.
Explore the Economic Impact and the Role of Local Champions Related to Increasing Access to Local Foods. A recent NOPREN Rural Food Access Working Group study examined rural stakeholders' views about the most promising strategies for improving healthy food access in rural areas. Among the workgroup's top recommendations was research on the economic impact that strategies have on communities as well as the implications of revenue generation and job creation on increased healthy food access and purchasing power among individuals. For example, policy and environmental changes that increase local market and supply chain business opportunities have potential economic benefits for agricultural communities while also increasing access to healthy foods. The study's recommendations align with COCOMO strategies 5 ("improve availability of mechanisms for purchasing food from farms") and 6 ("provide incentives for the production, distribution, and procurement of foods from local farms"). There is little available research about the effect that local champions, such as policymakers, food policy councils, and other community-driven coalitions, have on nutrition-related policy and environmental change in rural communities. A better understanding could be gained through qualitative work with community stakeholders to determine who local champions are and to identify the best ways to connect with and engage those champions.
These findings help to inform the adaption and implementation of nutrition-related policy and environmental strategies for obesity prevention in rural communities. Although our review was not able to provide policy-makers with information about the effectiveness of different policy approaches, these findings offer insights into the various options available to improve the food environment in rural communities. Moreover, decision-makers should understand the limitations of adopting strategies generated from and tested in geographically diverse settings. The findings also indicate the need for additional research. One major research gap that remains is the limited number of studies testing effectiveness of nutrition-related policy and environmental strategies in rural communities. Future work could identify strategies that have not yet been formally evaluated but that could be feasible in rural communities, such as mobile farmers markets and community garden initiatives.