Background
Research consistently supports greater health disparities for rural residents compared with urban residents, such as higher rates of chronic diseases, including obesity. Sixteen percent of Americans live in rural areas encompassing 72% of land in the U.S. Evidence supports the effectiveness of environmental and policy strategies to prevent obesity and promote health equity. In 2009, the CDC recommended 24 evidence-based strategies for communities to use in planning and monitoring obesity-related environmental and policy changes; the “Common Community Measures for Obesity Prevention” (COCOMO; Kettel Kahn, 2009). Twelve strategies focused on physical activity to “encourage physical activity or limit sedentary activity among children and youth” or “create safe communities that support physical activity”. However, evidence supporting environmental and policy strategies is largely derived from research conducted in urban and suburban settings.

Objectives
Objectives were to conduct a systematic literature review to describe physical activity-related policy and environmental strategies being implemented in rural communities and how COCOMO strategies have been applied.

Methods
This project was conducted by a workgroup within the CDC-funded Physical Activity Policy and Research Network (PAPRN; http://paprn.wustl.edu).   A primary and secondary literature search was conducted in PubMed, PsychInfo, Web of Science, CINHAL, and PAIS databases for articles published between 2002 and 2013, in English, that reported findings from physical activity-related policy and/or environmental interventions. Each search used the following terms: rural AND (physical activity or exercise or sedentary or inactivity) AND (community or environment or policy). Searches were repeated using search terms representing Native American communities and predominantly rural states. Methods mirror a sister review conducted by the CDC-funded Nutrition and Obesity Policy Research and Evaluation Network to help provide a more complete picture of obesity prevention in rural communities.     Inclusion and Exclusion Criteria:   At least two researchers reviewed titles, abstracts, and texts of articles for inclusion. To be included an article had to report findings from empirical formative, process, or outcome research with strategies aimed to change policy and/or environments to support physical activity in rural North American communities. No studies were excluded a priori based on study design or location. Publications were excluded if both rural and urban communities were included, but rural-specific findings were not reported; the primary focus was on instrument development or individual-level behavioral change; or if descriptive studies were not associated with an intervention.   Extraction Process:   Each article was extracted independently by two researchers who recorded results using a customized Qualtrics online survey software. Extraction results were compared and discrepancies were resolved by consensus. Study quality was examined using Cochrane and GRADE assessments of bias risk for randomized and non-randomized studies, respectively. Risk of bias was rated as low, high, or unclear for each category and overall summary scores for bias risk were calculated and categorized as low, medium, or high.

Results
Searches returned 9,879 articles, of which 2,002 were identified as relevant based on their title and abstract for further screening. Duplicates were removed, leaving 488 records for full-text screening; 443 of these did not meet inclusion criteria.  Of the remaining 45 articles representing 41 distinct studies, 11 additional articles were excluded during the extraction phase, thus 34 articles representing 30 distinct studies were extracted. Each physical activity-related COCOMO strategy was mentioned at least once within these 30 studies. The two most commonly applied COCOMO strategies were #14 “communities should increase opportunities for extracurricular physical activity” (n=10) and #18 “communities should enhance infrastructure supporting walking” (n=9).  In addition, the following non-COCOMO strategies were identified: increasing physical activity opportunities at school (e.g., classroom activity breaks, longer school recess); increasing physical activity equipment, access to equipment, or improving existing resources; promotion of physical activity resources (e.g., signs to promote hallway walking routes); access to public buildings after hours for walking; reducing screen time at home; worksite or school policies/practices; and increasing community green space.   Study settings included schools (n=19), community (n=13), worksites (n=5), churches (n=1), and family (n=1); four interventions targeted multiple settings. Four studies were randomized control trials. Bias risk assessments revealed the majority of studies had a high risk of bias (n=21), five had a medium risk, and four studies had a low risk. Over half (67%) of the interventions had at least one positive policy and/or environmental result.

Conclusions
COCOMO strategies provide an evidence-based approach to promoting physical activity and appear to be applicable in rural communities. However, relatively few studies have incorporated these to date. Most strategies are being applied at school and community settings, which might have the greatest reach within rural areas. Future studies should consider study designs and methods to reduce these high bias risks.

Implications
Further understanding of policy and environmental strategies for rural areas can help policy makers and community leaders with decisions for resource allocations and COCOMO-related efforts in their communities. However, further research is needed in rural communities to better understand which COCOMO strategies are most applicable and effective.

References
Kettel Kahn, L., Sobush, K., Keener, D., Goodman, K., Lowry, A., Kakietek, J., & Zaro, S. (2009). Recommended community strategies and measurements to prevent obesity in the United States. Morbidity and Mortality Weekly Report Recommendations and Reports, 58(RR07), 1-26.

Support / Funding Source
This study was funded by the CDC Cooperative Agreement number U48/DP001903, Prevention Research Centers Program, Special Interest Project 9-09, and Physical Activity Policy Research Network to Washington University (PI: Amy Eyler), Baylor University, Department of Health, Human Performance & Recreation.