The Mediating Role of Income, Healthy Food Availability, and Consumption in Rural Health Disparities

Background. People in rural (vs. urban) places have worse health outcomes. We examined the role of healthy food availability and consumption in this health disparity. Method. We surveyed rural (n=313) and urban (n=458) Oregon residents online, and analyzed data from rural (n=1 235) and urban (n=13 912) respondents in the U.S. nationally representative Health Information National Trends Survey (HINTS). We followed up pre-registered simple mediation models with post-hoc multi-mediator models combining the datasets. Results. As pre-registered, healthy food availability mediated the rurality-BMI relationship in the Oregon survey (8% proportion mediated, 95% CI [2%, 48%], p<0.05). In HINTS, we found fruit and vegetable consumption mediated the relationships between rurality and self-rated health (ACME=0.03 [0.02, 0.04], p<0.001), high blood pressure (ACME=0.004 [0.002, 0.01], p<0.001), and metabolic health (0.008, [0.004, 0.01], p<0.001). In a hybrid model, the effect of rurality on BMI (ACME=0.0119 [0.0043, 0.0227], p=0.0292) and health outcomes (ACME=0.0029 [0.0011, 0.0054], p=0.0083) was mediated by a combination of income and perceived fruit and vegetable availability and consumption. Conclusion. Nationwide data demonstrate rural-urban disparities in cardiometabolic health, self-rated health, and BMI are mediated by a series of two factors: income, and fruit and vegetable consumption. Oregon data suggests those factors in turn are mediated by a third factor, fruit and vegetable availability, and overall, the three factors together appear to mediate the rural-urban disparities. To address rural-urban health disparities, individual health behaviors, household income, and community healthy food availability should be targeted together.