Role of community health fairs in providing health services, improving health of rural residents

Introduction: Obesity (BMI ≥ 30 kg m-2) is epidemic globally and is associated with increased risk for a wide range of physical and mental health comorbidities. This is a particular concern for rural residents who have a greater rate of obesity than urban residents, but are disadvantaged in obtaining care because of a shortage of health care professionals. Community health fairs provide an opportunity for rural residents to receive health care services and education at reduced or no cost. Therefore, this study explored the role of community health fairs for providing health services and improving the health of residents in a rural community where obesity is a serious health concern.


Introduction
Obesity (BMI ≥ 30 kg m -2 ) is epidemic globally with prevalence nearly tripling since 1975 [1]. In 2016, 39% of adults worldwide were overweight (˃ 1.9 billion people) and 13% were obese (˃ 650 million people) [1]. Obesity increases risk for a wide range of physical and mental health comorbidities, contributing to mortality and decreasing quality of life [2]. Worldwide ≥ 2.8 million people die from being overweight/obese each year [3]. Furthermore, health care costs are approximately 42% greater for obese than for normal weight patients [4].
These trends are particularly concerning for rural residents, who have a greater rate of obesity than urban residents [5], but are disadvantaged in obtaining care because of a shortage of health care professionals. The Rural Healthy People 2020 Survey re lected these concerns, with access to health care and nutrition and weight status identi ied as the top two priorities [6]. Even when health care services are available, appointments often do not allow enough time for patient education and cost may prevent lower income patients from visiting providers. Community health fairs provide an opportunity for rural patients to receive health care services at reduced or no cost with thorough discussion of their screening results. Data collected during health fairs can also provide insight into the community's health status, potentially leading to better designed interventions. This study explored the role of community health fairs for providing health services and improving the health of residents in a rural community where obesity is a serious health concern.

Theoretical framework
The Planned Approach to Community Health (PATCH) framework [7] was used to target health education in this rural community. This approach involved 1. Mobilizing the community (via health fairs), 2. Collecting and organizing data (from consented attendees), 3. Selecting health priorities (obesity), 4. Developing a comprehensive intervention (nutrition and physical activity education), and 5. Evaluating the effectiveness of the framework (declines in measures of obesity over time).

Study design
This study was a retrospective longitudinal analysis of data collected during community health fairs conducted in a rural western Nebraska, USA community during 2014, 2015, and 2016. Analyses of body composition measures and BP are reported here.

Health fairs
The health fairs provided free or low cost health screenings. Attendees freely chose the screenings of interest, therefore, sample size differed among variables (n = 57 -62). Trained and supervised University of Nebraska Medical Center (UNMC) nursing students performed the measurements, discussed results with participants, and provided nutrition and physical activity education. Participants received copies of their screening results and associated information sheets.

Study population
These health fairs were designed for community outreach rather than research, therefore, no sociodemographic or health history data were collected. Residents of this community are primarily non-Hispanic white (62%) or Latino (34%), with 18% having income below the poverty level [8]. Before performing health screenings, potential participants (any attendee regardless of age or health condition) received an invitation letter describing the study. Those choosing to participate were consented and assigned an ID number. Eighty-three participants were consented over the 3 health fairs. Twenty-eight percent of those identifying their gender were men (n = 17) and 72% were women (n = 44). Mean age was 54.6 years (n = 60, range = 9 -85, SD = 16.7).

Measures
Height: Participants' height (used in determining BMI and body composition measures) was the average of 2 heights (cm) measured with a stadiometer.

Body mass index: BMI [calculated by the Tanita Body
Composition Analyzer, model SC-250 (Tanita BCA)] was included because it is a standard used by WHO and the Centers for Disease Control and Prevention, despite its limitations (only accounts for height/weight; disregards body symmetries, muscle vs fat composition, differences in body proportions) [9,10]. BMI values < 25 kg m -2 were considered normal, those ≥ 25 kg m -2 and ˂ 30 kg m -2 were considered overweight, and those ≥ 30 kg m -2 were considered obese [1].

Percent body fat:
This variable (assessed using bioelectrical impedance analysis, Tanita BCA) was included because medically, obesity is de ined as the excess accumulation of body fat that may impair health [1] and because it is more closely associated with health outcomes than BMI [9,10]. Though a useful guide, BMI may not correspond to the same level of fatness in different individuals [1]. Body fat levels ˂ 33% for women and ˂ 22% men were considered healthy.

Visceral body fat:
This variable (rating determined by the Tanita BCA) was included because visceral adiposity is associated with greater cardiometabolic risk [11,12]. Visceral fat ratings ˂ 12 were considered healthy.

Data analysis
Mann-Whitney U tests were used to compare outcome measures between genders. Data from all three health fairs were pooled for these analyses. Few participants attended the health fair in multiple years, precluding assessment of change over time. Analyses were performed using the Statistical Package for the Social Sciences Version 25 (IBM; http://www. spss.com) with signi icance at p = .05.

Ethics approval
This study was conducted in accordance with UNMC Institutional Review Board protocol # 714-15-EP.

Percentage of body fat
As expected, percent body fat differed between genders (U = 529.5, z = 3.579, p = < .001) and was greater in women (mean = 39.4, SD = 9.44, n = 41) than in men (mean = 28.8, SD = 7.58, n = 16). Mean levels in both genders were in the unhealthy range. The mean value for women was similar to that found in previous health events in this community that only included women (40%) [14][15][16]. It is concerning that only 19% of participants (1 man, 10 women) had healthy levels of body fat.

Visceral fat
Visceral fat level differed between genders (U = 137, z = -3.404, p = .001) and was greater in men (mean = 16, SD = 5.6, n = 16) than in women (mean = 10, SD = 4.0, n = 41). The mean level for men was in the unhealthy range; only 5 men (31%) had healthy levels. In contrast, the mean level for women was in the healthy range, re lecting that 66% of women (n = 27) had healthy levels.

Blood pressure
Mean systolic BP was 134 mg Hg (n = 62, SD = 19.2), within the prehypertensive range, and mean diastolic BP was 78 mg Hg (n = 62, SD = 11.7), within the normotensive range. Based on data from the 42 participants who recorded their gender (14 men, 28 women), systolic and diastolic BP did not differ between genders (U = 143.5, z = -1.402, p = .163). Based on the systolic reading, 57% of men (n = 8) and 32% of women (n = 9) were hypertensive and 21% of men (n = 3) and 39% of women (n = 11) were prehypertensive. Based on the diastolic reading, 24% of men (n = 3) and 7% of women (n = 2) were hypertensive and 36% of both men and women (n = 5 and 10, respectively) were prehypertensive. Previous studies in this area also found that the majority of participants (all women) were hypertensive or prehypertensive (systolic mean = 130 and 132 mm Hg, diastolic mean = 78 mm Hg) [15,16].

Conclusion
Community health fairs provide an economical means for rural residents to assess their health status and receive information to address their health concerns. Data from these health fairs revealed that obesity and high BP were prevalent in this population, increasing affected individual's risk for cardiovascular disease and their need for/cost of health care. These indings support the need for effective education and intervention efforts to address obesity and hypertension in this rural area. Attendance at the health fairs was modest and not all attendees chose to participate in the study. It is concerning that few men attended the health fairs and few individuals attended in multiple years. The lack of repeat attendees prevented assessment of the ef icacy of the education intervention. The timing, location, and promotion of the health fairs need to be re-evaluated to improve participation, particularly by men and previous attendees. Repeatedly attending health fairs enables participants to monitor their progress and discuss any health concerns and helps researchers assess the ef icacy of interventions.