Rurality, Gender, and Obesity: An Intersectionality Perspective on Rural Men’s Health

Rural residents in the United States tend to experience poorer health outcomes than urban residents, largely because of disadvantages in social determinants of health, including access to care, health insurance, and socioeconomic conditions.¹ Although addressing these social determinants of health remains imperative for improving health in rural America, we propose that additional emphasis should be given to intersectionality to better understand and address rural health disparities. Intersectionality is a theoretical framework that recognizes the interaction of multiple socially disadvantaged statuses that reflect broader structural systems of privilege and power.² In this editorial, we highlight how rurality and gender as characteristics of intersectionality may adversely affect rural men’s health, with an emphasis on masculinity and obesity as an outcome of interest.

OBESITY AND HEALTH DISPARITIES IN RURAL MEN

Rural men live nearly two, six, and seven fewer years compared with urban men, rural women, and urban women, respectively.³ Obesity is associated with multiple chronic diseases that contribute to higher excess mortality in rural compared with urban areas.⁴ The prevalence of adult obesity among US men is nearly 37% but is higher in medium and small metropolitan statistical areas (MSAs; 42.7%) and non-MSAs (38.6%) than in large MSAs (31.8%).⁵ The prevalence of severe obesity (defined as a body mass index of 40 kg/m² or higher) among men is highest in non-MSAs (9.3%) compared with medium and small MSAs (6.0%) and large MSAs (4.1%).⁵

INTERSECTION OF RURALITY AND GENDER ON MEN’S HEALTH

The American Psychological Association’s Guidelines for Psychological Practice With Boys and Men define masculinity as “a set of descriptive, prescriptive, and proscriptive of [sic] cognitions about boys and men.”^6(p2) These guidelines emphasize the importance of contextual norms and briefly speculate that expressions of masculinity may vary between rural and urban settings. Geography is also considered a social determinant of health that interacts with masculinities in the Health, Illness, Men and Masculinities (HIMM) Framework, along with other social determinants, including race, ethnicity, community, socioeconomic indicators, sexuality, and ability.⁷ However, potential ways in which rurality and masculinities may interact to affect men’s health are not discussed in the HIMM Framework. Considering ways in which rurality and gender may interact to affect obesity prevention and management among rural men can guide future initiatives seeking to improve the health of this population.

CHALLENGES OF GEOGRAPHY AND WEIGHT PERCEPTIONS

Men are more difficult to recruit into weight loss trials than women, and very few weight loss trials to date have been conducted specifically for men.⁸ Rural men may be particularly difficult to recruit because of the combined effects of geographic constraints and socially constructed perceptions pertaining to body weight. Geographic constraints to recruiting rural men into weight loss trials may include factors such as relatively fewer recruitment opportunities and longer travel distances to recruitment sites compared with men living in urban areas. In addition to these geographic barriers, rural men have reported that social norms regarding masculinities allow men to have larger body sizes compared with expectations for women.⁹ Rural men are also more likely than rural women to underestimate their weight status, and the magnitude of this misperception is greatest for rural African American men.¹⁰ Consistent with the HIMM Framework, these findings highlight that interactions between geography, race, and masculinities may have important implications for addressing obesity and improving rural men’s health.

HEALTH CARE AND SOCIOECONOMIC BARRIERS

Rural men may lack awareness of their weight status because of challenges to accessing health care or the decision to forgo or postpone health care even when care is accessible. Evidence suggests that men and rural residents may be reluctant to seek care when needed,^6,11 and rural men may be most likely to avoid health care through the combined effects of barriers to health care access and the potential underlying masculinities that deter men in general from seeking care. The synergistic effects of these barriers may be strongest for health conditions such as obesity and related chronic diseases that do not significantly disrupt daily activities and therefore may not be perceived as an immediate health threat.

Although socioeconomic deprivation tends to be more prevalent in rural areas and contributes to poorer rural health outcomes,^1,3 interactions between rurality, socioeconomic conditions, and gender as barriers to obesity prevention and management among rural men have been understudied in the scholarly literature. In addition to limiting their ability to afford high-quality, nutritious food and to engage in physical activities requiring financial resources (e.g., gym memberships), adverse socioeconomic conditions may contribute to rural men needing to work even when they are ill or cannot perform work safely. For example, rural Latino men have reported that being the family provider is an important masculine role and that men will work even when it threatens their health to maintain their household income.¹² The travel time required to obtain health care may further prevent many rural men from missing work and losing income. This may be particularly true in remote rural areas where health care may not be readily available and residents must travel substantial distances to receive care. With health care avoidance being a concern among men in general, the intersections of masculinities, barriers to accessing health care, and socioeconomic disadvantage can potentially be deleterious for rural men and underscore the importance of the social determinants of health in the HIMM framework.

PERCEPTIONS ABOUT OCCUPATIONAL AND LEISURE ACTIVITIES

Other ways in which rurality may interact with gender to affect obesity prevention and management efforts for rural men is through occupational and leisure activities. There is some qualitative evidence that manual labor may be a barrier for rural men to engage in sufficient physical activity (PA) because of perceptions linking PA with work activities rather than leisure, health-enhancing activity.^9,13 This perspective has been observed among rural Canadian men who view laborious work as a replacement for recreational PA and prioritize physical strength over aerobic capacity.¹⁴ Data from qualitative studies also indicate that rural men understand the importance of PA for obesity prevention but report lacking motivation for engaging in PA and report engaging in PA when performing leisure activities such as hunting and fishing.^9,13 Research is needed to understand how occupational and leisure activity contributes to meeting PA recommendations among rural men and how these activities might be leveraged to promote rural men’s health.

CULTURE, RURAL ENVIRONMENTS, AND GENDER

Interactions between gender, rural culture, and aspects of rural environments related to diet and PA may also negatively affect obesity prevention and management among rural men. Indeed, residents of rural communities have described the synergistic effects of cultural and structural factors as contributors to obesity.¹⁵ Commonly noted cultural factors include obesogenic food preparation methods, events and celebrations revolving around unhealthy foods, and social norms involving technology use as a barrier to PA. Environmental barriers noted by rural residents include challenges to accessing affordable and high-quality healthy foods and an abundance of fast-food restaurants.¹⁵ The intersection between gender and these aspects of some rural environments may be particularly concerning for rural men given qualitative evidence that rural men with overweight and obesity perceive themselves as healthy, adopt fatalistic beliefs about weight-related health outcomes, and brag about not engaging in healthy behaviors.¹³ Researchers who conduct obesity trials in rural areas are well positioned to begin addressing the intersection between rurality and gender, and the HIMM Framework can serve as a useful guide for endeavors to improve health outcomes among rural men.

CONCLUSIONS

In this editorial, we have highlighted several ways in which gender and rurality may interact to hinder obesity prevention and management among rural men. Because there is very little research specifically addressing obesity, men, and rurality, we also highlight several opportunities for future research and contend that such research is warranted as part of ongoing efforts to reduce rural health disparities. Considering the intersection between gender and rurality does not imply that masculinity is the sole driver of poor health outcomes among rural men or that researchers should abandon ongoing efforts to improve rural environments to promote health. Critical work remains to improve the social determinants of health that are substantial contributors to rural health disparities.^1,3 However, adopting an intersectional approach to understanding and addressing rural health disparities may offer new and promising insights for improving health outcomes for men in rural America.