Examining the association between rurality and positive childhood experiences among a national sample

Abstract Purpose The present study examines the association between rurality and positive childhood experiences (PCEs) among children and adolescents across all 50 states and the District of Columbia. Recent work has quantified the prevalence of PCEs at the national level, but these studies have been based on public use data files, which lack rurality information for 19 states. Methods Data for this cross‐sectional analysis were drawn from 2016 to 2018 National Survey of Children's Health (NSCH), using the full data set with restricted geographic data (n = 63,000). Descriptive statistics and bivariate analyses were used to calculate proportions and unadjusted associations. Multivariable regression models were used to examine the association between residence and the PCEs that were significant in the bivariate analyses. Findings Rural children were more likely than urban children to be reported as having PCEs: volunteering in their community (aOR 1.29; 95% CI 1.18‐1.42), having a guiding mentor (aOR 1.75; 95% CI 1.45‐2.10), residing in a safe neighborhood (aOR 1.97; 95% CI 1.54‐2.53), and residing in a supportive neighborhood (aOR 1.10; 95% CI 1.01‐1.20) than urban children. Conclusions The assessment of rural‐urban differences in PCEs using the full NSCH is a unique opportunity to quantify exposure to PCEs. Given the higher baseline rate of PCEs in rural than urban children, programs to increase opportunities for PCEs in urban communities are warranted. Future research should delve further into whether these PCEs translate to better mental health outcomes in rural children.

behaviors and poorer outcomes, PCEs have been shown to help reduce the effects of ACEs and build resilience in rural and urban communities. 5,6 While ACEs may mostly occur inside the home, PCEs are often provided in community settings, such as schools or churches. 7 Prior work has focused on the higher rates of ACE exposure in rural areas, with rural children and adolescents having higher rates of exposure to parental separation/divorce, parental death, household incarceration, household violence, household mental illness, and household substance abuse than their urban peers. 8 The National Advisory Committee on Health and Human Services states that the prevention and mitigation of ACEs is one of their priority areas. 9 One way to prevent, mitigate, and build resilience among children is through PCEs, which have been best described through the Healthy Outcomes Positive Experiences framework. 2 This framework categorizes PCEs into 4 categories: (1) nurturing, supportive relationships, (2) safe, stable environments, (3) constructive social engagement, and (4) development of social and emotional competencies. 2 PCEs have been previously shown to enhance healthy social-emotional development in children. [10][11][12] Recent work has begun to quantify the prevalence of PCEs at the national level, but these studies have been based on public use data files, which lack rurality information for 19 states. 8,13 While this early work found that rural children had a higher likelihood of experiencing community service or volunteer work, school, or faith-based organizations and having a mentor for guidance, compared to their urban counterparts, 8 it is unclear whether these findings would hold true for a sample that includes all 50 states. The present study examines the association between rurality and PCEs among children and adolescents across all 50 states and the District of Columbia, while also including adjusted analyses to highlight rural-influenced outcomes. Examining the factors that are associated with exposure to PCEs may be helpful to policymakers and stakeholders as they design interventions for children and adolescents in rural communities.

Data source
Data for this cross-sectional analysis were drawn from 2016 to 2018 National Survey of Children's Health (NSCH). The NSCH is a combined online and mail survey, asking caregivers of children and adolescents (up to 17 years) about child health. 14 Because detailed address information is not available in the public use data set, we used NSCH restricted data sets at the Triangle Research Data Center (RDC) in Raleigh, NC. While data access through an RDC allowed complete identification of rural versus urban residence, it came with restrictions designed to prevent inadvertent data disclosure. These are more fully discussed below.

Population studied
The 2016-2018 NSCH included 102,341 children, with 50,212 interviews in 2016, 21,599 in 2017, and 30,530 in 2018. We restricted our sample to school-age children (age 6 and older) who would have been of age to experience the PCEs measured. The sample was further restricted to respondents with complete demographic information, ACE, and PCE questions. The final unweighted data sample used for this study was approximately 63,000 children. Data were subject to rounding to meet RDC disclosure restrictions.

Construction of primary outcome of interest and covariates
There were 7 PCEs constructed based on prior literature 8,15  American Indian/Alaska Native, Asian/Pacific Islander, and "Other" racial groups. Special health care needs were codified using the NSCH 5-item indicator tool that asks about prescription medicine, use of services, functional mobility, therapy, and ongoing conditions (physical, emotional, developmental, and behavioral).
Household and caregiver characteristics included residence (rural or urban), respondent relation to the child, primary language spoken in the home, educational attainment of the caregiver, family structure, or poverty/income level. Rural-urban status was determined at the census tract level using the 2013 Rural-Urban Commuting Area codes, 17 with codes 1-3 categorized as urban and codes 4-10 considered rural.
Relations with the child included mother, father, and other. The primary language in the home was coded as English or not English. Caregiver educational attainment was dichotomized into those with less than or equal to high school/GED and those with at least some college education or more. The family structure had 4 groups: 2 parents, currently married; 2 parents, not currently married; a single mother; and other. Poverty/income level had 4 levels: 0%-99% of the federal poverty level (FPL), 100%-199% FPL, 200%-399% FPL, and 400% FPL or above.

Analytic methods
Descriptive statistics and bivariate analyses were used to calculate proportions and unadjusted associations. Multivariable regression models were used to examine the association between residence and the PCEs that were significant in the bivariate analyses. The survey sampling weights, cluster, and strata that were constructed by TA B L E 1 NSCH questions used to identify positive childhood experiences

Concept Questions
After-school activities During the past 12 months, did this child participate in any organized activities or lessons, after school or on weekend?
Community volunteer During the past 12 months, did this child participate in any type of community service or volunteer work at school, church, or in the community?
Guiding mentor Other than you or other adults in your home, is there at least 1 other adult in this child's school, neighborhood, or community who knows this child well and who he or she can rely on for advice or guidance?
Connected caregiver How well can you and this child share ideas or talk about things that really matter?

Ethical considerations
The study was approved as exempt by the [name concealed for review] Institutional Review Board.

Characteristics of studied children and adolescents
Nearly, 12% of our sample resided in a rural area (11.7%,

Prevalence of PCEs by rural/urban
A higher percentage of rural children reported engaging with a guiding mentor than urban children (94.6% vs 89.0%, P < .01;

DISCUSSION
This is the first study to use the full NSCH, with all 50 states and the District of Columbia, to examine rural-urban differences in PCEs using multivariable analysis. Prior research had used 2017-2018 public use NSCH, which had residence information for 31 states and the District of Columbia, to examine rural-urban differences in PCES, finding that rural children were more likely to volunteer in their church, school, or community, and more likely to have a mentor for advice or guidance, in adjusted analyses. 8 Our findings confirm and expand upon this prior work, finding that rural children were more likely to volunteer and have a mentor, but they were also more likely to live in a safe neighborhood and live in supportive neighborhood, which was not found in prior work. Finally, school mental health professionals may be a primary way for children, particularly rural children who have lower access to mental health providers as they may reside in health care professional shortage areas, to receive mental health services and support. 21,22 School mental health services provide a location to receive services that are fully integrated into the community and thus less likely to be seen as a place of stigma for receiving services. Prior work has shown that school mental health can be an ideal way to address and improve mental health in rural communities. 23

Strengths and limitations
There are numerous strengths to this study including that this is the first study to use the full NSCH, with all 50 states and the District of Columbia, to examine rural-urban differences in PCEs using multivariable analysis. Limitations of the study include the use of the NSCH which uses an addressed-based sampling plan, thus not including homeless or transient populations. Further, the PCEs measured in our study are limited to those collected by the NSCH and may not necessarily capture all PCEs that could be experienced by a child.
Caregivers may also overstate PCEs since they are socially desirable events.

CONCLUSIONS
Improving the mental health of rural children through the experience of PCEs is 1 avenue to prevent, moderate, or mitigate the experience of ACEs. The assessment of rural-urban differences in PCEs using the full NSCH is a unique opportunity to quantify exposure to PCEs. Findings from this study can help to support rural stakeholders, such as rural mental health professionals in their work to improve rural child and adolescent mental health. Further, the findings from this study may help policymakers and program developers best determine how to leverage community resources and assets for the maximum benefit of their residents.