Understanding Barriers and Facilitators to Healthy Eating and Active Living in Rural Communities

Objective. Studies demonstrate that people's food and physical activity (PA) environments influence behavior, yet research examining this in rural communities is limited. Methods. Focus groups of 8–15 women were conducted in rural communities in seven US states. Questions were designed to identify factors within residents' food and PA environments they felt helped or hindered them from eating healthfully and being physically active. Results. Participants were aged 30–84 years; mean (SD) = 61 (14) (N = 95). On average, communities had fewer than 5,000 residents. Limited time, social norms, and distances from or lack of exercise facilities were common PA barriers. Facilitators for PA included social support, dog walking, and availability of affordable facilities. Healthy eating barriers included the perception that healthy foods were too expensive; calorically dense large portion sizes served at family meals; and frequency of eating foods away from home, which were perceived as generally unhealthy. Healthy eating supports included culture/value around local food gathering (e.g., hunting and gardening) and preservation (e.g., canning and smoking). Friends and family were frequently identified as key influencers of eating and PA behavior. Conclusions. Targeting both social and built environment factors, particularly those unique to rural locales, may enhance support for healthy eating and PA behavior change interventions.


Introduction
The consequences of obesity are well known. They include risk of developing chronic diseases such as cardiovascular disease, hypertension, diabetes, and several types of cancer [1]. The prevalence of obesity is higher in adults who live in rural areas compared to those who reside in urban areas [2,3], and rural adults are less likely to meet physical activity guidelines than urban residents [1].
The influence of the built environment on physical activity and healthy eating behavior is an important issue, with the Centers for Disease Control, Institute of Medicine, and World Health Organization all prioritizing changes in built environment as one of the top recommendations for increasing physical activity [4][5][6]. Many aspects of built environment barriers to physical activity and healthy eating are common to both rural and urban areas, including cost of accessible food and recreation, access to healthy foods, and the "walkability" and "bikeability" of communities [7][8][9][10]. However, rural residents may face additional obstacles, such as travel distances from recreational facilities and lack of facilities themselves [11,12]. Research also suggests that people in rural areas who aim to exercise outside (as a remedy for the lack of or distance from exercise facilities) may face barriers such as weather extremes and safety issues such as busy roads, lack of sidewalks and lighting on streets, loose dogs, and the presence of hunters during hunting season [13][14][15][16][17][18][19][20][21][22]. Likewise, access to healthy, affordable foods may be a problem in rural areas: in small grocery, convenience, or village stores there may be a lack of high-quality, healthy options or high costs. Stores and restaurants with more nutritious selections may be a long distance away [16,[23][24][25].
Despite these unique considerations, research examining barriers and facilitators of physical activity and healthy eating in rural communities is limited. Much of the emphasis has been on youth [26][27][28][29][30][31][32][33][34][35][36][37][38][39] and areas with large population groups [9,12]. Additionally, research in rural areas has often included participants from only one or two communities and/or limited geographic scope [14-16, 21, 40]. The present study aimed to better identify and understand common rural barriers to healthy eating and active living in a geographically diverse, rural sample.

Methods
The research team traveled to seven rural communities in seven states in the USA as part of a larger project, called the StrongWomen Change Club project (manuscript currently in review). StrongWomen Change Clubs (SWCC) were developed through an academic-community research partnership guided by community-based participatory research principles. Local leaders, all cooperative extension educators with whom our research team has been working for the past decade, each recruited 10-15 residents to undertake a project to improve some aspect of the nutrition or physical activity environment. Most SWCC participants had limited (or no) experience in civic engagement and/or policy work. At 6-and 12-month after implementation, the research team conducted key informant interviews with each SWCC leader to capture their perceptions of program process, benchmark achievement, and self-efficacy. The first step in implementing the project was to better understand barriers and facilitators to healthy eating and active living among residents in those rural townships, defined as a population of fewer than 15,000 people. Focus groups were conducted with community members in each of the following states: Alaska, Arkansas, Kansas, Missouri, Montana, Pennsylvania, and Wisconsin ( Figure 1).
Seven focus groups (one in each location, with SWCC participants) were conducted (by RAS or MEN), lasting approximately 45-60 minutes per focus group. Researchers asked open-ended questions about factors that influence physical activity and healthy eating among residents. They asked residents to think about both the barriers and facilitators that contribute to their exercise and eating habits in their community. In addition to participating in the focus groups, participants were asked to complete a brief, self-report questionnaire that contained demographic and health behavior questions derived from standard inventories (e.g., Behavioral Risk Factor Surveillance System (BRFSS)). All materials and procedures were approved by the Tufts University Institutional Review Board. All study activities were conducted with the understanding and consent of the study subjects.

Analysis.
Qualitative data analysis was conducted by LMC and RAS between May and October 2013. Transcript files were entered and coded using NVivo (QSR International, version 9.0, 2011), led by LMC with a subset of double coding and agreement checks between RAS and LMC. Manifest content analysis was used to analyze the data, employing the following process: verbatim transcription; transcription review by multiple coauthors; development of and connection between codes and themes (based upon the main focus group questions and the addition of emergent subthemes); and data interpretation and review by the research team in an iterative process until agreement was reached. Quantitative (survey) data were analyzed by RAS using SPSS version 21.

Results
The main focus group questions informed the initial development of the coding structure with the original questions serving as the main themes: (1) barriers to physical activity; (2) facilitators to physical activity; (3) barriers to healthy eating; and (4) facilitators to healthy eating. Reoccurring subthemes were identified through an iterative process and confirmed for agreement. Themes and subthemes are displayed in Table 1.
Demographic characteristics of participants are displayed in Table 2. Focus groups contained 8-18 female participants ( = 95) per focus group. The average (SD) age of the 95 women was 59.3 years (14.0). The majority of the women were white (94.7%), married (68.1%), and educated beyond high school (92.6%). Focus group participants (82.4%) described the area they lived in as very rural or mostly rural. The average population size of the seven towns was 4,747 residents. Demographic characteristics of participants were compared to the overall population using census data for each town (American Community Survey 2010).
Survey responses related to physical activity and nutrition are displayed in Table 3. Survey responses indicated that more than half of the women were overweight or obese (57.9%) based on self-report height and weight (shown as body mass index (BMI)). Women self-reported their health status as excellent (20.0%), very good (49.5%), or good (28.4%), based upon a 5-point Likert scale. The majority of participants (63.2%) considered themselves active, defined as "generally active daily and exercise two or more times per week. " Exercising was usually performed in a combination of settings including inside at home, outdoors, and/or inside at a facility (71.0%). Most participants (51.6%) engaged in physical activity in a combination of ways including alone, with one other person, and/or in a group or class. Thirty-eight percent of participants reported excellent access to physical activity facilities and 22.3% reported excellent access to healthy foods within their neighborhood or community.

Perceived Facilitators to Healthy
Eating. Facilitators to healthy eating common to focus group participants included ability to grow and produce food and access to farmers' markets and farm shares.
Ability to Grow and Produce Food. Several women reported growing and producing their own food. They not only had access to fresh food, but were able to control the production process as well.

Discussion
Much of the research examining barriers and facilitators to active living and healthy eating among residents in rural communities has only focused on one geographic location [15,16,22,40]. This study aimed to gather perspectives from a broad geographic range-from Alaska to Pennsylvania and in between. Interestingly, there were findings that are similar to what has been reported in studies not focused on rural locales-particularly lack of time and competing priorities to exercising and eating healthfully.
Our study also supports and expands upon existing research related to barriers to physical activity and healthy eating specific to rural communities such as busy roads and fast traffic, poor access to fitness facilities, expensive costs of healthy food, difficulty adjusting eating habits like consuming large portions, lack of variety and quality of food at local stores, and difficulty avoiding unhealthy food at community events and gatherings [14-16, 22, 24, 40]. Primary facilitators to active living and healthy eating in this study also confirm prior findings, highlighting factors such as accessible and affordable fitness facilities, social support, and access to fresh and local food [15,24,40].
Participant and community characteristics from prior studies differed from our sample of participants with respect to gender [24,40], education [24,40], geographic location [14-16, 22, 24, 40], and race [15,40]. This suggests that similar barriers and facilitators exist around healthy eating and active living in rural communities and across a range of demographic characteristics.
A major theme that was discussed in four of the seven focus groups was the attempt to build physical activity into daily routines. In some instances, this meant that participants proactively sought ways to increase their activity such as waking up early to work out, parking further away from destinations, taking the stairs when an elevator is an option, and engaging in activity on lunch breaks. In other cases, physical activity was naturally a part of daily routines like housework, laundry, gardening, and walking the dog.
Several themes identified may be specific to rural communities. A unique finding that emerged from the focus groups is the stigma associated with being physically active in some of these small rural communities. If a person was routinely seen riding a bicycle or walking to work it might be assumed that he/she had lost his/her driver's license. This finding may be specific to rural communities where active transport is not common and residents in the community can easily identify one another.
Changing dietary habits is difficult and the reduction of perceived barriers, increased overall health concern, social modeling, and self-efficacy may be necessary to take action and maintain change [41]. Our findings suggest that making dietary changes can be difficult, especially when women are accustomed to preparing large portions of high-caloric food for men who have physically demanding jobs such as farming and field labor. As these men age and transition away from these physically demanding occupations, adjusting cooking practices can be a difficult challenge unique to rural and farming households.
As documented in other studies, rural residents may have improved access to healthy foods due to the availability of fresh and local produce offered through farmers' markets and roadside stands [24,40]. Our participants discussed in detail how they produced their own food. Joining farm shares and acquiring local meats and produce were commonly reported as well. Although access to healthy foods may be limited in traditional food stores, other alternative options to acquiring fresh produce and meats are available and may be more common among rural communities.
Many of the subthemes identified in our study were interconnected across other subthemes and main themes illustrated in this project. For example, living in a rural community may require long distance travel to access food or physical activity venues which may put a strain on budgets and time. Our participants identified the cost of healthy food and lack of time as barriers to engaging in physical activity and healthy eating. The interconnection among these themes may amplify the barriers that rural residents face. In prior research, Wilcox et al. found that many of the facilitators identified in focus groups were opposite to the barriers and vice versa [15]. Some of our results indicated a similar pattern. For example, access to farmers' markets and farm shares was identified as a facilitator to eating healthfully, while long distances from food outlets was discussed as a barrier. Social support was viewed as a positive contributor to engaging in physical activity while social norms and stigma acted as a barrier to engaging in active transport such as cycling.
The main limitation to this study is the inclusion of primarily white, educated women, which hinders the generalizability of our findings. However, the women were generally representative of the communities visited. Also, we identified several common barriers and facilitators in this work compared to past research that suggests that key themes are stable across demographic groups. Another limitation is the lack of urban comparison groups. Because of this, we are not able to conclude that the themes that emerged are specifically associated with rural communities. Lastly, social desirability bias may have occurred if focus group participants felt that they could not express personal barriers or if they overreported or exaggerated positive physical activity or healthy eating behaviors.
Overall, this study fills an important gap in knowledge related to barriers and facilitators to physical activity and healthy eating in rural communities. Future intervention strategies should target the identified factors and place specific emphasis on the overlapping themes that emerged from our study and past studies. In addition, addressing stigma related active transport, adjusting cooking practices and habits, and increasing awareness of local food options could be of particular interest when working with rural communities.