Cancer is a major public health threat, accounting for 25% of all deaths, and is the second most common cause of death in the United States [
1,
2]. Moreover, up to 50% of cancer-related deaths are preventable through evidence-based lifestyle modifications, such as increasing physical activity (PA) levels, enhancing nutrition, and reducing obesity rates [
3‐
5]. Among major cancer risk factors, physical inactivity is estimated to cause 12.4% of breast cancer and 12.0% of colon cancer [
6].
Across the US, approximately 21% of the adult population achieves the recommended 150 min of PA per week [
7]. PA rates are disproportionately lower in rural areas, with rural residents least likely to meet PA recommendations compared to urban and suburban residents [
8]. Further, rates of PA are lowest in smaller rural communities (i.e., populations under 10,000 persons) [
9]. Accordingly, decreased PA rates among rural residents elicits a higher risk for cancer and other chronic diseases, as compared to urban/suburban residents [
10,
11]. Rural residents make up 15% of the US population [
12]; therefore, it is imperative to determine effective interventions for increasing PA in order to decrease risk of chronic diseases.
There is little evidence for increasing PA in rural areas at the population level. The present study aims to utilize feedback from community members and key stakeholders to deliver an effective and tailored multilevel intervention. The multilevel intervention will consist of events at local walking trails, formation of walking groups, and text messaging. This manuscript describes a two-group randomized controlled trial to investigate the effectiveness of a multilevel intervention designed to increase PA rates among rural populations.
Intervention background and development
In the past decade, research on the connection between the built environment (BE) and PA has grown considerably [
13‐
15]. It remains unclear if findings from urban areas can be generalized to rural communities due to differences in culture, population densities, physical environment, and other contextual factors [
16,
17]. In a review, safety, aesthetics, and the existence of parks, walking trails and recreation centers were positively associated with PA in rural residents [
18]. Yet, even with the existence of these amenities, the use of trails remains low (regular use from 15 to 33%) [
19‐
21].
Changing the BE (e.g., building walking trails) is likely a necessary but not sufficient approach for increasing rates of PA—that is, communication/promotional efforts are warranted [
22‐
24]. PA and obesity intervention success has been shown to be moderated by proximity, access, and use of natural environments [
25‐
27]. For example, Epstein et al. [
25] found greater park area near one’s home was associated with decreased body mass index. Merom et al. [
27] demonstrated the success of a promotional campaign encouraging use of a rail-trail was moderated by proximity to the trail. PA in outdoor settings, as compared to indoor settings, is associated with a number of co-benefits including feelings of revitalization, engagement, enjoyment, and decreases in anger, tension, and depression [
28]. In addition, growing evidence suggests a moderating (interactive) effect between proximity to parks/green space and physical activity interventions [
29,
30]. The lone review focusing on built environment effects in rural settings concluded research is limited by methods and external validity, and consists mainly of cross-sectional studies in middle-aged adults [
18]. While increasing evidence shows the importance of the built environments (e.g., mixed use development, presence of parks) in supporting PA [
13,
18,
31‐
35], few studies in rural communities are available [
16].
Walking groups provide participants with social support to increase exercise adherence [
36,
37]. Further, walking groups have been found to be advantageous for enhancing health [
38], increasing PA [
39], and increasing interconnectedness among neighbors [
40]. Despite the potential benefits of walking groups, little is known about whether the results seen in urban/suburban populations generalize to rural counterparts. In a rural study, Brownson et al. [
41] found a tendency of walking groups to impact PA; however, recommend a higher dose intervention to detect significant results.
Access to cell phones are nearly ubiquitous—in 2015, 92% of Americans owned a cell phone and coverage rates have increased every year since 2010 [
42]. In 2014, 88% of rural residents owned a cell phone [
43]. With worldwide availability and shrinking costs of mobile phones, more options are available for mobile health intervention delivery. Advice and support through short message service (SMS, or text messaging) has shown promise for improving adherence in diabetes self-management and weight loss [
44‐
48]. However, relatively less SMS research has been aimed specifically at PA in underserved populations, particularly those living in rural communities.
Text messaging has excellent health promotion potential given mobile phones and text messaging are commonly used among the majority of US adults, including rural residents and those who have limited computer and reading literacy skills [
49,
50]. In addition, multiple studies have shown the feasibility of reaching lower income, rural residents with simple cell phone-based communication channels such as text messaging [
51‐
53]. While a few SMS PA programs are currently available, most lack formal evaluation and published evidence of effectiveness. Those SMS PA programs that have been scientifically tested, have not been assessed specifically among rural populations, who are at high risk for physical inactivity [
9].
A recent study explored issues such as interests (e.g., volunteering); values (e.g., personal health); awareness, access, and use of local trails; cell phone use; and physical activity level using a telephone interview with 524 adults from eight towns in rural Missouri (i.e., towns with trails in the same region as the current study) [
54]. In this study, individuals who reported doing some walking but did not meet PA recommendations were identified as a key group to target. Participants were asked, “what sort of events or activities could be held at the trail that might encourage you to visit the trail?” Many respondents mentioned community events, such as picnics, races or walking events, festivals, and kid-friendly activities. Others mentioned sports and having social support, such as group walks or walking partners. Working in the yard, bike riding, fishing, dancing, hiking and camping were done more often within the past 6 months among those who walk. Relationships with friends, personal health, finances/housing/standard of living, conditions at work/job satisfaction, being outdoors and in nature were rated as more important among those who use walking trails compared to those who did not.
The present study is based on research demonstrating: 1) the burden of physical inactivity is large, increasing, and disproportionately affects rural residents; 2) the pressing need for high-impact, scalable interventions; 3) new technologies (e.g., SMS) need to be tested in rural settings; and 4) participatory approaches supporting life priorities other than health show promise for increasing the effectiveness of PA interventions.