Abstract
Policy, systems, and environment (PSE) change interventions are an evidence-based approach to take in rural areas of the US to improve physical activity (PA) rates. However, there is a need to understand the unique factors that affect such interventions in rural areas. This study used a descriptive, qualitative design to capture the perspectives of 25 key informants across eight participating counties as part of federally funded project. After purposive recruiting of participants via community-based coalition meetings and snowball sampling, trained researchers conducted semi-structured interviews via Zoom. Multiple team members developed a hierarchical coding structure of facilitators and barriers of PSE change including interpersonal, environmental, systems, or policy-related factors. Systems factors, when conceptualized using a resources-based model of public health capacity, were more often mentioned as facilitating or presenting a barrier to PSE change than were interpersonal, policy, or environmental factors. Specifically, the existence (or absence) of organizations and their financial and operational priorities were critical determinants of PA PSE change. The findings from this qualitative descriptive study can be used by rural practitioners to identify key facilitators of community-based PA PSE change to focus on based on the size and scope of the environmental change and may offer guidance for researchers doing similar work.
References
Abildso, C. G., Daily, S. M., Umstattd Meyer, M. R., Perry, C. K., & Eyler, A. (2023). Prevalence of meeting aerobic, muscle-strengthening, and combined physical activity guidelines during leisure time among adults, by rural-urban classification and region - United States, 2020. Morbidity and Mortality Weekly Report, 72(4), 85-89. https://doi.org/10.15585/mmwr.mm7204a1
Abildso, C. G., Perry, C. K., Jacobs, L., Umstattd Meyer, M. R., McClendon, M., Edwards, M. B., Roemmich, J. N., Ramsey, Z., & Stout, M. (2021). What sets physically active rural communities apart from less active ones? A comparative case study of three U.S. counties. International Journal of Environmental Research and Public Health, 18(20). https://doi.org/10.3390/ijerph182010574
Association of Public and Land-Grant Universities (APLU). (2022). Extension Committee on Organization and Policy (ECOP), Handout Oct 2022. https://www.aplu.org/wp-content/uploads/ecop-handout.pdf
Barnidge, E. K., Radvanyi, C., Duggan, K., Motton, F., Wiggs, I., Baker, E. A., & Brownson, R. C. (2013). Understanding and addressing barriers to implementation of environmental and policy interventions to support physical activity and healthy eating in rural communities. The Journal of Rural Health, 29(1), 97-105. https://doi.org/10.1111/j.1748-0361.2012.00431.x
Beatty, K., Heffernan, M., Hale, N., & Meit, M. (2020). Funding and service delivery in rural and urban local U.S. health departments in 2010 and 2016. American Journal of Public Health, 110(9), 1293-1299. https://doi.org/10.2105/ajph.2020.305757
Beck, A. M., Eyler, A. A., Aaron Hipp, J., King, A. C., Tabak, R. G., Yan, Y., Reis, R. S., Duncan, D. D., Gilbert, A. S., Serrano, N. H., & Brownson, R. C. (2019). A multilevel approach for promoting physical activity in rural communities: A cluster randomized controlled trial. BMC Public Health, 19, 10. https://doi.org/10.1186/s12889-019-6443-8
Bernhart, J. A., Dunn, C. G., Wilcox, S., Stucker, J., & Kinnard, D. (2022). The FAN program plan: Creating a healthy church environment for physical activity and healthy eating. Dialogues in Health, 1, 100019. https://doi.org/10.1016/j.dialog.2022.100019
Bingham, A. J., & Witkowsky, P. (2021). Deductive and inductive approaches to qualitative data analysis. In C. Vanover, P. Mihas, & J. Saldana (Eds.), Analyzing and interpreting qualitative data: After the interview (Vol. 1, pp. 133-146). SAGE Publications.
Bobbitt-Cooke, M. (2005). Energizing community health improvement: The promise of microgrants. Preventing Chronic Disease, 2. https://www.cdc.gov/pcd/issues/2005/nov/05_0064.htm
Buys, D. R., & Rennekamp, R. (2020). Cooperative Extension as a force for healthy, rural communities: Historical perspectives and future directions. American Journal of Public Health, 110(9), 1300-1303. https://doi.org/10.2105/AJPH.2020.305767
Caperchione, C. M., Mummery, W. K., & Joyner, K. (2010). WALK community grants scheme: lessons learned in developing and administering a health promotion microgrants program. Health Promotion Practice, 11(5), 637-644. https://doi.org/10.1177/1524839908328996
Carter, W. M., Morse, W. C., Brock, R. W., & Struempler, B. (2019). Improving physical activity and outdoor recreation in rural Alabama through community coalitions. Preventing Chronic Disease, 16, 6. https://www.cdc.gov/pcd/issues/2019/19_0062.htm
Casanave, K., Gabbert, K., Tompkins, N. O. H., Murphy, E., Elliott, E., & Zizzi, S. (2021). Environmental factors affecting rural physical activity behaviors: Learning from community partners. Progress in Community Health Partnerships: Research, Education, and Action, 15(3), 349-359. https://doi.org/10.1353/cpr.2021.0037
Efird, C. R., & Griffith, D. M. (2025). Whiteness: A fundamental determinant of the health of rural white Americans. American Journal of Public Health, 115(2), 152-160. https://doi.org/10.2105/ajph.2024.307904
Emery, M., & Flora, C. (2006). Spiraling-up: Mapping community transformation with community capitals framework. Community Development: Journal of the Community Development Society, 37(1), 19-35. https://doi.org/10.1080/15575330609490152
Farrigan, T., Genetin, B., Sanders, A., Pender, J., Thomas, K. L., Winkler, R., & Cromartie, J. (2024). Rural America at a glance: 2024 edition (Report No. EIB-282). United States Department of Agriculture, Economic Research Service.
Fulton, J. E., Buchner, D. M., Carlson, S. A., Borbely, D., Rose, K. M., O’Connor, A. E., Gunn, J. P., & Petersen, R. (2018). CDC’s Active People, Healthy NationSM: Creating an active America, together. Journal of Physical Activity and Health, 15(7), 469-473. https://doi.org/10.1123/jpah.2018-0249
Gabbert, K. D., Tompkins, N. O. H., & Murphy, E. (2023). Addressing the gap between academic research and grassroots public health practice: Supporting policy, systems, and environmental changes in rural communities. Health Promotion Practice, 24(Suppl.1), 161S-169S. https://doi.org/10.1177/15248399221115452
Guide to Community Preventive Services. (November 8, 2022). CPSTF findings for physical activity. https://www.thecommunityguide.org/pages/task-force-findings-physical-activity.html
Hahn, C. (2008). Doing qualitative research using your computer: A practical guide. SAGE Publications.
Handler, A., Issel, M., & Turnock, B. (2001). A conceptual framework to measure performance of the public health system. American Journal of Public Health, 91(8), 1235-1239. https://doi.org/10.2105/ajph.91.8.1235
Harden, S. M., Balis, L., Strayer III, T., Prosch, N., Carlson, B., Lindsay, A., Estabrooks, P. A., Dzewaltowski, D. A., & Gunter, K. B. (2020). Strengths, challenges, and opportunities for physical activity promotion in the century-old national Cooperative Extension System. Journal of Human Sciences and Extension, 8(3), 7.
Harden, S. M., Ramalingam, N. S., Breig, S. A., & Estabrooks, P. A. (2019). Walk this way: Our perspective on challenges and opportunities for Extension statewide walking promotion programs. Journal of Nutrition Education and Behavior, 51(5), 636-643. https://doi.org/10.1016/j.jneb.2018.12.010
Hardison-Moody, A., Fuller, S., Jones, L., Franck, K., Rodibaugh, R., Washburn, L., Corrick, L., Shelnutt, K. P., Stumm, L., & Ammerman, A. S. (2020). Evaluation of a policy, systems, and environmental-focused faith-based health promotion program. Journal of Nutrition Education and Behavior, 52(6), 640-645. https://doi.org/https://doi.org/10.1016/j.jneb.2019.11.011
Holston, D., Stroope, J., & Cater, M. (2021). Facilitators and barriers to implementation of community-based socio-ecological approaches to obesity prevention among cooperative extension agents. Journal of Human Sciences and Extension, 9(1), 139-155.
Krippendorff, K. (2018). Content analysis: An introduction to its methodology. SAGE Publications.
Moore, J. B., Brinkley, J., Morris, S. F., Oniffrey, T. M., & Kolbe, M. B. (2016). Effectiveness of community-based minigrants to increase physical activity and decrease sedentary time in youth. Journal of Public Health Management and Practice, 22(4), 370-378. https://doi.org/10.1097/phh.0000000000000274
Oliffe, J. L., Kelly, M. T., Gonzalez Montaner, G., & Yu Ko, W. F. (2021). Zoom interviews: Benefits and concessions. International Journal of Qualitative Methods, 20. https://doi.org/10.1177/16094069211053522
Piercy, K. L., Troiano, R. P., Ballard, R. M., Carlson, S. A., Fulton, J. E., Galuska, D. A., George, S. M., & Olson, R. D. (2018). The physical activity guidelines for Americans. JAMA: Journal of the American Medical Association, 320(19), 2020-2028. https://doi.org/10.1001/jama.2018.14854
Sandelowski, M. (2000). Whatever happened to qualitative description? Research in Nursing & Health, 23(4), 334-340. https://doi.org/10.1002/1098-240X(200008)23:4<334::AID-NUR9>3.0.CO;2-G
Smathers, C., Toomey, M., Washburn, L., Johnston, K., Iaccopucci, A. M., Johannes, E., & Ravola, M. (2019). Positive youth development for health: Extension's readiness for multilevel public health approaches. The Journal of Extension, 57(1), 22.
Stroope, J., Jones, M., Nunes, B., & Holston, D. (2024). Improving access to the transportation alternatives program for rural communities. Journal of Healthy Eating and Active Living, 4(3), 189-195. https://doi.org/10.51250/jheal.v4i3.94
Stroope, J., Umstattd Meyer, M. R., Gabbert, K., John, D. H., Kellstedt, D., Orzech, K. M., & Wende, M. E. (2025). Physical activity policy, systems, and environment change through Extension SNAP-Ed: A multistate perspective. Health Promotion Practice, 26(1), 39-45. https://doi.org/10.1177/15248399231221779
Tamminen, K. A., Faulkner, G., Witcher, C. S. G., & Spence, J. C. (2014). A qualitative examination of the impact of microgrants to promote physical activity among adolescents. BMC Public Health, 14(1), 1206. http://dx.doi.org/10.1186/1471-2458-14-1206
Umstattd Meyer, M. R., Moore, J. B., Abildso, C., Edwards, M. B., Gamble, A., & Baskin, M. L. (2016). Rural active living: A call to action. Journal of Public Health Management and Practice, 22(5), E11-E20. https://doi.org/10.1097/phh.0000000000000333
Umstattd Meyer, M. R., Perry, C. K., Sumrall, J. C., Patterson, M. S., Walsh, S. M., Clendennen, S. C., Hooker, S. P., Evenson, K. R., Goins, K. V., Heinrich, K. M., O'Hara Tompkins, N., Eyler, A. A., Jones, S., Tabak, R., & Valko, C. (2016). Physical activity-related policy and environmental strategies to prevent obesity in rural communities: A systematic review of the literature, 2002-2013. Preventing Chronic Disease, 13, E03. https://www.cdc.gov/pcd/issues/2016/15_0406.htm
United States Census Bureau. 2020 Decennial Census [Data set]. (https://data.census.gov/).
United States Census Bureau. American Community Survey 5-Year Estimates, 2020 [Data set]. (https://www.census.gov/programs-surveys/acs/).
United States Department of Health and Human Services (USDHHS), Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health. PLACES: Local Data for Better Health, County Data 2022 release [Data set]. (https://data.cdc.gov/500-Cities-Places/PLACES-Local-Data-for-Better-Health-County-Data-20/duw2-7jbt/about_data).
University of Wisconsin Population Health Institute. County Health Rankings & Roadmaps; West Virginia Data and Resources [Data set]. https://www.countyhealthrankings.org/health-data/west-virginia/data-and-resources.
United States Department of Health and Human Services (USDHHS). (2018). Physical Activity Guidelines for Americans, 2nd edition.
Wallace, H. S., Franck, K. L., & Sweet, C. L. (2019). Community coalitions for change and the policy, systems, and environment model: A community-based participatory approach to addressing obesity in rural Tennessee. Preventing Chronic Disease, 16, E120. https://doi.org/10.5888/pcd16.180678
Washburn, L., Norman-Burgdolf, H., Jones, N., Kennedy, L. E., & Jarvandi, S. (2022). Exploring Extension agent capacity and readiness to adopt policy, systems and environmental change approaches. Frontiers in Public Health, 10. https://doi.org/10.3389/fpubh.2022.856788
Whitfield, G. P., Carlson, S. A., Ussery, E. N., Fulton, J. E., Galuska, D. A., & Petersen, R. (2019). Trends in meeting physical activity guidelines among urban and rural dwelling adults – United States, 2008–2017. MMWR Morbidity and Mortality Weekly Report, 68(23), 513-518. https://doi.org/10.15585/mmwr.mm6823a1
Whitfield, G. P., Carlson, S. A., Ussery, E. N., Watson, K. B., Berrigan, D., & Fulton, J. E. (2019). National-level environmental perceptions and walking among urban and rural residents: Informing surveillance of walkability. Preventive Medicine, 123, 101-108. https://doi.org/10.1016/j.ypmed.2019.03.019
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Copyright (c) 2026 Christiaan G. Abildso, Udday Datta, Samantha I. Moyers-Kinsella, Daniel Eades, Emily Murphy, Dana K. Voelker, Sam Zizzi