This study adds to the understanding of family and neighborhood determinants of healthy eating and physical activity by focusing on older adults living in rural communities. Moreover, the qualitative nature of the study provides insight into findings from previous research, such as limited associations between physical activity and environmental variables among rural residents, and equivocal findings on the role of family support in physical activity and healthy eating.
Most research on neighborhood walkability has been conducted in urban areas and supports the importance of higher residential density, mixed use and connected streets as facilitators for walking [12–15]. Our participants, in contrast, emphasized plenty of space for walking, in addition to minimal traffic and living in safe and friendly neighborhoods. Given the lack of mixed use development in rural areas, and the associated scarcity of destinations such as stores or restaurants within walking distance, neighborhood characteristics that support walking likely differ between urban and rural locations . In addition, the paucity of features typically associated with walking (e.g., fewer recreational facilities, limited sidewalks), may help explain why physical activity rates are lower among rural residents, at least in the southeastern U.S. Our findings on the barriers to physical activity were similar to findings on barriers reported by others [8, 39].
This study also explored the perceived availability of healthy foods in both the home and community environment. Although most participants reported that they often or frequently had fruits and vegetables available in their homes, the cost of healthy foods and access to larger grocery stores for a wider selection emerged as potential barriers for some rural residents. Other studies have documented that rural residents live a greater distance from larger supermarkets and often have more direct access to convenience stores that typically have higher prices for the more nutritious options [24, 25]. A significant number of our participants reported driving a considerable distance to grocery shop for at least some of their trips. Frequency of shopping at larger stores with better selection and lower-priced healthy foods may affect how often fruits and vegetables are available in the home environment.
This study also explored the role of family social support in physical activity and weight management. Our findings corroborate the association between physical activity and family support noted in other studies [8, 30, 39, 40]. The majority of participants reported that their families were not physically active together, but that family members, often spouses or children, did play a role in encouraging physical activity. Results of these efforts were mixed, however, with refusal or procrastination by some family members and increased participation in physical activity by others. Neighborhood walkability did not appear to influence whether families exercised together or whether someone in the family had encouraged physical activity.
Prior research shows that family members can be supportive in improving dietary behaviors by encouraging change, and that individuals turn to spouses or other family members as primary support for improving diet and activity [28, 41]. In our study, about half of participants reported discussions with family members about their weight. Anger and frustration were common reactions, particularly among women, to a family member's encouragement to lose weight. This suggests that family social support may be complex and vary by gender or other family dynamics. Our findings also indicated that family conversations about weight loss do not consistently include physical activity.
This study has several limitations. First, our participants were older African American and white residents of rural, low-income counties in the southeastern U.S., with 41.4% reporting less than a high school education. As a result, our findings are not transferable to other types of rural communities. Second, although all participants lived in rural counties, they lived in a variety of types of neighborhoods. For example, some lived on farms with few nearby neighbors and others lived in neighborhoods within small towns. It is likely that neighborhood determinants of physical activity and nutrition vary for these different types of rural neighborhoods. Third, the possibility of socially desirable responses also exists, with participants potentially exaggerating family and neighborhood support for healthy behaviors.
This study has numerous implications for health promotion practitioners working in rural communities. Our study, as well as past research, suggests that the distance to recreational facilities is a particularly common barrier to physical activity for rural residents [42, 43]. Establishing walking trails is a relatively low-cost approach to removing some of the environmental barriers found in this study and walking trails have been shown to increase amount of time walking . In addition, the positive aspects of rural areas, such as space for walking and minimal traffic, should be emphasized, and the use of existing low-cost or free facilities (e.g, high school fields or tracks) should be encouraged. Our study found that most participants did not have a produce garden or access to one. Berti and colleagues reported that home gardens had a higher success rate in increasing nutrition outcomes than other strategies in a review of agricultural interventions . Although promoting gardening could serve two purposes, increasing access to fruit and vegetables and increasing physical activity, barriers such as cost and skills would need to be addressed.
Our study also suggests several areas for future research. It is unclear, for example, whether urban findings, such as mixed use development, connected streets and sidewalks, etc, apply to walking behavior in rural areas. Eyler et al. found that traffic, sidewalks, safety and destinations within walking distance were not associated with physical activity among rural women in the Midwest ; Sanderson reported parallel findings for rural African American women . Similar questions arise for healthy eating. How does the scarcity of large supermarkets in small towns affect fruit and vegetable consumption? Is it moderated by the availability of local produce through other mechanisms, or by weekly shopping trips into a larger town? Based on our study findings, family social support appears to have potential, but is not uniformly effective. Under what circumstances is family social support helpful and when is it detrimental? Are certain types of support (i.e., emotional, informational) more effective than others in promoting healthy eating and physical activity? Does it vary by gender? Lastly, additional intervention research is needed to develop and evaluate strategies to increase healthy eating and physical activity among rural families.