Abstract
BackgroundPrevious reviews of rural physical activity interventions were focused on intervention effectiveness and had reported overall mixed findings. The purpose of this systematic review was to apply the Reach, Efficacy, Adoption, Implementation and Maintenance (RE-AIM) framework to evaluate the extent to which rural physical activity interventions in the U.S. have reported on dimensions of internal and external validity and to offer suggestions for future physical activity interventions for rural U.S. populations.MethodsPubmed, PsychINFO, CINAHL, PAIS, and Web of Science were searched through February 2019 to identify physical activity intervention studies conducted in rural regions in the U.S. with adult populations. Titles, abstracts, and full texts of articles were reviewed against inclusion and exclusion criteria. Data extraction from included articles included a summary of study details, rural classification system used, and the presence or absence of a total 61 RE-AIM indicators, including reach (n = 13), efficacy/effectiveness (n = 10), adoption (n = 21), implementation (n = 9), and maintenance (n = 8).ResultsA total of 40 full-text articles representing 29 unique studies were included. Classifications of rurality included self-statements by authors (n = 19, 65.5%), population/census-based definitions (n = 3, 10.3%), Rural Urban Continuum Codes (n = 3, 10.3%), Rural Urban Commuting Area codes (n = 2, 6.9%), the 2014 Alabama Rural Health Association classification system (n = 1, 3.4%) and the U.S. Office of Management and Budget classification system (n = 1, 3.4%). Individual studies reported between 14.8 to 52.5% of total RE-AIM indicators. Studies reported 15.4 to 84.6% indicators for reach; 20.0 to 70.0% indicators for efficacy/effectiveness; 4.8 to 47.6% indicators for adoption; 11.1 to 88.9% indicators for implementation; and 0 to 25.0% indicators for maintenance.ConclusionsWe found an overall poor reporting of components related to external validity, which hinders the generalizability of intervention findings, and a lack of consistency in the definition of rurality. Future research should focus on balancing factors of internal and external validity, and should aim to develop a greater understanding of how rurality influences health and behavior to provide contextual knowledge needed to advance the translation of physical activity interventions into practice in rural communities and reduce rural health disparities.Trial registrationThe review protocol was registered with PROSPERO: CRD42019116308.
Highlights
Previous reviews of rural physical activity interventions were focused on intervention effectiveness and had reported overall mixed findings
The search strategy was developed in consultation with a health sciences librarian and included the following search concepts: 1) rural population, rural health services, or rural health; 2) exercise, physical activity, walking, jogging, bicycling, or recreation; and 3) intervention studies, health promotion, or wellness programs
The current study extended this literature by examining the extent to which physical activity interventions in rural populations reported on reach, efficacy and effectiveness, adoption, implementation, and maintenance and provides recommendations for future research based on findings
Summary
Previous reviews of rural physical activity interventions were focused on intervention effectiveness and had reported overall mixed findings. Rural residents face increased rates of mortality and disease related to inactivity, such as obesity and heart disease, when compared to urban counterparts [3]. Adopting healthful behaviors, such as physical activity, reduces the risk of morbidity and mortality [4]. Several reviews have assessed the effectiveness of physical activity interventions among rural populations and have reported mixed findings [5–8] Results of these reviews conclude that to be effective, interventions should include low- to moderate-intensity aerobic exercise [7], be personalized and tailored with multiple intervention contacts [5], and incorporate behavior change theory [8]. This meta-analysis demonstrated an intervention effect in favor of studies using objective measures of physical activity, but no intervention effect among studies using self-report measures of physical activity [6]
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