Health behavior change in rural populations: insights to inform nutrition and physical activity programming

Abstract

Rural communities across the United States face unique barriers to maintaining healthy behaviors, including limited access to nutritious foods, exercise opportunities, and supportive health programs. These challenges contribute to higher rates of chronic illness and lower overall quality of life compared to urban populations. Despite growing interest in public health strategies that promote nutrition and physical activity, there remains a critical need to understand how to design and implement effective, sustainable interventions that reflect the specific needs of rural residents. This dissertation examines the problem of how to support health behavior change in rural communities, using the Social Ecological Model (SEM) to explore the multiple levels of influence that shape individual health choices. Three studies were conducted in rural Montana to investigate different aspects of nutrition and exercise behavior. The first study evaluated the reach, implementation, and sustainability of community-based produce prescription programs that provide free or discounted fruits and vegetables to individuals experiencing food insecurity. The second study explored the life experiences, environmental factors, and supports that encourage long-term physical activity among older adults. The third study examined how different types of support influence older adults' confidence in their ability to engage in and maintain regular exercise. Findings from the first study showed that produce prescription programs are more successful when they involve strong community partnerships, flexible distribution methods, and tailored educational components. The second study found that factors such as early-life activity habits, personal motivation, and social support were key to ongoing participation in exercise. The third study identified that facilitators like enjoyment, community encouragement, and accessible programming were linked to higher levels of exercise confidence among older adults. These findings suggest that promoting healthy behavior in rural communities requires attention to individual preferences as well as social and structural conditions. By applying the SEM framework, this research highlights the importance of addressing multiple levels of influence such as individual beliefs, social networks, community infrastructure, and health policies. Together, these studies offer practical guidance for developing locally relevant, sustainable health programs that improve nutrition and physical activity, ultimately supporting better health outcomes in underserved rural populations.