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. Author manuscript; available in PMC: 2025 Mar 1.
Published in final edited form as: Women Health. 2024 Jan 25;64(3):235–249. doi: 10.1080/03630242.2024.2310050

An exploratory study of mothers engaging in physical activity in rural communities

Susan J Andreae 1, Thomas Casey 1, Anna Lindberg 1, Kecia Doyle 1, Kristen A Pickett 1,2
PMCID: PMC10939792  NIHMSID: NIHMS1962689  PMID: 38273717

Abstract

Gender gaps in physical activity (PA) exist with women being less active than men. Multiple cultural and psychosocial factors influence women’s ability to successfully negotiate barriers to PA and other health promoting behaviors. The goal of this exploratory descriptive study was to better understand the daily experiences of mothers in making health promoting decisions for themselves and their families.

Semi-structured interviews (N=17) were conducted with rural dwelling mothers who were the primary caregivers of children in the home. Participants were asked to share their experiences with PA and other health behaviors, focusing on their motivators, barriers, and facilitators. Interviews were audio-recorded, transcribed verbatim, and analyzed using thematic content analysis.

Emerging themes focused on 1) feeling internal and external pressures to prioritize family’s needs over one’s health, 2) family exerting both positive and negative influences on health choices, and 3) living in a rural community often resulting in a lack of opportunities to engage in physical activity and feelings of being isolated from social networks.

To close the gender gap in PA, interventions should support mothers in navigating their multiple roles and competing demands while engaging in health promoting behaviors such as physical activity.

Keywords: Physical activity, women’s health, caregiver, social norms, behavior change

Physical inactivity substantially increases the risk for chronic conditions (Aune et al., 2015; Chomistek et al., 2018), negatively impacts multiple dimensions of health (Faienza et al., 2020; Yoneda et al., 2021), and causes considerable economic burdens (Ding et al., 2016). Approximately 25% of U.S. adults report zero PA participation in the past month (Centers for Disease Control and Prevention, 2022), with significant PA disparities existing by gender. Gender differences in PA are seen as early as preschool (Sallis et al., 1996), with the trends continuing into adulthood (Troiano et al., 2008). Activity levels decrease further after life events such as parenthood (Bellows-Riecken & Rhodes, 2008; Engberg et al., 2012; Gropper et al., 2020; Hull et al., 2010; Larouche et al., 2012). Women’s lower PA levels are associated with an increased risk of multiple chronic conditions, such as cardiovascular disease, cancer, and diabetes (Aune et al., 2015; Chomistek et al., 2018).

Complex cultural and psychosocial issues influence these disparities (Edwards & Sackett, 2016; Hankonen et al., 2010). A frequently cited barrier to PA is the dual workload of women in the home and work (Caperchoine et al., 2009). Although women are more than 50% of the U.S. labor force, women continue to be primarily responsible for household tasks such as laundry, cleaning, preparing meals, grocery shopping, and dishwashing (Brenan, 2020; United States Bureau of Labor Statistics, 2021). Many women are also the primary caregivers (Brenan, 2020). These factors impact the ability of women to successfully engage in PA and health behaviors (Dixon, 2009; Yarwood et al., 2005). In fact, some mothers noted that the need for PA was an additional source of stress or guilt (Dixon, 2009).

Mothers in rural communities often face additional barriers to health. Rural residents are often geographically and socially isolated (Holmes & Thompson, 2019) while facing significant barriers in accessing health resources compared to urban and suburban residents (Garcia et al., 2017; "Rural Health Snapshot," 2017). Living in social, physical, and economic environments that are less supportive of health-enhancing behaviors contributes to rural regions carrying a disproportionate burden of poor health outcomes such as diabetes, stroke, and heart disease (Anderson et al., 2015; Garcia et al., 2017; Holmes & Thompson, 2019; Matthews et al., 2017; Pender et al., 2019; "Rural Health Snapshot," 2017). Moreover, rural communities are traditionally underrepresented in health research due to barriers such as cost, time, trust, and distance (Pender et al., 2019).

To develop effective health promotion programs to reduce gender disparities in PA levels, a better understanding of the factors that influence women’s participation in PA is needed (Cleland et al., 2010). Previous research examining rural health barriers noted the need for better understanding individual-level factors impacting health priorities and decisions as well as the unique sociocultural and physical environments of rural communities (Frost et al., 2010; Whitfield et al., 2019; Wilcox et al., 2000). Therefore, this qualitative study explored the day-to-day experiences, motivators, facilitators, and barriers that mothers experience in rural communities to better understand the context in which they make health behavior decisions for their families and themselves.

Methods

This report follows guidelines outlined by the Standards for Reporting Qualitative Research (O'Brien et al., 2014). The university IRB approved study activities. Eligible participants were adults, primary caregivers of children, and willing to participate in an interview. Participants were recruited from the Survey of the Health of Wisconsin, a representative cohort of Wisconsin residents (Malecki et al., 2022; Nieto et al., 2010). Recruitment letters were mailed to individuals in rural communities as defined by the 2010 Census Urban and Rural Classification (United States Census Bureau). Eligibility screenings were completed by telephone and informed consent discussions were completed before the interview. Interviews were conducted between April-August 2021 and lasted 30-65 minutes, averaging 45 minutes.

An interviewer guide was used to maintain consistency over the interviews. Questions were guided by constructs of the Social Cognitive Theory (Bandura, 1977, 2004) and Self-Determination Theory (Ng et al., 2012). To test readability and comprehension, questions were pretested with two rural dwelling caregivers. Their feedback was used to refine the questions. Interviews began with a discussion regarding the definition of family health. Then, factors that influenced the participants’ decision to engage or not engage in health enhancing-behaviors were explored, including motivations, barriers and facilitators, behavioral capability and efficacy, and social support and norms. Interviews concluded with a discussion regarding activities and supports that would be important to include in future health programs. After each interview, the interviewer completed field notes. Debriefing meetings were completed within two days of the interview and included the interviewer and project PI (SA) reflecting on the interview’s tone, flow, and emerging findings (McMahon & Winch, 2018). Interviews were audio-recorded and transcribed verbatim. Transcriptions were checked for completeness and accuracy by comparing the transcript to the audio recordings and then deidentified.

Coding occurred concurrently as the interviews were being conducted by SA and research assistants working in teams of three. Data were organized in NVivo 12 (NVivo qualitative data analysis software, 2018) using a procedure similar to those described by Braun and Clarke (Braun & Clarke, 2012). The initial codebook was developed by two coders working independently using the first two transcripts. These codes and definitions were discussed as a team with differences reviewed and resolved through group consensus. This codebook was used by two coders working independently to code remaining transcripts. After each transcript, coding teams met to review the application of codes. Reliability was assessed during these meetings by identifying coding discrepancies. Disagreements were discussed and a consensus was reached by the coders in consultation with a third team member. After these meetings, recoding was performed, as needed, to ensure consistent application of the codes.

Themes were developed by reviewing the coded data to identify patterns, similarities, and differences (Braun & Clarke, 2012). Codes were grouped into broad categories that reflected a meaningful idea or explored similar phenomena. Themes were then reviewed, defined, and example quotes selected. To improve rigor, multiple independent coders were used to ensure consistent application of codes (O’Connor & Joffe, 2020) and an audit trail tracked the development of codes and themes (Nowell et al., 2017).

Results

Of the 28 mothers that expressed interest in the study, 17 were enrolled. Two were not eligible and nine declined or did not complete the enrollment process. On reaching thematic saturation, recruitment stopped with no further attempts to contact additional participants. Participants were white, on average 41 years (SD=7.4), with an average of two children in the home (SD=1.1, range=1-5). Most had graduated from college (14, 82%), had an annual income of $40,000 (12, 71%), were married (13, 77%), and employed full or part-time (14, 82%) (table 1).

Table 1.

Participant Characteristics

Characteristic Full Sample
N=17
Number of children in the home, mean±SD 2.4±1.1
Age in years, mean±SD 41.3±7.4
Education (n, %)
 HS graduate 2, 11.8
 College Graduate 14, 82.3
 Missing 1, 5.9
Income (n, %)
 Less than 40,000 2, 11.8
 40,000 or greater 12, 70.6
 Missing, declined to respond 3, 17.6
Employment (n, %)
 Full-time 10, 58.8
 Part-time 4, 23.5
 Does not work 1, 5.9
 Missing, declined to respond 1, 5.9
Marital status (n, %)
 Married 13, 76.5
 Divorced 3, 17.6
 Missing 1, 5.9
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Three key themes emerged from the data: 1) feeling pressures to prioritize family’s needs over their own, 2) family exerting positive and negative influences on health choices, and 3) living in a rural community often resulting in a lack of health opportunities and feelings of being isolated. Illustrative quotes for each theme are presented in table 2. Appendix table 1 presents the percentage in which the themes and subthemes emerged across the interviews.

Table 2.

Themes with example quotes.

Major Themes Subthemes Example quote
Theme 1: Feeling pressure to prioritize family’s needs over one’s own health Prioritizing family’s needs …it's an internal struggle sometimes. It's not necessarily a physical struggle. It's an internal thing, like feeling like you’re not spending enough time with family or whatnot, instead of doing something healthy for yourself. (P007)
Well, for myself, I have a hard time worrying about myself, I'm more dealing with making my children happy, more so myself. Yeah, so I take more time and looking at what they need compared to what I need. (P025)
All the time, I want my kids active. I want them to be I want them to know and have an experience that they feel they want… I'm just always trying to make sure that they're healthy, they're active, and are getting those essential experiences in life. (P003)
Making choices to be a healthy role model for their family I have a desire to make healthy foods for them. And for my son, I want to teach him, you know, I need to be a good role model for him and teach him otherwise. No, nobody else will. And then my husband too, for an accountability partner (P023)
I wanted them to see play is the highest form of learning and we're going to do it together and it's going to be an adventure, our way of life or whatever. I just wanted them to catch, catch it versus, you know, this is a punishment. I didn't want it to be exercising to be a punishment because I think that's what most people do. You view exercise or physical movement as being punishment versus, hey, my body can do this. Isn't that amazing? (P020)
I try to be healthier myself because I know that I'm an influence to my children. That my behaviors directly influence my children and my husband's behaviors as well, and vice versa. (P014)
Engaging in physical activity to be a better caregiver I want to show my son the benefits of being healthy. So he is an athlete, and I want to show him if you put good food in your body, you're body will be more efficient. And I want to have longevity, I want to stave off diseases. You know, cancer and diabetes have been linked to healthy eating and activity and healthy hearts. (P023)
I want to stay around for my kids longer. You know, if I don't take care of myself, I can't, I can't, be around for them or grandchildren or whatnot. (p007)
Well, my family, my kids, I have four kids. I guess I just do want to be there for them. You know, i have a family history of diseases also, so that kind of plays a part in some of this. And I guess, I feel that God has given me these tools. So sometimes I should use them to the best of my abilities…I just feel better. Eat better. Yeah, you just, overall, your mind just clear. Your ideas, you get more productive. (P022)
Impact of expectations regarding family roles Um, I don't know, I mean, they're always supportive about it. It’s that internal thing that tells you like, oh I should stay home and not go workout…I think, I mean, I have a really supportive husband. So he would do anything for me to do what I need to do, but it's just that internal thing that you deal with all the time. Like, I should be there for them and not necessarily me all the time. (P007)
But just, you know, you're, you're on the clock. Twenty-four hours a day….you know, any anybody and especially any parent knows that they the schedules can be quite ridiculous. And just to find the time to fit in your own health care can be difficult. (P013)
Being the decision maker for family health But I think in terms of being healthy, you know, we are kind of, or I think most families’ moms are the hub. And if the hub doesn’t feel good, then the whole family doesn’t feel good. (P019)
Not prioritizing their own selfcare because time with children was limited and timebound … when they are smaller, you want to spend time with them. And so, in order to go out and do something really healthy by yourself, it’s not always, you know, um, I guess the guilt part of it usually overrides that so I'm not going to go out for a run or go for a bike ride by myself (P007)
So, I think for me, the too many activities would be things that take up all of our time. Time is spent and you don't get it back. (P020)
Intrinsic enjoyment engaging with family as motivation for physical activity If it's hard to get out and find time you can just do it in your house. Yeah, I am in the kitchen cooking dinner and me and my daughter were doing squats and then every time we had to get up and we had to change of pot or pan or something we'd have to change the activities, we did push up. Oh, and we did some yoga. Yeah. So I get my I get my kids involved so they want to be in the kitchen and they like to help cooking. So whenever I do in between they have to do it with me. OK, and then I think that is really a bonding time. Yeah. Because you get a laugh with each other and joke and then you know, make it into a dance doesn't have to be that hard exercise. (p026)
I use them as my weight. And they love it. They love that. That’s interaction with me that’s enjoyable but then also it's, it's giving me and them exercise and tiring them out. (p005)
Theme 2: Family exerting positive and negative influences on health choices Difficultly finding activities for entire family Do the five kids inhibit me? Oh man. That that's an ever changing, ever changing deal. I don't know if it was and I don't know if it inhibits or a challenge. I think it depends on your perspective. So some days it does feel like an inhibition, having five kids and then other ways I see it as a challenge, um, passing on the desire to be helpful. When they were little, you know, strap them on a backpack and head out. Now you do it at their, they want to do it by themselves. I guess I have an 11 and 9, a 7 and twin 4 year olds, but they do it at their pace. And so it is slower. And then I just need to be more mindful of passing on good habits and I guess so that comes into the mental and emotional and psychological health too. So I don't know, I guess is perspective and it goes day by day whether I see them as an inhibition or as a challenge, you know, as a positive challenge. (P020)
Lack of support from partners Yeah, my husband, I think that I don't want to say that's a lost cause, but I can try and try and try it and unless he's in the mood. He's not going to. (P017)
Desire for dedicated time to participate in exercise alone or with friends When I'm accountable to someone other than myself, because I don't have any trouble letting myself down. But if there are things that are scheduled, and I sign up for in advance, I always do them or if I pick someone out or if I have a commitment to someone else, and I, and I do as well. (P006)
Family encourages trying new or different activities We got into all of that, dancing more and singing more, and moving more. My son could now participate because he was like two at the time. So I definitely think when I get them involved, things have been easier. The walking has definitely helped a lot. I mean, three miles is still a good workout. (P026)
I think it's both. I think daily they keep me on my toes. I honestly can say without my kids I don’t know I’d be bike riding. It’s like one of those things, it’s like, I’m not going to say, I’m going to go bike riding. It’s my kids, they make me go do it. (P019)
And just that extra encouragement to go for a walk or let's go walk around the farm. Yes. Or my daughter will want to ride her bike and then we'll walk with her. Just different, different things. (P017)
Sharing responsibilities with family members From like a social standpoint, when, um, your spouse steps in to help you do things that allow you, you know, or to take over something that you feel like you need to have done before you can take the time to do that. That helps. Or if they are active with you. (P006)
I tend to work out in the morning and my husband gets the kids up for school and then I take them. Yeah, but he gets it in at night so we just try to divide up our time. (P026)
Support and encouragement from family So I will say my husband was not always on board with the physical activity. He was a farmer. And so a lot of his job is sedentary, you know, I mean, you're getting on and off of trackers and things like that, but not cardio workout. And so over time, I think he's seen how fun it is to bike and how much better he feels. So I will say that it's gotten easier if we're both on the same page. (P023)
I do think relationships are huge with that. I didn't realize until I made the choices to change, kind of, my lifestyle, and then so it's not, like, causing, um, I think that anytime that you're kind of, on that same path when somebody decides like, hey, I need to wait or now have diabetes and I have to make changes, but the other parties are not on board, then all the sudden now, you not only are dealing with the difficulties of living that life, but now having that somebody not necessarily against you, but yet they're not with you. And so that you don't have that support. (P005)
But yeah, no I mean and even if you don't have kids, I mean I think just having, having someone there to help push you, especially at times I just don't feel like doing anything. And if I go up to the farm, you know, she'll say, or my mother-in-law will say, oh lets go for a walk on the farm, or, it's just so nice out. (P017)
Theme 3: Living in rural communities often resulted in a lack of health opportunities and feelings of isolation from social networks and health resources Distance from family and social network: Now, when I you know, everything is pretty much focused on the boys, I've lost some of that opportunity just because I'm busy with the kids. So that's where I try to make up for that in, you know, getting them out. I don't I don't have a lot of opportunities for social circles. I don't really have I don't really have any friends that I could even exercise with. Like I have a good friend who she gets up at five o'clock every morning and goes walking with someone else, but which is fantastic. But she also lives in town. And so it's a little more easy. So and you might touch on that, too, you know, geography. But out in the country, your options are a little less. We do live next to a bike path. (P013)
Lack of community resources I know some towns have things where you can walk like you could walk malls if you're living in the cities or you could walk. I don't know you places where you could walk inside [in my town]. (P005)
Um, I think if there was more, well, I live in a rural area. I think if there was more availability to something more local for like a gym, or even daycare. If there was an outlet for me to go do, like a moms like, something that was specifically for me that was local would be tremendously helpful. (P018)
We live in a very small community. There's nothing here. I would love to take my kids to, like, a pool, but now you have to go to a pool that is like 50 minutes away. It’ll be nicer if offered within our community. (P019)
Don't have the time to drive somewhere really far to workout, like going to a YMCA or going to a workout class, because I just don't have the time. And if I was part of a club, I feel like I would be throwing money away. And I would be stressed out knowing I'm throwing money away and I'm still not getting there to work out. Or it would take more time away from our family. Because you also have to take into consideration the driving time. (P021)
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Theme 1: Prioritizing family needs over own.

Caregivers prioritizing their family’s health over their own self-care was often driven by internalized social norms and expectations. Participants reported that as mothers, they felt social pressures to prioritize their family’s needs over their own. They noted experiencing feelings of guilt missing events because they were taking time for self-care. One participant described, “…say I don't go to my kid's soccer game so that I can work out and then you kind of feel guilty about it. I don't know if it's society. No one says anything to me. Like, you're a bad mom for not going…It’s just the messages you kind of get. So, I would say this inherent guilt and that if you do something for yourself and you know your kids [are] not number one all the time, there's kind of guilt associated with that (P012).”

Additional pressures were felt by working mothers that impacted their health decisions, “… you're not prioritizing your family over your job…And if I say I want to take 45-minutes for myself to go for a run. How dare you? You've been working for eight hours. The kids haven't even seen you. You need to get dinner ready (P026).”

Participants’ leading motivations for engaging in self-care behaviors were often tied to their families. Participants wanted to be a role model, wanting their children to develop healthy habits. One participant shared, “I [try] to be a good example of health because that's what I want for them. And I want to make sure they're super active and they get out there and they can achieve anything (P026).” In addition, participants discussed that it was important for them to engage in PA to be a better caregiver. One participant stated, “…as a mom, I'm more worried about being healthy for my kids than more so myself. Yes, I know I should be healthy for myself, too, but I [don’t want] to put them [in] any sort of position to not have a mom, or have to take care of us (P017).” Another participant described her experiences in realizing how her health impacts her family, “…I wasn't finding any time for myself. That, I just felt like I was, again, was like, kind of following, you know, the day-to-day tasks and not getting anything out of life…I wanted to drop some weight. The weight not only was, you know, affecting how I felt about myself, but it was affecting my family (P014).

Participants expressed that majority of the caregiving and household responsibilities often fell on the mother, even those who had supportive partners. This left little time for engaging in health behaviors. Participants noted that these added pressures would result in prioritizing their caregiver role. One participant shared, “I feel like there's a lot of guilt in traditional family roles, a lot of the childcare piles on the mother…the transporting and the homework and all that stuff. Even though I think fathers are becoming a more active role now. But it still feels like if the mom tries to do everything she can do…we feel like we have to do it all (P006).”

In addition, participants were often the primary decision maker regarding their household’s health, “I'm the one who kind of dictates what we're going to do. So, but I guess there's a certain level of activity that just comes with parenting (P012).” As a result, they had limited energy or time for their self-care activities. A participant noted, “…if my kids have sports or something…I need to make sure I drive them to school activities or things like that. So, I always feel like as a mom that those things take priority over doing something different like going off and exercising that doesn't involve them (P006).”

This was connected to participants feeling that time with their children was timebound, thus justifying the delay of self-care activities. One participant described, “I wish I could say my attitude was super-duper and it's not I'm, I'm usually frustrated…I am really trying to hold the perspective of, this is a season of life. Motherhood, goes by super-fast. You know, you get 18 summers with them. And if you hold on to that perspective, I realized eventually the kids will be not at home anymore and I will have copious amounts of time to go do whatever I want to do (P020).”

Finally, when asked to think about strategies to help support caregivers, participants discussed the importance of valuing an activity’s intrinsic incentive. Participants expressed that focusing on the positive experience and the enjoyment of engaging in the activity was motivating. One participant described past experience of walking as a family as, “…enjoying each other’s company, it’s fun, everybody's getting the exercise…Trying to encourage a habit in my children that now that they're older too, to think about how that impacts other family members (P003).”

Theme 2: Family exert both positive and negative influences on health choices.

When considering the impact of family on health choices, participants described both positive and negative examples. While the family was often the leading motivator to be healthy, they were often a barrier in performing that behavior. One challenge was the emotional work required in managing the dynamics of multiple family members when engaging in PA, such as the need to identify activities that were age appropriate and satisfied different interests. One participant shared, “it takes a ton of patience to exercise with children…I'm sure you've seen Toy Story and there's tour guide Barbie and she just has that smile plastered. And, you know, you can do it and they're doing great. It's just it takes a lot of your patience. But again, and that's that a growth opportunity as an adult, because I guess what I pep talk myself all the time when I'm exercising, you can do it. You can power through. So, I think it takes a lot of energy. But again, the energy then is like, hey, guess what? This is part of my, my workout, my mental workout, or whatever when I'm taking my kids out to do something (P021).”

Participants also discussed the challenge of engaging in self-care activities without supportive partners and the desire to have dedicated time to exercise without being in the caregiver role. As a participant stated, “honestly, for me, I am with my kids all the time…I have such a lack of social, that…I would just love the one-on-one time for me to exercise by myself (P010).”

Similarly, participants wanted an exercise partner able to take equal responsibility for planning activities. One participant noted how this would provide accountability as well as support, “I think having some kind of a partner to exercise with would be helpful. I often long for a walking buddy. Somebody that, you know, would walk with me and would suggest walking. So it was a balanced relationship and not one-sided (P003).”

Despite these challenges, participants discussed the positive influence of their family in engaging in regular self-care behaviors. For example, family, especially their children, often initiated or encouraged new and different types of activities. One participant noted, “In a lot of ways my kids make it easier because they will do activities with me, they’ll either be happy to go out and take a walk or might suggest it (P003).”

One participant described the material and emotional assistance from her family that supported her in sustaining behavioral changes. “I had to take a couple hours a week to go to my meetings and I had to take time to plan meals. And every Monday, [my mom] would come over for a couple hours while I went to my meeting… I was a happier mom, and happier self. And I might cook meals that were more healthier. And my kids were watching me eat better, they were watching me, you know, looking for opportunities to be physically active with them…Even though I was taking time away from them to do those things, it was obviously affecting them so much. So much more in a healthier way (P014).”

Theme 3: Living in rural communities often resulted in a lack of health opportunities and feelings of isolation from social networks and health resources.

Living in rural communities often meant having access to abundant green spaces. One participant noted, “we always have access to that [park near their home], which is fantastic, because biking on country roads isn't always so safe. I have a bike rack and the boys and I go hiking on trails (P013).” However, living in rural communities also meant having access to fewer resources and opportunities for PA. This made identifying appropriate activities for the entire family more challenging. One participant described how additional resources would support her family to be more active, “something that you could do together, something that would be affordable, obviously…if there was a place nearby like, you know, like a YMCA or whatever, where there were many choices for activities like, say this kid can go swimming this one to play basketball, this one could play tennis, you know, and the mom could be there (P013).” Moreover, mothers discussed that distance from their social support networks was often an added barrier, “I live about an hour away from my family, so about the only thing I get is just phone calls from them (P025).”

Discussion

Better understanding the factors that impact caregivers’ ability to engage in PA and other health-enhancing behaviors can help identify feasible and acceptable strategies that support health-enhancing behaviors. When we spoke with mothers from rural Wisconsin communities, three themes were identified that would be important to acknowledge and address in future health programs.

First, the importance of women’s identity and role as a caregiver emerged as a significant factor influencing decisions to engage or not engage in health-enhancing activities. Participants discussed the ways in which social expectations regarding household responsibilities often resulted in the women prioritizing family needs over their own. Prior studies have also found that women were often responsible for a greater share of caregiving and household tasks (Brenan, 2020; Hankonen et al., 2010; United States Bureau of Labor Statistics, 2021). This may contribute to women delaying or participating in less self-care because of limited time or to avoid feelings of stress or guilt (Dennison et al., 2019; Mailey et al., 2014). In fact, fathers were more likely to perceive PA as a controllable, self-regulated choice compared to mothers when asked the same question (Dixon, 2009). The resulting delay or avoidance of healthy behaviors may be contributing to the gender disparities in PA and increased risk of chronic conditions (Aune et al., 2015; Chomistek et al., 2018).

Previous research examining PA in rural women found that caregiving was frequently identified as a barrier in addition to time, energy, motivation, sociocultural norms, resources, and the lack of short-term benefits experienced after making lifestyle changes (Peterson et al., 2013; Whitfield et al., 2019; Wilcox et al., 2000). Our participants provided in-depth insights into the ways in which these barriers, particularly the norms around caregiving, were internalized and impacted health decisions. Furthermore, participants identified several leverage points that could potentially be used to develop strategies to enable PA participation. For example, being a caregiver was a significant motivator to engage in health behaviors. This identified a promising way to incorporate health activities into families’ daily routines. Engaging in health-enhancing behaviors provided opportunities to model healthy behaviors. Participants felt that it was easier to engage in such activities when it included family. Similarly, the importance of emphasizing an activity’s intrinsic incentive was noted as a potential strategy to increase PA and other health behaviors. Along these lines, the literature suggests that programs that help women identify intrinsic reasons for making health choices are important for sustainability (Brown et al., 2017; Santos et al., 2016) and that women who focus on PA as a means to improve well-being and quality of life had higher participation rates compared to those whose goals were centered on weight loss (Segar et al., 2008).

Another leverage point for future health promotion efforts was to engage the entire family. Such programs would benefit the whole family while providing opportunities to enjoy each other’s company. As one participant described, “just something to get families playing again and moving together… So, starting somebody out young…and making it part of a fun family activity or weekly thing with a reward or something would be a nice thing for families (P005).” Findings also reiterated the need for future health promotion efforts that do not ask already overloaded caregivers to take on additional responsibilities and the emotional work that may be required in coordinating program activities.

The second theme identified was that social networks served as both a facilitator and barrier to health choices. This has been previously noted in the literature (Dennison et al., 2019). Like our study, research shows that the absence of social support is a difficult barrier to overcome (Janssen et al., 2014). Our study found that the emotional and material assistance from family was critically important to support mothers engaging in healthy behaviors. Similarly, Kinsey and colleagues found that women who participated in sustained PA were more likely to engage in a variety of activities and to have a supportive social network (Kinsey et al., 2019). In our study, participants noted that their family often encouraged them to try new or different activities and offered material assistance in the form of childcare and sharing household responsibilities.

Finally, participants were impacted by their rural setting. In addition to long distances and fewer available resources, moms discussed the challenge of being geographically and socially isolated from their support networks. Our findings are like previous studies of rural communities. Women in rural communities were more likely to report caregiving duties and other personal barriers to PA compared to women in non-rural communities (Wilcox et al., 2000). In addition, studies of rural communities show that different types of PA behaviors are impacted differently by built environmental elements (Frost et al., 2010) highlighting the need to better understand contextual differences of rural communites. For example, although rural living often means abundant green spaces, it also means having access to fewer community resources or opportunities for health promotion (Anderson et al., 2015; Garcia et al., 2017; Holmes & Thompson, 2019; Matthews et al., 2017; Pender et al., 2019). Moreover, rural parks are often less safe or suitable for walking compared to urban parks (Veitch et al., 2013). Rural residents were also less likely to report seeing neighbors engaging in PA (Wilcox et al., 2000) have fewer sidewalks and biking paths (Whitfield et al., 2019), and had increased risk of traffic deaths (Raymond, 2022). Our participants shared the ways in which these issues impacted their daily lives and how the physical and social environments influenced the health behaviors of rural community members.

Our study was limited by several factors. First, this study focused on caregivers who were women. Future work should include the experiences of all caregivers. Second, there is a potential for history bias as interviews occurred during the COVID-19 pandemic. Third, while our study recruited participants from multiple Wisconsin communities, our sample had higher education and income levels compared to rural Wisconsin communities. In addition, the participants in our study were all white. Although rural Wisconsin is 93.5% white (United States Census Bureau, 2019), this report does not include the experiences of mothers who are non-white which would be important to include in future studies. And, because of the nature of qualitative data, our findings are not generalizable. Rather, the experiences shared by our participants may represent the experiences of other mothers in similar contexts. Finally, it is important to acknowledge that rural communities are distinct, with each community impacted differently by determinants of health. Thus, it would be important to learn about the unique issues faced by specific rural contexts prior to the design and implementation of health promotion programs. Despite these limitations, this study provides insight into the priorities and motivators of rural-dwelling caregivers as they make health decisions for themselves and their families.

Lower PA levels negatively impact women’s health (Chomistek et al., 2018). Challenges remain in identifying effective strategies that support women in engaging in health behaviors (Global Status Report on Physical Activity 2022, 2022). These must be addressed to close the gender gaps in PA levels and the associated negative health outcomes. Moreover, rural residents are at higher risk for being physically inactive and experiencing poor health outcomes (Matthews et al., 2017). This study adds to prior research that illustrates the need for multilevel health promotion efforts addressing social determinants of health behaviors (Ball et al., 2015). This study explored the daily experiences, motivators, facilitators, and barriers faced by mothers in rural communities to better understand the context in which they make health choices. These findings have the potential to help inform future health promotion efforts.

Acknowledgement

We thank the participants who volunteered for this research study. We also thank the graduate and undergraduate student researchers who contributed to this study.

Funding:

Funding for this study was providing in part by the Virginia Horne Henry Fund for Women’s Physical Education, School of Education, UW-Madison, University of Wisconsin-Madison, Office of the Vice Chancellor for Research and Graduate Education with funding from the Wisconsin Alumni Research Foundation (WARF), and Eunice Kennedy Shriver National Institute of Child Health & Human Development, the Office of Research on Women’s Health, Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) program, the Office of The Director, National Institutes of Health and the National Cancer Institute, under Award Number K12HD101368

Funding for the Survey of the Health of Wisconsin (SHOW) was provided by the Wisconsin Partnership Program PERC Award (#AAL2297). The authors would also like to thank the University of Wisconsin Survey Center, SHOW administrative, field, and scientific staff, as well as all the SHOW participants for their contributions to this study.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health

Appendix Table 1. Saturation of themes and subthemes.

Subthemes p003 p005 p006 p007 p010 p012 p013 p014 p017 p018 p019 p020 p021 p022 p023 p025 p026
Theme 1 Prioritizing family’s needs x x x x x x x x x x x x x x x x
Making choices to be a healthy role model for their family x x x x x x x x x x x x x x x
Engaging in physical activity to be a better caregiver x x x x x x x x x x x x x x x
Impact of expectations regarding family roles x x x x x x x x x x x x x x
Moms are the primary decision maker in regarding family health decisions x x x x x x x x x x x x x
Not prioritizing their own selfcare because time with children was limited and timebound x x x x x x x x x x x x x
Intrinsic enjoyment engaging with family as motivation for physical activity x x x x x x x x x x x x x x x x
Theme 2 Difficultly finding activities for entire family x x x x x x x x x x x x
Lack of support from partners x x x x x x x x x
Desire for dedicated time to participate in exercise alone or with friends x x x x x x x x x x
Family encourages trying new or different activities x x x x x x x x x x x x x x x
Sharing responsibilities with family members x x x x x x x x x x x x x x
Support and encouragement from family x x x x x x x x x x x x x x x
Theme 3 Distance from family and social network: x x x x x x x x x x x x x
Lack of community resources x x x x x x x x x x x x x
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Footnotes

Disclosure statement

Authors have no conflicts of interest to declare.

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