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. 2026 Jan 29;62:103400. doi: 10.1016/j.pmedr.2026.103400

Rural-urban differences in perceived social and built environments and associations with physical activity among youth in the United States

Christopher D Pfledderer a,⁎, Emma J Mullane b, Denver MY Brown c, Ethan T Hunt a, Kevin Lanza d, Ashleigh Johnson e
PMCID: PMC12874348  PMID: 41657812

Abstract

Objective

To examine rural-urban differences in perceived social and built environment characteristics and assess associations with the frequency of meeting physical activity guidelines among United States youth.

Methods

We used data from the 2022-2023 National Survey of Children’s Health, a nationally representative sample of United States children and adolescents. Weighted cumulative logit models were used to determine associations between parental perceptions of social/built environments and number of days youth met physical activity guidelines, stratified by rural-urban status.

Results

The total sample included 55,551 (Representative N=41,792,444, 11.9 ± 3.5 years, 48% female) youth. Positive perceptions of neighborhood support were associated with higher odds of meeting physical activity guidelines (OR:1.43; 95% CI:1.32,1.54) as were perceptions of school safety (OR:1.29; 95% CI:1.08,1.54). Access to neighborhood amenities was associated with higher odds of meeting guidelines (OR:1.18; 95% CI:1.05,1.34). For rural youth, neighborhood support (OR:1.62; 95% CI: 1.34,1.95) and neighborhood amenities (OR:1.26; 95% CI:1.05,1.52) were positively associated with odds of meeting guidelines. For urban youth, neighborhood support (OR:1.40; 95% CI:1.29,1.53) and school safety (OR:1.31; 95% CI:1.07,1.59) were positively associated with odds of meeting guidelines.

Conclusions

Perceived social/built environmental factors are associated with youth physical activity, although associations differ by urbanicity.

Keywords: Physical Activity, Rural, Urban, Social Environment, Built Environment, Children, Adolescents

Highlights

  • •

    Positive associations between perceived environment and youth physical activity.

  • •

    Neighborhood support more strongly associated with physical activity in rural youth.

  • •

    Study underscores critical role of perceptions shaping physical activity.

1. Introduction

Physical activity is a critical component of youth health, associating with a range of physical, mental, and psychosocial benefits. Sufficient levels of moderate-to-vigorous physical activity in youth are associated with cardiovascular fitness, musculoskeletal health, body composition, and reduced risk of chronic diseases including obesity and diabetes (Anderson and Durstine, 2019; Akseer et al., 2020). Regular physical activity contributes to better mental health and well-being, as well as improved academic outcomes (Dale et al., 2019; Biddle et al., 2019; Singh et al., 2025).

Despite benefits, most United States youth fail to meet national aerobic physical activity guidelines (≥ 60 minutes moderate-to-vigorous physical activity per day) (Piercy et al., 2018). Current estimates from the United States show <25% of children and adolescents meet physical activity guidelines (Physical Activity Alliance, 2024). The prevalence of inactivity is even more pronounced among certain groups, including youth living in poverty, youth with overweight/obesity, and across the rural-urban continuum, with some studies showing the prevalence of physical inactivity higher in rural settings and others showing this in urban settings (Lohman et al., 2008; Biswas et al., 2022; Armstrong et al., 2018).

In addition to individual determinants, the environments in which youth live and play are increasingly recognized as influential factors in shaping physical activity behaviors. Guided in large part by ecological models of health (Centers for Disease Control and Prevention, 2022), researchers have identified a range of environmental attributes that can facilitate or be a barrier for youth physical activity. These include features of the built environment (e.g., sidewalks, parks, recreational facilities), the social environment (e.g., neighborhood cohesion, perceived safety, social support), and institutional environments like schools (McGrath et al., 2015; Li et al., 2025; Prince et al., 2022). Additionally, parental perceptions of these environments, including perceptions of neighborhood/school built and social environments, are known to be consistently associated with physical activity and other health behaviors/outcomes among youth (Xing et al., 2025a; D’Haese et al., 2015; Pfledderer et al., 2021).

Rural-urban status can further influence youth physical activity. Urban areas are generally characterized by greater population density and more developed infrastructure, which can provide youth with increased access to parks, playgrounds, sidewalks, and public transit (Veitch et al., 2013). However, urban settings may also present barriers to physical activity, such as higher crime rates, traffic congestion, and perceptions of poorer safety (Addas, 2025). Rural areas often benefit from strong social cohesion and greater open space but typically lack formal physical activity infrastructure such as community recreation centers, safe walking paths, and a wide variety of sports programming (Müller et al., 2024; Pelletier et al., 2022). Rural youth may also face transportation barriers and reduced access to school-based or after-school physical activity opportunities. Additionally, socioeconomic disadvantages are pronounced in many rural regions, which may further prohibit access to safe, supportive environments for activity (Weeks et al., 2023; Lu et al., 2022).

Despite these differences, few studies have examined how parental perceptions of their social and built environments differ between rural and urban settings and how perceptions relate to physical activity among youth. Most research has focused on urban populations or has not adequately disaggregated data by urbanicity when identifying social and built environmental influences on physical activity. There remains a limited understanding of how social and built environmental perceptions interact with geographic context to influence youth physical activity.

Our study seeks to address these gaps by using nationally representative United States data from the 2022-2023 National Survey of Children’s Health to (1) describe rural-urban differences in parental perceptions of neighborhood support, safety, amenities, detracting elements, and school safety; (2) assess the associations between these environmental perceptions and the number of days youth meet physical activity guidelines; and (3) evaluate whether these associations differ by rural-urban status.

2. Methods

2.1. Study design and population

This cross-sectional study used data from the 2022 and 2023 National Survey of Children’s Health, a nationally representative household survey sponsored by the United States Health Resources and Services Administration’s Maternal and Child Health Bureau. The National Survey of Children’s Health collects information on the health of children and adolescents ages 0-17 years. The survey is administered annually via web- and paper-based questionnaires and is designed to be representative of the non-institutionalized pediatric population in all 50 states and the District of Columbia (Data Resource Center for Child and Adolescent Health, 2024). Initially, respondents are sent a screener survey to indicate if one or more children live in their household. If yes, respondents are sent the main topical survey for a randomly selected child in that household. Approximately 375,000 households were screened for age-eligible children. Survey respondents were 89% biological/adopted parents, 6% were grandparents, the remaining were step/foster parents, and 69% of all respondents were female. Additional information on survey methodology/sampling design, and non-response bias analyses can be found at the Data Resource Center for Child and Adolescent Health website. For this analysis, we restricted the sample to youth aged 6 to 17 years, consistent with national physical activity guidelines for this age group. Exclusion criteria included children who were less than 6 years old and those who did not have complete data for each of the measures below. All procedures were approved by the National Center for Health Statistics Ethics Review Board (Protocol #2021-05).

2.2. Measures

Physical activity was assessed via a parent-reported item: “During the past week, on how many days did the child exercise, play a sport, or participate in physical activity for at least 60 minutes of physical activity?” Responses ranged from 0 days, 1-3 days, 4-6 days, and 7 days (daily). We examined five domains of perceived social and built environments, based on National Survey of Children’s Health items, the socioecological model, and previous literature supporting associations between these domains and youth physical activity (Centers for Disease Control and Prevention, 2022; McGrath et al., 2015; Li et al., 2025; Prince et al., 2022; Xing et al., 2025a; D’Haese et al., 2015; Pfledderer et al., 2021). For neighborhood support, Parents were asked whether people in the neighborhood help each other, watch out for each other’s children, and know where to go for help. Responses to each of these questions were “definitely agree”, “somewhat agree”, “somewhat disagree”, or “definitely disagree”. The National Survey of Children’s Health included a composite measure of neighborhood support based on responses which is dichotomized as “supportive” vs. “not supportive”. To be in the “supportive category, parents had to report “definitely agree” to at least one of the three items and “somewhat agree” or “definitely agree” to the other two items. For neighborhood safety, parents reported how strongly they agreed with the statement: “Does the child live in a safe neighborhood?”. Responses were categorized by the National Survey of Children’s Health as “definitely agree”, “somewhat agree”, or “somewhat/definitely disagree”. Neighborhood amenities were assessed based on the parent-reported presence of sidewalks or walking paths, parks or playgrounds, recreation centers, community centers, or boys’ and girls’ club, and libraries or bookmobiles. A count variable (0-4) was created by the National Survey of Children’s Health and categorized into “none,” “one,” “two,” “three,” or “all four”. For detracting elements, parents indicated whether the neighborhood had litter or garbage, poorly kept or rundown housing, or vandalism such as broken windows and graffiti. Responses were summed by the National Survey of Children’s Health and categorized into four levels: none, one, two, or three detractors. For school safety, parents reported how strongly they agreed with the statement: “Is this child safe at school?”. Responses were categorized as “definitely agree”, “somewhat agree”, or “somewhat/definitely disagree”.

Urban versus rural classification was determined using Metropolitan Statistical Area designations in the dataset. An urban county (or core-based statistical area) is defined as a county with at least one urbanized area with a population of at least 50,000, and a rural county as any county that does not have a core-based statistical area of at least 50,000 (U.S. Census Bureau, 2023). Children were classified as living in a rural area if they resided outside a designated Metropolitan Statistical Area.

We included covariates known to be associated with physical activity and social/built environment perceptions, including age (continuous), sex (male, female), race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Asian, other/multiracial), Body Mass Index category (based on percentiles: <5th, 5th to <85th, 85th to <95th, ≥95th percentile) (CDC, 2023), and Federal Poverty Level (categorized as <100%, 100-199%, 200-399%, ≥400%) (Sterdt et al., 2014).

2.3. Statistical analysis

All analyses accounted for the complex survey design of the National Survey of Children’s Health with sampling weights, strata, and primary sampling units and utilized Taylor Series Linearization variance estimation. Descriptive statistics were computed to compare demographic and environmental characteristics and physical activity levels between rural and urban youth, with weighted chi-square tests used for categorical variables and t-tests for age, which was treated as a continuous variable. To assess associations between social and built environment perceptions and the number of days with ≥60 minutes of physical activity, we employed cumulative logit models. Initial models were conducted for the full sample, adjusting for all covariates. We then estimated separate models stratified by rural and urban status to examine potential differences in associations by geographic context. Adjusted Odds Ratios (ORs) and 95% Confidence Intervals (95% CIs) were reported for all models. Sensitivity analyses, in the form of statistical comparisons between the full and analytic samples were conducted for key demographic variables including age, sex, race/ethnicity, Body Mass Index category, and Federal Poverty Level. A type I error level of 0.05 was used to establish statistical significance, All analyses were conducted using Stata v18.0 (StataCorp LP, College Station, Texas, USA).

3. Results

The final sample included 55,551 (Weighted N=41,792,444) children and adolescents (11.9 ± 3.5 years, 48% female, 47% Non-Hispanic White, 12% rural) after excluding records with missing data on physical activity and environmental perception variables (missing n=10,263). Briefly, a higher proportion of rural youth were non-Hispanic White (67% vs. 44%), were from lower-income households (22% vs. 18% at <100% Federal Poverty Level), and a higher proportion had overweight/obesity (21% vs. 16%), compared to youth living in urban areas (Table 1). Sensitivity analyses revealed no significant differences between those included and excluded from the analytical sample with respect to age, sex, and Body Mass Index (p>0.05). Significant differences were found for race/ethnicity and Federal Poverty Level between the full and analytic sample (p<0.05), although distribution percentage differences were minimal. The largest weighted difference between those included and excluded from the analytical sample for race/ethnicity was 1.3% in the “White, non-Hispanic” category and for Federal Poverty Level it was 1.7% in the “100-199%” category.

Table 1.

Demographic characteristics presented as unweighted counts and weighted prevalence for the total sample and for youth living in urban and rural areas separately.

Demographic Characteristics Total Sample
N = 55,551
Weighted N = 41,792,444
 Urban
N=48,696
Weighted N = 36,635,256
 Rural
N=6,855
Weighted N = 5,157,188
 p-value⁎
Unweighted Count Weighted Prevalence (%) Unweighted Count Weighted Prevalence (%) Unweighted Count Weighted Prevalence (%)
Age (Years), Mean, Standard Deviation 11.9 3.5 11.9 3.5 12.0 3.5 0.23
Sex (Female) 27,109 48.8 22,353 48.9 4,770 48.4 0.61
Race/Ethnicity <0.01
Hispanic 15,110 27.2 13,392 29.3 1,489 15.1
White, Non-Hispanic 26,276 47.3 20,196 44.2 6,693 67.9
Black, Non-Hispanic 7,333 13.2 6,263 13.7 876 8.9
Asian, Non-Hispanic 2,778 5.0 2,512 5.5 108 1.1
Other/Multi-Racial, Non-Hispanic 4,055 7.3 3,288 7.2 701 7.1
Federal Poverty Level Status <0.01
0-99% Federal Poverty Level 10,166 18.3 8,225 18.0 2,209 22.4
100-199% Federal Poverty Level 10,991 19.8 8,776 19.2 2,544 25.8
200-399% Federal Poverty Level 16,164 29.1 13,206 28.9 3,193 32.4
≥ 400% Federal Poverty Level 18,278 32.9 15,536 34.0 1,912 19.4
Body Mass Index Percentile <0.01
< 5th percentile 4,944 8.9 4,203 9.2 670 6.8
5th-85th percentile 32,775 59.0 27,115 59.3 5,452 55.3
85th-95th percentile 8,438 15.2 6,809 14.9 1,666 16.9
95th percentile or greater 9,444 17.0 7,586 16.6 2,070 21.0
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⁎

Indicates statistical differences between urban and rural youth calculated via weighted chi-square tests

3.1. Physical activity by rural-urban status

Less than 20% of youth met daily physical activity guidelines. A significantly higher portion of rural youth met guidelines every day compared to urban youth (25% vs. 18%, p<0.01) (Fig. 1).

Fig. 1.

Fig. 1

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Rural-urban differences in days meeting physical activity guidelines and perceived social and built environment characteristics (National Survey of Children’s Health, 2022-2023, N=55,551, Weighted N =41,792,444)

3.2. Perceived built and social environment differences across rural-urban status

Parents living in rural areas reported significantly greater neighborhood support (60% vs. 55%, p<0.01) and perceived safety (72% vs. 65%, p<0.01) than urban youth (Fig. 1). However, rural neighborhoods had fewer amenities, with only 22% of rural parents reporting access to all four amenities, compared to 39.9% of urban parents. School safety perceptions were also higher among rural respondents (70% vs. 65%, p<0.01).

3.3. Associations between perceived built and social environment with physical activity

Positive perceptions of neighborhood support were significantly associated with higher odds of youth meeting physical activity guidelines (OR: 1.43; 95% CI: 1.32,1.54) as was perceptions of school safety (OR: 1.29; 95% CI: 1.08,1.54) (Fig. 2). Parent reported access to all four neighborhood amenities was associated with higher odds of youth meeting physical activity guidelines compared to those that reported access to fewer amenities (OR: 1.18; 95% CI: 1.05,1.34).

Fig. 2.

Fig. 2

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Weighted cumulative logit model estimates for perceived neighborhood support, neighborhood safety, neighborhood amenities, neighborhood detracting elements, and school safety predicting days meeting physical activity guidelines.

3.4. Rural-urban stratification

For rural youth, parental perceptions of both neighborhood support (OR: 1.62; 95% CI: 1.34,1.95) and neighborhood amenities (OR: 1.26; 95% CI: 1.05,1.52) were positively associated with odds of youth meeting physical activity guidelines (Fig. 2). For urban youth, parental perceptions of neighborhood support (OR: 1.40; 95% CI: 1.29,1.53) and school safety (OR: 1.31; 95% CI: 1.07,1.59) were positively associated with odds of youth meeting guidelines. All other associations did not reach statistical significance.

4. Discussion

In this nationally representative United States study, we examined how parental perceptions of social and built environments vary by rural-urban status and how these perceptions influence adherence to physical activity guidelines among youth. Our findings revealed significant associations between perceptions, such as neighborhood support, school safety, and the presence of amenities, and meeting physical activity guidelines among youth in both rural and urban environments. Importantly, when stratified, these associations differed between those living in rural and urban environments, highlighting the distinct ways in which perceptions of the social and built environment influence behavior across geographic contexts.

Perceptions of neighborhood support were positively associated with physical activity. This finding aligns with a recent systematic review examining parental perceptions of neighborhood environments and youth physical activity, which identified neighborhood cohesion and social support as consistent facilitators of children's physical activity across diverse contexts (Xing et al., 2025b). This association held for the total sample and for those living in both rural and urban environments. However, the magnitude of the association was greater for youth in rural settings compared to urban settings, suggesting that neighborhood support, cohesion, and social capital may play an especially critical role in fostering physical activity in rural areas where built environment infrastructure is limited. This pattern is consistent with another review of built environments and active living in rural areas (Hansen et al., 2015), which emphasized that strong social cohesion and community networks in rural settings can compensate for limited formal recreational infrastructure. Our findings suggest in rural communities, interventions aimed at strengthening neighborhood social cohesion/support may be particularly effective strategies for promoting youth physical activity, potentially offsetting physical activity resource constraints.

The number of parent-reported neighborhood amenities was also a significant predictor of physical activity among youth. However, our findings revealed a nuanced relationship between amenities, physical activity, and rural-urban status. First, a significant relationship between neighborhood amenities and physical activity was only found for those reporting the presence of all four amenities, which included sidewalks or walking paths, parks or playgrounds, recreation centers, and libraries. The presence of one, two, and even three of these amenities was not significantly associated with physical activity, suggesting built environment features may not work individually to beneficially influence health behavior, but that a holistic approach which offers multiple forms of amenities is most important for physical activity promotion efforts. This "threshold effect" builds on prior research which found that individual built-environment attributes showed modest associations with physical activity, and suggests that multiple complementary amenities may be necessary to create an environment that sufficiently supports and encourages regular physical activity (McGrath et al., 2015).

Second, the association between neighborhood amenities and physical activity was only significant for the total sample and for those living in rural environments, which suggests that the availability, or lack of, such resources may play a more critical role in rural settings, where alternatives such as organized sports facilities or safe pedestrian infrastructure may be limited. In contrast, the absence of a significant association in urban settings could reflect the greater diversity and density of opportunities for physical activity, which may mitigate the relative importance of any single amenity or small group of amenities. The differences in the number of reported amenities between rural and urban areas, with parents from rural areas reporting fewer amenities than those from urban areas, further underscores this nuance. Rural areas often face challenges related to infrastructure, funding, and geographic dispersion, which may limit the development and maintenance of recreational facilities (Umstattd Meyer et al., 2025). It is also possible that the types of amenities valued or utilized by youth differ by rural-urban status.

Nonetheless, a higher prevalence of rural youth met physical activity guidelines every day, although the prevalence of overweight/obesity was higher among rural youth compared to urban youth. This somewhat counterintuitive finding may be explained by compensatory mechanisms such as stronger social cohesion, greater use of informal or natural play spaces, and differences in parental supervision or cultural norms around outdoor play and physical activity (Beck et al., 2024). It also emphasizes the importance of not assuming lower physical access equates to inactivity without considering contextual factors. Finally, it is possible that the types of amenities valued or utilized by youth differ by rural-urban status, a nuance that warrants further investigation in future research.

Parental perceptions of school safety were significantly associated with physical activity in the total sample and among urban participants, but not among rural participants. The significant association found in the total and urban samples aligns with prior research indicating that perceived safety, particularly in the school environment, can be a critical determinant of children's ability and freedom to engage in physical activity (Addas, 2025; Son and Kim, 2024; Galaviz et al., 2016).

The absence of significant associations between perceptions of school safety and physical activity in the rural subsample may reflect a differing sociocultural or environmental context. Interestingly, descriptive analyses revealed that a greater proportion of rural parents perceived their children's school environment as safe compared to urban parents. The elevated perception of school safety in rural areas may have reduced variability, potentially attenuating predictive power in statistical models. Furthermore, rural youth may encounter different barriers to physical activity, such as limited access to facilities, greater distances to organized activity venues, or fewer structured opportunities within schools, that mask the influence of parental safety perceptions on physical activity (Pelletier et al., 2021; Hudson et al., 2025). These findings highlight the importance of contextualizing health behavior interventions and policies. In urban settings, efforts to enhance school safety, whether through policy, infrastructure, or community engagement, may have downstream benefits for increasing physical activity. In rural areas, strategies may need to shift focus toward improving access and opportunity, rather than altering perceptions of school safety.

The cross-sectional design prevents determination of causality. All measures, including physical activity and perceptions, were reported by parents and may be subject to recall or social desirability bias. Further, the physical activity variable does not contain contextual information, is likely to represent leisure-time, and may not include physical activity accrued during active commuting or school. Objective measures of environment (e.g., Geographic Information System data, audits) were not available, limiting our ability to validate perceptions against actual environmental features. Also, urbanicity was classified based on Metropolitan Statistical Area status, which may not capture the full complexity of rural-urban gradients (e.g., suburban or peri-urban areas). Relatedly, this definition is based on county-level data, which is in contrast to the neighborhood-level context for the parental perceptions of environment.

5. Conclusion

This study underscores the critical role of environmental perceptions in shaping physical actvity behaviors among youth in the United States and highlights key differences between rural and urban populations. Tailoring interventions to the unique environmental and social contexts of different communities may be essential to improving youth physical activity and addressing geographic and health disparities nationwide.

Author contribution

CDP conceived the study, carried out formal analyses and data management, prepared visualizations, and drafted and finalized the manuscript; EJM carried out formal analyses and data management, prepared tables and figures, and drafted and edited the manuscript; DMYB drafted and edited the manuscript and carried out formal analysis; ETH conceived the study and drafted and edited the manuscript; KL conceived the study, drafted and edited the manuscript; AJ conceived the study and drafted and edited the manuscript; All authors have read and approved the final version of the manuscript and agree with the order of presentation of the authors.

CRediT authorship contribution statement

Christopher D. Pfledderer: Writing – review & editing, Writing – original draft, Visualization, Project administration, Investigation, Formal analysis, Conceptualization. Emma J. Mullane: Writing – review & editing, Writing – original draft, Visualization, Formal analysis. Denver M.Y. Brown: Writing – review & editing, Writing – original draft, Investigation, Conceptualization. Ethan T. Hunt: Writing – review & editing, Writing – original draft, Conceptualization. Kevin Lanza: Writing – review & editing, Writing – original draft, Investigation, Conceptualization. Ashleigh Johnson: Writing – review & editing, Writing – original draft, Investigation, Conceptualization.

Ethics approval and consent to participate

The United States Census Bureau conducts the NSCH on behalf of HHS under Title 13, United States Code, Section (b), which allows the Census Bureau to conduct surveys on behalf of other agencies. Title 42 U.S.C. Section 701(a)(2) allows HHS to collect information for the purpose of understanding the health and well-being of children in the U.S.

Funding

Data Resource Center for Child and Adolescent Health supported by Cooperative Agreement U59MC27866 from the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB).

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability

Data is publicly available and the source has been cited in the manuscript

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