When taking part in standard physical activity interventions, adults with obesity may face specific challenges due to excess body weight and may not be as successful as individuals with lower BMI [17, 32]. Furthermore, these difficulties may be exacerbated for those living in rural areas as a result of environmental barriers (e.g., limited space/facilities for physical activity), potentially contributing to the worsening of rural health disparities. No reviews have identified physical activity barriers, facilitators and preferences among rural adults with obesity. Thus, we conducted a scoping review of the current research on the physical activity-related needs of this population (e.g., social support, integration of activity monitors) and identified future directions for intervention research (e.g., applying a mixed methods strategy to better understand physical activity preferences).

Overall, barriers were the most investigated and reported factor for physical activity. Our findings show the primary physical activity barriers were environmental factors and a lack of time. There are consistencies and differences with a previous review and study focused on adults with obesity or rural dwelling adults [18, 19]. Our findings are similar to the findings from a recent systematic conducted by Baillot et al. among adults with obesity, which found pain or physical discomfort, lack of time, and lack of self-discipline/motivation, as the three most reported barriers to physical activity [18]. Seguin and colleagues reported social norms, limited time, and distance from or lack of facilities as top barriers among mostly rural adults with overweight or obesity, who considered themselves as active or very active [19]. When identifying differences in barriers by obesity class, we found that lack of self-discipline was a consistent barrier across all classes of obesity. No differences were found across obesity classes I-III, with a pattern of similar self-reported ecological, psychosocial, and physical difficulties [33]. Regarding the difference in barriers by obesity class, the findings from this review are inconclusive, highlighting an understudied area needing further examination.

We found that the most frequently reported physical activity facilitators were the use of activity monitors (e.g., Fitbit) and social interaction/being part of a group. Participants stated that the monitors improved awareness of their activity level [26]. These participants also found the feedback from the monitors to be helpful [27], and the monitors were easy to use [26, 27]. Increases in physical activity among non-rural populations including older adults and adults with medical conditions (e.g., type 2 diabetes and musculoskeletal diseases) [34,35,36,37] and overweight and obesity, following participation in interventions using activity monitors for self-monitoring have been documented [38]. Such devices could enable individuals in rural communities with limited resources and amenities (e.g., recreational facilities), to independently track and be accountable for their physical activity.

While weight loss was not a primary facilitator in our review, it is notable that rural-dwelling African American women reported it as a motivator in one study [25]. Previous studies emphasize the importance of considering cultural norms [25] and unmet weight loss expectations [39] when aiming to increase motivation for exercise/physical activity. Therefore, prioritizing weight loss as the primary target of physical activity interventions is not recommended [40]. Instead, it is recommended to consider culturally-tailored physical activity interventions.

Our findings related to social interaction align with findings from a recent systematic review focused on adults with obesity [18] and a study among rural residing adults with overweight and obesity [19]. The findings from these articles highlight social support [18, 19], in addition to weight management [18], energy/physical fitness [18], and accessible and affordable fitness facilities as primary facilitators for physical activity [19]. We hypothesize that the social interaction motivation aspect is related to the lack of social support, a top barrier identified in our review. Social support is a multifaceted construct that has been found to be a key facilitator and determinant for physical activity adherence across adult populations underscoring its importance in intervention strategies [41,42,43].

Consistent with the Baillot et al. systematic review among adults with obesity [18], there were limited findings for physical activity preferences. Only one study included in this review reported intervention delivery preferences that were associated with individual characteristics (e.g., rurality, obesity) [28]. Results from the Baillot et al. review also showed variance in physical activity type, context and delivery preferences, across their included studies. Results indicated walking, water aerobics, cycling, swimming and rowing, dance or Zumba, and martial arts as the preferred physical activity types, with resistance training being less preferred by adults with obesity [18]. For context, there was preference for low- or no-cost physical activity interventions not solely focused on activity/exercise, structured routine. However, there was variation in social preferences with some participants preferring activities that could be done alone, and others favoring activities with people of similar ages and sex [18]. Given the overlapped focus on adults with obesity, our findings regarding preferences align closely with those of the review conducted by Short et al., which was included in both reviews [28]. Similar to social interaction/being part of a group facilitating physical activity reported earlier, we believe this preference for group interaction may be influenced by motivation from others [44]. Future research should explore the potential influence of the social interaction that occurs during sports and dance classes at local facilities on preferences for exercise location.

This review provides insights on the commonly reported physical activity barriers and facilitators cited by rural adults with obesity, an underserved, high-risk population in need of effective physical activity interventions. These findings have implications for healthcare professionals, researchers, and policy makers and local leaders. It is important that healthcare providers are cognizant of the barriers that individuals frequently encounter when recommending that their patients increase their physical activity. As for researchers, understanding the barriers and facilitators is key when designing future interventions for rural adult populations with obesity. Our findings regarding environmental barriers including the lack of sidewalks and bike lanes are applicable to policy makers and local leaders in rural communities. The existing policies that require or suggest walkways or bikeways in new public infrastructure projects to accommodate pedestrians [45], is inconsistently implemented in rural regions which warrants attention [46,47,48].

Although the American Heart Association (AHA)/American College of Cardiology (ACC)/ Obesity Society (TOS) has existing guidelines recommending that primary care practitioners evaluate and manage overweight and obesity in their patients [49], several challenges hinder effective treatment in rural areas. Limited healthcare access [50], health insurance challenges [51], low reimbursement rates [52], lack of specialized training in obesity medicine [53] makes it difficult to address obesity. Additionally, providers often fail to provide a diagnosis of obesity [54, 55] and even when a diagnosis is made, the limitations in specialized services [56] such as nutritionists, weight management professionals and obesity prevention programs can hinder necessary counselling and support. These limitations can impact the barriers, facilitators and preferences for physical activity among rural adult populations, particularly those with obesity. For instance, limited access to resources such as weight management professionals can lead to a lack of awareness about the importance of physical activity in relation to obesity creating a barrier to physical activity participation.

In response to these challenges in rural areas, the National Rural Health Association Rural Obesity and Chronic Disease Initiative Task Force has emphasized the need for state and national policies to include rural-specific programming ensuring that rural residents have access to obesity prevention and treatment services [54]. Recommended actions to support these initiatives consist of reintroducing the Halt Obesity in America Act, allowing rural residents to receive preventative obesity care, and the Improving Social Determinants of Health Act which mandates the Centers for Disease Control and Prevention (CDC) to establish a program aimed at improving health outcomes and reduce health inequities [54].

We were not able to draw conclusions related to physical activity preferences as only one included study reported on this aspect. Future research directions consist of assessing preferences (e.g., program type, duration, and time of day) [15] using mixed methods approaches as a qualitative approach would shed light on these preferences in addition to why certain aspects such as face-to-face interventions are preferred by some, but not others. This understanding would guide the development and design of future physical activity interventions.

Despite the existing definition and classification of ‘rural’ in the U.S [57]., there is no wide-spread agreement on what constitutes rural [58]. For instance, in Australia, ‘rural and remote’ comprises all areas beyond major cities [59] whereas in Nepal, rural areas are ‘small-tight knit communities” lacking amenities and resources [60]. Even with an established definition and classification of rural in the U.S., rural areas within the US are heterogenous in many aspects (e.g., demographics, built environment, resources) [46,47,48] and the rural regions within other countries differ as well. Though most of the studies were conducted in the US, four were completed among adults residing in rural regions within Australia, Nepal, and Mexico. Given the heterogeneity across the countries in terms of demographics, built environment, resources, this introduces complexity for future research and physical activity programming, particularly in countries outside of the US. No themes or conclusions could be generated on barriers, facilitators, or preferences as each of the included studies from other countries provided findings for one category. Specifically, the study conducted in Mexico examined barriers [31], while the two studies from Australia focused on preferences [28], and barriers [29], and the study undertaken in Nepal delved into facilitators [30].

This review is the first to identify barriers, facilitators, and preferences for physical activity among rural adult populations with obesity. Also, this review integrates qualitative and quantitative literature, allowing insights from interviews to complement numerical data. Interestingly, the representation of men was higher in comparison to previous obesity-focused reviews [18, 61]. However, there are limitations to note. Multiple articles were omitted as they were published in a language other than English. Participant characteristics were inconsistently reported; for example, information on prevalence of obesity, comorbidities, and average BMI, were not provided in some articles. This lack of detailed reporting hinders accurate representation of participants and applicability to the broader population. Most studies included in our review did not provide sufficient detail to differentiate barriers and facilitators specific to obesity versus coexisting comorbidities (e.g., diabetes, ischemic heart disease). While this limitation does not dimmish the value of our results – since obesity rarely occurs in isolation – it highlights the need for additional research to better tailor programs for individuals with both obesity and coexisting medical conditions.