Introduction

Increasing the prevalence of meeting the physical activity guidelines (PAGs) is vital for public health [1]. Despite population-level increases in meeting the aerobic, muscle strengthening, and combined PAGs, and corresponding decreases in inactivity over the last quarter century among adults in the United States (US) [2,3], there remain pernicious disparities by sociodemographic characteristics, region, sex, and urbanicity/rurality [3–7].

Population-level physical activity (PA) promotion should be targeted to the activities people prefer [8], what they have – or could have – access to [9], and what is culturally appropriate [10–14], safe [15], enjoyable [16]. and effective (i.e., likelihood the activity will help people meet PAGs) [17,18]. Similar to the frequency, intensity, time, and type (FITT) principle of individual-level exercise prescription [19]. population surveillance documenting the prevalence of meeting PAGs (i.e., the frequency, intensity, time) would benefit from greater understanding of the type of activities people engage in to meet PAGs. This information would provide valuable insight into what is popular for population subgroups and what types of activities are associated with meeting the PAGs. For example, people who cycle during their leisure time are more likely to meet PAGs, yet rural adults are less likely to cycle [20]. Thus, before promoting cycling to meet PAGs in a rural setting, factors such as the expense of owning a bicycle, and lack of a supportive physical and cultural environment may need to be addressed.

It is also particularly important to target population-level PA promotion in areas and among demographic groups with persistently low rates of leisure-time physical activity (LTPA) [1]. In the US, rural-residing adults have lagged behind adults in urban areas in the prevalence of meeting the aerobic, muscle strengthening, and combined PAGs for decades [4,5,7]. Specific to rural areas, the prevalence of meeting the combined PAGs is lower among women, older adults, individuals who did not attend college, individuals of Hispanic ethnicity, and individuals living in the US South [4].

Little is known about US adults’ preferred types of LTPA [8], especially those residing in rural areas. The most recent research on LTPA type preferences, using 2011 Behavior Risk Factor Surveillance System (BRFSS) data, showed walking was the most popular LTPA among US adults, with differences by age and sex [8]. Women were more likely to engage in walking than men (especially those under 65 years old) and dancing/aerobics activities across all ages; men were more likely to engage in higher intensity activities (i.e., sports, bicycling, running/jogging) across all age groups [8]. These results are concordant with analyses of NHANES data from the 2003−04 and 2005−06 data collection cycles, which found walking was by far the most popular LTPA, though engaged in at a level, on average, below what is necessary to meet PAGs [17]. Importantly, this body of literature has not been updated since the revision of the PAGs in 2018; nor has it included muscle strengthening activities. To address these needs, the objective of this study was to identify rural/urban differences in the prevalence of specific types of LTPA, the prevalence of meeting PAGs, and the relationship between LTPA types and meeting PAGs among US adults.

Methods

This study utilized de-identified data from the 2019 BRFSS public-use dataset, downloaded on August 20, 2024. The BRFSS is a collaborative project of the Centers for Disease Control and Prevention (CDC) with the 50 states, the District of Columbia, and 3 US territories. Utilizing telephone surveys of the noninstitutionalized adult population (18 years and older) within the US, the focus of the BRFSS is to measure health-related risk behaviors, chronic health conditions, and preventive services [21].

Results

Information about the 2019 BRFSS participants and population-weighted analytical comparisons of metropolitan and non-metropolitan participants are displayed in Table 1. Analyses revealed significant demographic differences between metropolitan and non-metropolitan populations. Non-metropolitan populations tended to be older, less racially/ethnically diverse, less likely to have earned a 4-year college degree, have a lower income, have fair or poor perceived health, and have obesity (all p < .0001).

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Table 1. Selected Participant Characteristics and Population-weighted Comparisons by Metropolitan Status: 2019 BRFSS.

https://doi.org/10.1371/journal.pone.0345026.t001

LTPA Types by metropolitan status

The age-adjusted prevalence of all LTPA types, categories of LTPA types, and comparisons by metropolitan status are shown in Table 2 (categories ordered from highest to lowest prevalence). The most popular LTPAs were walking (44.1%, 95% CI = 43.8-44.4%), running (11.7%, 95% CI = 11.5-11.9%), weightlifting (10.7%, 95% CI = 10.4-10.9%), gardening (5.8%, 95% CI = 5.7-6.0%), and bicycling (3.8%, 95% CI = 3.7-4.0%). Of these, only gardening was more prevalent among residents of non-metropolitan (6.9%) than metropolitan (5.7%) areas; the others were more prevalent among metropolitan residents. Nearly one-tenth of respondents reported “other activity” (9.3%; 95% CI = 9.1-9.5%).

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Table 2. Age-Adjusted Rates of Adults Participating in Specific Leisure-Time Physical Activities by Metropolitan Status – 2019 BRFSS.

https://doi.org/10.1371/journal.pone.0345026.t002

Table 2 also displays the metropolitan and non-metropolitan comparison of LTPAs when condensed to the 11 activity categories. Differences demonstrated by these analyses include significantly higher participation in lawn/garden, hunting/fishing, and winter activities in non-metropolitan residents than metropolitan residents; and significantly higher participation in walking, running/jogging, weightlifting, conditioning, sports, dance, and water activities by metropolitan residents.

Prevalence of meeting PAGs by metropolitan status

Metropolitan and non-metropolitan residents differed in the prevalence of meeting the aerobic and muscle strengthening PAGs. In the fully adjusted models displayed in Table 3, residents of non-metropolitan counties were 6% less likely to meet the aerobic PAG (AOR = 0.94; 95% CI 0.91-0.97) and 8% less likely to meet the muscle-strengthening activity guideline (AOR = 0.92; 95% CI 0.89-0.96) than metropolitan residents.

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Table 3. Adjusted and Weighted Proportion* of Adults Meeting the Leisure-Time Aerobic, Muscle Strengthening, and Combined Physical Activity Guidelines by Metropolitan Residential Status – 2019 BRFSS.

https://doi.org/10.1371/journal.pone.0345026.t003

Metropolitan and non-metropolitan residents also differed in the prevalence of meeting the 4-level high aerobic- and combined PAG measures. Non-metropolitan residents were 11% more likely to be inactive than metropolitan residents (29.9% versus 26.9%, respectively) and 3% more likely to meet the highly active PAG than metropolitan residents (33.9% versus 32.8%, respectively). Non-metropolitan residents were 5% less likely to meet the combined PAGs than metropolitan residents (22.6% versus 23.9%, respectively) and 5% more likely to meet neither PAG than metropolitan residents (37.2% versus 35.3%, respectively).

Prevalence of meeting the combined PAGs by LTPA category and metropolitan status

Displayed in Table 4 are the prevalence rates of meeting the combined PAGs by PA category compared by metropolitan residential status. Individuals who engaged in running/jogging, weightlifting, conditioning, other PA, and dancing had the highest rates of meeting the combined PAGs (all ≥ 44.9%). The lowest rates of meeting the combined PAGs regardless of residential status were achieved by those who engaged in walking, lawn/garden, fishing/hunting, and winter activities (all ≤ 32.4%). The highest rates of not meeting either PAG were witnessed in those who engaged in walking (22.7% in metropolitan and 23.2% in non-metropolitan residents).

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Table 4. Age-Adjusted Prevalence of Meeting the Combined-, Aerobic Only, Muscle Strengthening Only, and Neither Physical Activity Guideline in Leisure-Time by Physical Activity Category and Metropolitan Residential Status – 2019 BRFSS.

https://doi.org/10.1371/journal.pone.0345026.t004

There were significant differences in meeting the combined PAGs by metropolitan status for only 2 categories of activities: weightlifting and other PA. Among the respondents who engaged in weightlifting (10.7%), non-metropolitan residents (7.3%; 95% CI = 6.1-8.4%) had lower prevalence of not meeting either PAG than metropolitan residents (9.3%; 95% CI = 8.6-10.0%). Among the respondents who engaged in other PA (9.3%), non-metropolitan residents had greater prevalence of meeting only the aerobic PAG (36.9%; 95% CI = 35.0-38.9%) than metropolitan residents (31.8%; 95% CI = 30.6-33.0%).

Discussion

The most prevalent types of LTPA in these analyses of 2019 BRFSS data were similar to those of US adults in the 2011 BRFSS data [8] and older NHANES data [17,18]. That is, walking continues to be the most common LTPA at roughly 45% participation, with a wide margin between walking and the next most common groups of activities: running/jogging, weightlifting, conditioning exercises, and lawn/garden activities. Notably, our analyses indicate the LTPAs most prevalent among non-metropolitan (i.e., rural) residents are activities with a utilitarian purpose, including gardening, yard work, household activities, farm/ranch work, childcare, hunting, fishing, and snow shoveling. Except for childcare and household activities, these are also seasonal activities dependent on the natural environment and weather. Conversely, the LTPAs less prevalent among rural residents are higher intensity activities with a health and fitness focus (e.g., running, conditioning exercises, sports, weightlifting) that are reliant on the built environment (e.g., sports fields/courts, fitness centers) and additional resources (e.g., fitness instructors, sports league directors, parks and recreation staff) that may be limited or lacking in rural areas of the US [28,29].

Differences in the type and amount of LTPA engaged in by rural adults relative to urban adults may be a result of several sociocultural factors specific to rural areas of the US that constrain how leisure time is used and the availability of leisure time for PA. First, rural culture values adults’ use of leisure time for additional manual labor or purposeful activities (e.g., farming, household maintenance) but not PA for the purpose of improving health [10]. Second, rural workers are more likely to be employed in occupations requiring manual labor and/or non-traditional work hours [30]. Consequently, survey research among samples of rural US adults have found tiredness as a common barrier to PA among rural men [31] and occupational PA as the primary PA domain linked to meeting PAGs with recreational PA (i.e., LTPA) being quite low [32]. However, recent research suggests that high amounts of occupational PA are negatively associated with cardiovascular health [33,34], highlighting the need for greater emphasis on increasing LTPA. Third, the available time for leisure may also be constrained by higher rates of poverty [35], a point supported by research in urban areas showing that the provision of a guaranteed income alleviates time scarcity, anxiety, and poor health associated with income scarcity [36]. Finally, family and caregiving obligations are additional barriers for rural adults, especially women [37], further constraining the availability of leisure time for PA. These mechanisms are worth exploring in future descriptive and/or intervention research.

Our findings that rural (i.e., non-metropolitan) adults had a significantly higher prevalence of meeting the high aerobic PAG is novel, though minimally significant, and worth reassessing in 2023 BRFSS and future analyses of surveillance data. If replicated, it will be important to identify what LTPAs the high active group engages in and whether that group also meets the muscle-strengthening PAG. Consistent with extant literature, rural adults are more likely to be sedentary and less likely to meet aerobic, muscle strengthening, and combined PAGs [4,7]. Additionally, with the increased emphasis to “move more and sit less” in the 2018 Physical Activity Guidelines for Americans [1], it is worth highlighting that urban (i.e., metropolitan) adults have a higher prevalence of being insufficiently active (1–149 minutes MVPA/week) and meeting the minimal activity threshold (150–299 minutes MVPA/week). Exact PAG prevalence rates should be compared with caution to previous research using pre-2019 NHIS data because of differences in analytic approaches and survey prompts (i.e., NHIS asked respondents to report only activities engaged in “at least 10 minutes at a time,” whereas BRFSS excludes activities of <10 minutes in duration when calculating PA minutes and PAGs) [23,38].

Importantly, these analyses provide insight into prevalence of meeting PAGs by activity type. Unlike previous analyses [8], we included weightlifting and “other” PA in our study. Regardless of metropolitan status, roughly half of the respondents who engaged in weightlifting and other activities met the combined PAG. Conversely, walking stands out as the activity type with one of the lowest rates of meeting the combined PAGs and the highest rate of not meeting either PAG regardless of metropolitan status. It is discouraging that the activity that is by far the most popular is associated with such high rates of not meeting either PAG. Though novel, our findings are similar to research using NHANES 2003−04 and 2005−06 data collection cycles demonstrating that individuals who only engaged in walking had lower prevalence of meeting the aerobic PAG than those who engaged in 2 or more activities for all but the least active cluster of respondents [17,18]. Future research could add to our understanding by creating combinations of the 2 most frequent activities engaged in by BRFSS respondents (e.g., walking and weightlifting) and their association with PAGs to identify the most beneficial activity combinations. Changes in design of the BRFSS questionnaire to include more than the 2 most frequent activities engaged in, as was done in NHANES 2003−04 and 2005−06 cycles, may provide a more detailed picture of the associations among activities and PAGs, but should be considered in tandem with participant burden.

Overall, the activities more popular in metropolitan areas (i.e., running/jogging, weightlifting, conditioning, sports, dance) were associated with higher overall rates of meeting the combined PAGs than the activities more popular in non-metropolitan areas (i.e., lawn/garden, fishing/hunting, winter activities). This difference in activity preference may help explain the rural-urban disparities in meeting PAGs. There are numerous implications of these findings for rural PA promotion and link to the FITT principle of exercise prescription. First, the activity types associated with the highest prevalence of meeting the combined PAGs but lower prevalence among rural respondents (i.e., conditioning, dance, weightlifting, running) could be encouraged in non-metropolitan areas. This encouragement could meet resistance, however, for cultural, physical access, and/or demographic reasons (i.e., rural populations tend to be older and have higher rates of disability and chronic conditions) [39,40]. Dance or conditioning activities of cultural importance by geography or age could be considered when promoting PA in rural areas; activities for people of varying abilities due to age, injury, or existing chronic conditions could also be considered. The importance of promoting culturally relevant PA has been noted, for example, by authors from Hawaii who have used Hula for PA promotion/disease prevention [13] and begun surveilling Hula (and paddling) prevalence on the Hawaii BRFSS [12].

Second, as suggested by Burnet and colleagues [16], fun and beliefs (e.g., self-efficacy) should be considered in addition to FITT. That is, a fun, accomplishable activity may increase the likelihood of the uptake of an exercise prescription [16]. At the population level, this could be reflected by encouraging fun to increase engagement in the activities less popular in rural areas but associated with meeting PAGs. For example, engaging in activities with groups, such as a weightlifting or dance class or a running group, could help make the beneficial activities more fun and further improve health by strengthening social ties. Additionally, group activity could be used to increase the amount and types of PA when engaging in LTPAs of greater prevalence but lower association with meeting the combined PAGs. For example, walking groups are recommended in the Guide to Community Preventive Services [9] and have been shown to increase levels of PA, fitness, social support and connections, including with rural women [37,41,42]. These groups could be used with rural adult residents to increase aerobic PA and introduce them to muscle-strengthening activities in order to meet the combined PAG.

Third, engaging in LTPA for a more tangible or meaningful purpose than preventing or treating disease may be worth exploring to increase LTPA in rural areas. That is, linking LTPA engagement to benefits in the hunting, fishing, and childcare activities more prevalent in non-metropolitan areas may be effective in rural areas. For example, deer hunting is associated with large heart rate responses, heart attacks, and cardiovascular complications [43,44]. Thus, a multi-component intervention targeting hunters could be implemented at the locations or websites where hunting licenses are sold to integrate messages about PA (e.g., “Struggling to drag that deer out of the woods? Be more active year-round and drag that deer with ease.”) and/or a PA screening tool that could inform individuals at risk to seek a health care provider’s advice before going hunting [45].

The findings presented herein are novel, but worth viewing considering multiple limitations. First, rurality was defined by county of residence in the BRFSS dataset as within- or outside of a metropolitan statistical area. While this definition is common in the literature, it has at least 2 limitations – it lacks details about each respondent’s proximity to a metropolitan area and it lacks the assessment of the location of LTPA. To emphasize, an individual could live near a metropolitan county or commute to a metropolitan area for work and thus have easy access to the resources of that metropolitan area for LTPA. These are complications, hopefully attenuated by the large sample and population weighting employed in the analyses. Second, the 2 most common LTPAs in the previous month were assessed in the BRFSS. Though previous research suggests this encompasses roughly 80% of population preferences [18], it does not capture all LTPAs that each respondent participates in. Third, recall bias may impact the accurate self-reporting of activity types and/or PA duration by respondents. Lastly, the BRFSS assesses LTPA only, not PA engaged in for transportation or occupational purposes. Though the PAGs are based on LTPA, it does not give a complete assessment of PA across all domains of activity.

Acknowledgments

The authors would like to acknowledge the Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity, and Obesity, including the Physical Activity and Health Branch, for their ongoing dedication to maintaining, updating, and openly sharing the BRFSS database and increasing physical activity in the US.