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.
Physical inactivity substantially increases the risk for chronic conditions (Aune et al. Citation2015; Chomistek et al. Citation2018), negatively impacts multiple dimensions of health (Faienza et al. Citation2020; Yoneda et al. Citation2021), and causes considerable economic burdens (Ding et al. Citation2016). Approximately 25 percent of U.S. adults report zero PA participation in the past month (Centers for Disease Control and Prevention Citation2022), with significant PA disparities existing by gender. Gender differences in PA are seen as early as preschool (Sallis et al. Citation1996), with the trends continuing into adulthood (Troiano et al. Citation2008). Activity levels decrease further after life events such as parenthood (Bellows-Riecken and Rhodes Citation2008; Engberg et al. Citation2012; Gropper et al. Citation2020; Hull et al. Citation2010; Larouche et al. Citation2012). 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. Citation2015; Chomistek et al. Citation2018).
Complex cultural and psychosocial issues influence these disparities (Edwards and Sackett Citation2016; Hankonen et al. Citation2010). A frequently cited barrier to PA is the dual workload of women in the home and work (Caperchoine, Mummery, and Joyner Citation2009). Although women are more than 50 percent 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 Citation2020; United States Bureau of Labor Statistics Citation2021). Many women are also the primary caregivers (Brenan Citation2020). These factors impact the ability of women to successfully engage in PA and health behaviors (Dixon Citation2009; Yarwood, Carryer, and Gagan Citation2005). In fact, some mothers noted that the need for PA was an additional source of stress or guilt (Dixon Citation2009).
Mothers in rural communities often face additional barriers to health. Rural residents are often geographically and socially isolated (Holmes and Thompson Citation2019) while facing significant barriers in accessing health resources compared to urban and suburban residents (Garcia et al. Citation2017; Rural Health Snapshot Citation2017). 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. Citation2015; Garcia et al. Citation2017; Holmes and Thompson Citation2019; Matthews et al. Citation2017; Pender et al. Citation2019; Rural Health Snapshot Citation2017). Moreover, rural communities are traditionally underrepresented in health research due to barriers such as cost, time, trust, and distance (Pender et al. Citation2019).
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. Citation2010). 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. Citation2010; Whitfield et al. Citation2019; Wilcox et al. Citation2000). 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. Citation2014). 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. Citation2022; Nieto et al. Citation2010). Recruitment letters were mailed to individuals in rural communities as defined by the 2010 Census Urban and Rural Classification (United States Census Bureau Citation2021). 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 Citation1977, Citation2004) and Self-Determination Theory (Ng et al. Citation2012). 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 and Winch Citation2018). 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 Citation2018) using a procedure similar to those described by Braun and Clarke (Braun and Clarke Citation2012). 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 and Clarke Citation2012). 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 and Joffe Citation2020) and an audit trail tracked the development of codes and themes (Nowell et al. Citation2017).
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 percent), had an annual income of $40,000 (12, 71 percent), were married (13, 77 percent), and employed full or part-time (14, 82 percent) ().
Table 1. Participant characteristics.
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 . presents the percentage in which the themes and subthemes emerged across the interviews.
Table 2. Themes with example quotes.
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 Citation2020; Hankonen et al. Citation2010; United States Bureau of Labor Statistics Citation2021). 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. Citation2019; Mailey et al. Citation2014). In fact, fathers were more likely to perceive PA as a controllable, self-regulated choice compared to mothers when asked the same question (Dixon Citation2009). 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. Citation2015; Chomistek et al. Citation2018).
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, Schmer, and Ward-Smith Citation2013; Whitfield et al. Citation2019; Wilcox et al. Citation2000). 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, Miller, and Adams Citation2017; Santos et al. Citation2016) 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, Eccles, and Richardson Citation2008).
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. Citation2019). Like our study, research shows that the absence of social support is a difficult barrier to overcome (Janssen et al. Citation2014). 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. Citation2019). 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. Citation2000). In addition, studies of rural communities show that different types of PA behaviors are impacted differently by built environmental elements (Frost et al. Citation2010) 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. Citation2015; Garcia et al. Citation2017; Holmes and Thompson Citation2019; Matthews et al. Citation2017; Pender et al. Citation2019). Moreover, rural parks are often less safe or suitable for walking compared to urban parks (Veitch et al. Citation2013). Rural residents were also less likely to report seeing neighbors engaging in PA (Wilcox et al. Citation2000) have fewer sidewalks and biking paths (Whitfield et al. Citation2019), and had increased risk of traffic deaths (Raymond Citation2022). 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 percent white (United States Census Bureau Citation2019), this report does not include the experiences of mothers who are nonwhite 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. Citation2018). Challenges remain in identifying effective strategies that support women in engaging in health behaviors (Global Status Report on Physical Activity 2022 Citation2022). 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. Citation2017). This study adds to prior research that illustrates the need for multilevel health promotion efforts addressing social determinants of health behaviors (Ball et al. Citation2015). 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.
Acknowledgments
We thank the participants who volunteered for this research study. We also thank the graduate and undergraduate student researchers who contributed to this study.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
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References
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Appendix
Table A1. Saturation of themes and subthemes.