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In many countries, rural residents have lower life expectancies and poorer health outcomes than urban residents. Adults living in rural Australia have lower physical activity levels than major city counterparts, contributing to this observed health disparity. As physical activity interventions in rural populations have shown minimal success, there is an urgent need for innovative and affordable interventions that facilitate active lifestyles in this vulnerable population. This study assessed the feasibility of physical activity-focused motivational interviewing, delivered by university health sciences undergraduates in a rural Australian region. “Health age” was assessed at baseline (n = 62) from physiological and behavioral measures, immediately followed by the motivational interview, with health age again assessed at 8 weeks follow-up. Mixed methods using a questionnaire (n = 41 at both time points) and one-on-one interview (n = 8) identified aspects of intervention acceptability and feasibility. A large majority rated the motivational interview as meaningful (98%), empathetic (96%), autonomy-focused (88%), and likely to lead to sustained behavior change (98%). Interviews highlighted several potential attitudinal and structural factors that might influence long-term behavior change. Further development of this strategy in rural regions will depend on a deeper understanding of individuals’ and communities’ awareness, attitudes, and beliefs in relation to active lifestyles. Refereed/Peer-reviewed

This study aimed to explore barriers and facilitators that impact on farmers' help-seeking behaviours for health and mental health concerns. Fifteen semi-structured interviews were conducted with farmers (12 male; age 51.7 +/- 12.6 years) from three rural regions in South Australia. Interviews explored demographic and farm-related characteristics, perceptions of individual (and where relevant family) health and mental health concerns and experiences, and perceived barriers of health support-seeking. Thematic analysis was used to identify key themes. Four key themes were identified relating to help-seeking; personal attitudes and beliefs, farm-related barriers, health system barriers and the provision of support from family and friends. Dominant personal attitudes included valuing independence, strength and privacy. Farm related barriers included the 'farm comes first' and the fact that 'farm work is never done'. Health system barriers included issues relating to availability of choice and access, professionals (lack of) understanding of farm life, and time and financial costs of accessing care. Provision of support from family and friends involved informal help and advice, including facilitating access to professional support. Multiple attitudinal, structural, and farm-related issues affect farmers' help-seeking. Professionals who understand farm work practices and routines are valued by farmers and this is likely to facilitate access to care. Workforce development programs and community programs that involve farmers' perspectives as consumers and co-designers, using evidence-based strategies, may assist in strengthening these relationships. Refereed/Peer-reviewed

Background: Rural Australians experience higher prevalence of several chronic diseases than metropolitan Australians and are less likely to access supportive health services. This study explored associations of sociodemographic factors and barriers to support seeking for health in a sample of rural South Australians. Methods: Participants (n = 610) from three rural regions participated in a computer-assisted telephone interview (CATI), based on the Barriers to Help Seeking Scale. Each participant reported on barriers in one of three health contexts: ‘general’ physical health, skin cancer, and mental health. Sociodemographic factors included gender, age, highest education, region of residence, and presence of chronic conditions. Chi-squared Automatic Interaction Detection (CHAID) determined independent associations of sociodemographic factors and barrier categories (high, medium and low importance). Results: Privacy was a high-importance barrier in the mental health context, particularly among participants of age < 63 years. The tendency to minimise and normalise health issues was also a high-importance barrier in the mental health context. In the physical health context, those with a chronic condition were more likely to perceive normalisation as a barrier than those without a chronic condition. Need for control and self-reliance was a high-importance barrier in the mental health context and a low-importance barrier in the skin cancer context, particularly among participants < 63 years. Structural factors and distrust of providers were high-importance barriers among those who did not complete secondary education, regardless of context. Conclusion: This study highlights the importance of a nuanced approach to promoting help-seeking in rural Australians, with message content and delivery tailored to specific health conditions and demographic circumstances. Refereed/Peer-reviewed

Issue addressed: Australian women are less likely to participate in recommended levels of weekly physical activity compared with men. Physical activity participation rates decrease with geographical remoteness. Research suggests that a lack of social support mechanisms within the home environment may act as a barrier for rural women to engage in physical activity, along with discomfort experienced within exercise environments. The purpose of this study was to explore the social conditions that facilitate or inhibit physical activity participation amongst women from two rural South Australian communities. Methods: A qualitative descriptive approach underpinned by a phenomenological methodological orientation was applied. Participants were recruited using a purposive sampling strategy before semi-structured interviews (N = 16) were conducted and prepared for thematic analysis. Results: Four inter-related themes were identified: support from others, time, expectations and available opportunities. Further contextual analysis revealed interwoven notions of physical activity spaces, time and social context within the themes. Conclusions: Multiple types of regulators interact to shape the motivational pattern of an individual. The themes identified align with self-determination, transactional and structuration theory, suggesting a need to consider human behaviour both pragmatically and conceptually. So what?: Results provide insight into social barriers and facilitators for physical activity participation and concomitantly provide the initial development of a framework for local strategic planning of health-promoting activities, and individual reflection to increase physical activity participation amongst rural women. Refereed/Peer-reviewed

Purpose: People affected by cancer who live in rural Australia experience inferior survival compared to their urban counterparts. This study determines whether self-reported physical and mental health, as well as health-promoting behaviours, also differ between rural and urban Australian adults with a history of cancer. Methods: Weighted, representative population data were collected via the South Australian Monitoring and Surveillance System between 1 January 2010 and 1 June 2015. Data for participants with a history of cancer (n = 4295) were analysed with adjustment for survey year, gender, age group, education, income, family structure, work status, country of birth and area-level relative socioeconomic disadvantage (SEIFA). Results: Cancer risk factors and co-morbid physical and mental health issues were prevalent among cancer survivors regardless of residential location. In unadjusted analyses, rural survivors were more likely than urban survivors to be obese and be physically inactive. They were equally likely to experience other co-morbidities (diabetes, chronic obstructive pulmonary disease, cardiovascular disease, arthritis or osteoporosis). With adjustment for SEIFA, rural/urban differences in obesity and physical activity disappeared. Rural survivors were more likely to have trust in their communities, less likely to report high/very high distress, but equally likely to report a mental health condition, both with and without adjustment for SEIFA. Conclusions: There is a need for deeper understanding of the impact of relative socioeconomic disadvantage on health (particularly physical activity and obesity) in rural settings and the development of accessible and culturally appropriate interventions to address rural cancer survivors’ specific needs and risk factors. Refereed/Peer-reviewed

Objectives: Rural Australian adults are consistently identified as insufficiently active, likely due to challenges implementing community-based physical activity programs in rural settings. On-line strategies to promote physical activity may be particularly effective in rural settings where isolation and scarcity of qualified support are potential barriers. The Rural Environments and Community Health (REACH) study evaluated the effectiveness of an online-delivered walking intervention among South Australian rural adults. Design: Randomised controlled study design. Methods: A twelve-week intervention, with six- and twelve-month follow-up, was conducted. Participants (n = 171; 50.6 ± 12.5 years), recruited through flyers, local newspapers and radio, were randomised to comparison or intervention groups and received a pedometer. The intervention group received access to the REACH website and personalised step goals based on ratings of perceived exertion and daily affect. The comparison group received a paper diary and generic step goals. Outcome measures were accelerometry-assessed sedentary, light (LPA) and moderate-to-vigorous (MVPA) physical activity. Linear mixed models assessed changes over the intervention and follow-ups.Results: Sedentary time decreased, and LPA and MVPA increased in both groups across the intervention(p < 0.05). The intervention group demonstrated a larger increase in LPA at six-month follow-up relative to comparison (p < 0.05). Both groups decreased sedentary time, overall and in bouts ≥30 min, between baseline and twelve-month follow-up (p < 0.05). From baseline to twelve-month follow-up, MVPA (total min and bouts ≥10 min) declined more in the comparison group than the intervention group (p < 0.05). Results: Sedentary time decreased, and LPA and MVPA increased in both groups across the intervention(p < 0.05). The intervention group demonstrated a larger increase in LPA at six-month follow-up relative to comparison (p < 0.05). Both groups decreased sedentary time, overall and in bouts ≥30 min, between baseline and twelve-month follow-up (p < 0.05). From baseline to twelve-month follow-up, MVPA (total min and bouts ≥10 min) declined more in the comparison group than the intervention group (p < 0.05). Conclusion: While increased physical activity and decreased sedentary time were observed in both groups during the intervention period, maintenance was only observed for LPA at six-month follow-up in the intervention group. By twelve-month follow-up, post-intervention improvements had largely disappeared, suggesting that additional research is needed to identify ways to improve long-term adherence. Refereed/Peer-reviewed

Abstract. Background: Suicide rates are higher in rural and remote areas of Australia compared with major cities. Aim: To evaluate the impact of a brief, community-based suicide prevention educational intervention on the attitudes and confidence of rural South Australian health and human service professionals. Method: Participants attended a 1-day suicide prevention education program, and completed a survey at four time points: baseline (T1), immediately pretraining (T2), immediately posttraining (T3), and 4-month follow-up (T4). Main outcome measures were self-reported attitudes and confidence when working with people vulnerable to suicide. Results: A total of 248 people attended the training, with 213 participants completing the survey at T1, 236 at T2, 215 at T3, and 172 at T4. There were significant improvements in 11 of the 14 attitude items between T2 and T3 (immediate change), and between T1 and T4 (maintained change). Further, there were significant improvements in all four confidence items between T2 and T3, and T1 and T4. Limitations: Despite the repeated-measures design, findings are limited by the lack of a control group. Conclusion: Findings extend the international evidence by indicating the value of brief suicide prevention education for improving health and human service professionals' attitudes and confidence in rural Australia.

Issue addressed :Suicide rates in rural Australia are almost twice as high as those in urban areas. In rural communities, football clubs are often the ‘hub’ of the community and are being explored as an avenue to deliver mental health and wellbeing promotion. The aim of this study was to explore barriers and enablers for programs promoting mental health and wellbeing through rural Australian football clubs. Method: This qualitative descriptive study included 12 individuals of 10 rural clubs affiliated with the South Australian National Football League. Recruitment occurred via emails to club secretaries/presidents. Semi‐structured telephone interviews explored mental health and wellbeing issues experienced in clubs, previous involvement with mental wellbeing programs, and potential barriers/enablers for future programs. Interviews were transcribed verbatim and analysed thematically. Results: Thematic analysis identified three themes encompassing barriers and enablers: (1) more than a football club, (2) attitudes towards mental health, and (3) what is needed to implement a program. The third theme had subthemes of resources, importance of timing, mental health initiatives and components of a program. Conclusion: Key barriers included difficulty getting people involved due to individual attitudes towards mental health, and not having the finances/resources to implement a program. Major enablers included the important role the football club serves in the community, the inclusion of speakers with credibility, and making the program engaging. So what? This study identifies key factors which may impact on community engagement and program effectiveness for mental health and wellbeing programs delivered via rural football clubs. Refereed/Peer-reviewed

Objective: Little is known about how the physical environment impacts physical activity behaviour among rural populations, who are typically less active and at higher risk of chronic disease than urban dwellers. The lack of individual-level instruments to assess the physical environment in rural areas limits advancement of this field. Among rural adults, this study aimed to evaluate (a) the test-retest reliability of a self-reported questionnaire of individual-level perceptions of the physical activity environment, and (b) the stability of a self-reported physical activity questionnaire. Design: Cross-sectional questionnaire repeated twice, 2 weeks apart. The questionnaire included 94 items relating to the perceived physical environment (representing nine summary scores), demographic characteristics and physical activity. Setting: Rural Australia. Participants: Rurally residing adults (≥18 years) across three Australian states.Main outcome measures: Test-retest reliability evaluated by weighted Kappa statistics(individual items) and intra-class correlations (summary scores). Results: A total of 292 participants (20% men) completed both questionnaires, on average22 days apart. Test-retest reliability of individual items ranged from weighted Kappa 0.37-0.85 (median: 0.59). Internal reliability for five summary scores was good to excellent (Cronbach's alpha: 0.81-0.97). Test-retest reliability was good to excellent for six summary scores (intra-class correlations: 0.67-0.77). Conclusions: The findings indicated good to excellent test-retest reliability for most items, particularly “fixed” constructs for this new questionnaire measuring the perceived physical environment in rural populations. This study represents an important step towards improving measurement of physical activity environments in rural populations, potentially leading to better tailored interventions to promote active and healthy living in rural areas. Refereed/Peer-reviewed

Refereed/Peer-reviewed

Physical activity has numerous associated benefits for cancer survivors. Compared to their urban counterparts, rural and remote Australians experience a health disadvantage, including poorer survival rate after the diagnosis of cancer. The purpose of this qualitative study was to (a) investigate factors that motivated or inhibited walking in rural participants during a 12-week intervention and (b) to investigate factors that motivated or inhibited physical activity behavior change three months post-intervention. Ten cancer survivors living in rural areas of South Australia participated in a 12-week computer-delivered walking-based intervention during which they reported daily steps,daily affect, and ratings of perceived exertion. Based on this information, individualized daily step goals were sent to them to increase walking. Following the intervention, participants engaged in face-to-face semi-structured interviews. Interviews were recorded, transcribed and coded using thematic analysis. Participants identified a range of physical, psychological, social, environmental,and organizational motivators and barriers. Participants appreciated the monitoring and support from the research team, but some voiced a need for better transition to post-program and many desired ongoing support to maintain their motivation. Future studies should incorporate strategies to help walking behavior to become more intrinsically motivated and therefore sustained. Refereed/Peer-reviewed

Purpose/objective Cardiac rehabilitation aims to reduce the likelihood of recurrent cardiac events through physical activity (PA) and education. There is limited understanding about the predictors of physical activity behavior in rural adults beyond rehabilitation. This study explored predictors of regular physical activity in rural adults, 6-12 months post cardiac rehabilitation. Research Method/Design: A self-report questionnaire (quantitative cross-sectional design) was mailed to a simple random sample of rural South Australians who previously participated in cardiac rehabilitation (n = 315). Regression modeling was adjusted for physical activity history and gender to examine psychological, social, and environmental predictors of (a) current leisure-time physical activity, self-reported through the Godin Leisure Time Exercise Questionnaire expressed as the Leisure Score Index (LSI) and the weekly frequency of physical activity bouts that cause sweating ("sweat frequency"), and (b) stage of physical activity behavior change according to the Transtheoretical Model of Behavior Change ("Stage of PA change"). Results All measures of self-efficacy (barriers, task, and relapse), social assimilation, and self-regulation predicted LSI, whereas all measures of self-efficacy and self-regulation predicted both "Stage of PA change" and "sweat frequency." Self-regulation explained the highest percentage of explained variance in LSI (31.6%) and "sweat frequency" (12.5%). Home social support additionally predicted "Stage of PA change"; there were no environmental predictors of any of the outcome measures. Conclusion Similar to urban populations, the predictors of post-cardiac-rehab physical activity among rural adults predominantly emanate from the psychological domain. Findings support the need to strengthen the focus of cardiac rehabilitation program design on self-management skills and behaviors. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Objectives Associations between objectively measured sedentary behaviour, physical activity (PA) and metabolic syndrome (MetS)-classified using three different definitions were investigated in an inactive sample of rural Australian adults. Design Quantitative, cross-sectional. Methods 171 adults (50.7 ± 12.4 years) from two rural South Australian regions underwent seven-day accelerometer activity monitoring and MetS classification using the National Cholesterol Education Program, the International Diabetes Federation and the Harmonized definitions. Associations between sedentary and activity variables and MetS (adjusted for age, sex, diet and smoking status) were modelled using logistic regression. In secondary modelling, associations of sedentary and activity outcomes for each MetS definition were assessed, adjusting for other activity and sedentary variables. Prediction differences across the definitions of MetS were directly compared using Akaike’s Information Criterion. Results Sedentary behaviour increased MetS risk, whereas light physical activity (LPA) and moderate-to-vigorous physical activity (MVPA) reduced MetS risk, irrespective of definition. In secondary models, LPA predicted MetS independently of MVPA and total sedentary time. Time spent in sedentary bouts (>30 min) predicted MetS independently of MVPA and the number of sedentary bouts predicted MetS independently of LPA and MVPA. Prediction differences for MetS definitions failed to reach the critical threshold for difference (>10). Conclusions This study highlights the importance of sedentary behaviour and LPA on the prevalence of MetS in an inactive sample of rural Australian adults. Studies assessing the efficacy of increasing LPA on MetS in this population are needed. Minimal predictive differences across the three MetS definitions suggest evidence from previous studies can be considered cumulative.

Although the health benefits of walking are well established, participation is lower in rural areas compared to urban areas. Most studies on walkability and walking have been conducted in urban areas, thus little is known about the relevance of walkability to rural areas. A computer-assisted telephone survey of 2402 adults (aged ≥18 years) was conducted to determine walking behaviour and perceptions of neighbourhood walkability. Data were stratified by urban (n = 1738) and rural (n = 664). A greater proportion of respondents reported no walking in rural (25.8%) compared to urban areas (18.5%). Compared to urban areas, rural areas had lower walkability scores and urban residents reported higher frequency of walking. The association of perceived walkability with walking was significant only in urban areas. These results suggest that environmental factors associated with walking in urban areas may not be relevant in rural areas. Appropriate walkability measures specific to rural areas should be further researched. Refereed/Peer-reviewed

Objective: To determine differences in walking for recreation and transport between Accessibility/Remoteness Index of Australia (ARIA) categories, in South Australian adults. Design: Cross-sectional self-reported data from adult telephone survey respondents between April and May in 2012 and 2013. Setting: Population of South Australia. Participants: A total of 4004 adults (aged over 18 years) participated: n = 1956 men and n = 2048 women. Area of residence was categorised using ARIA (major city, inner regional, outer regional and remote/very remote). Main outcome measure(s): Self-reported participation in walking for transport and recreation/exercise as the number of times and minutes per week. Data were analysed using Kruskal-Wallis test for median minutes and negative binomial regression for times walked with adjustment for socioeconomic status, age and body mass index. Results: Average age was 47.8 ± 18.5 years, 51.1% were women, 70.9% lived in the major cities, 14.6% in inner regional, 10.8% in outer regional and 3.6% in remote/very remote areas. Relative to major city, times walked for recreation was lower for only remote/very remote residents (incidence rate ratio (IRR) 0.74 (95%CI 0.59-0.92), P = 0.008). This difference was only observed for men (IRR 0.54 (95%CI 0.39-0.73), P < 0.001). Relative to major city, times walked for transport was less for inner regional (IRR 0.74 (95%CI 0.67-0.85), P < 0.001) and outer regional (IRR 0.64 (95%CI 0.56-0.74), P < 0.001) only. This difference in transport walking was seen in both men and women. Conclusion: Frequency of walking varied by purpose, level of remoteness and sex. As walking is the focus of population-level health promotion, more detailed understanding of the aetiology of regular walking is needed. Refereed/Peer-reviewed

Objective: To assess the differences between farming and non-farming rural adults in perceived barriers to mental health service use. Design: A cross-sectional survey, modified from the Barriers to Help-Seeking Scale (BHSS), was conducted using a computer-assisted telephone interview. Setting: Respondents (age 52.6 ± 11.6 years) were recruited from three rural regions of South Australia. Participants: Approximately, 78 non-farmers and 45 farmers were included in analyses. 78 retired and two unemployed participants were excluded from the analyses. Main outcome measure: Farmers and non-farmers were compared on domain scores and individual item responses from the adapted BHSS that represent 'agrarian' attitudes to support-seeking for mental health: stoicism, self-reliance, minimisation of the problem, stigma and distrust of health professionals. Results: In the analysis of domain scores, 'Need for Control and Self-Reliance' was a stronger barrier for farmers than non-farmers (P = 0.009) with a trend (P = 0.07) towards stronger barriers among farmers in the 'Minimising Problem and Resignation' domain. In the analysis of item-level responses, there was a difference (P = 0.03) between farmers and non-farmers in responses to 'I find it difficult to understand my doctor/health professional', with 24.4% of the farmers agreeing that this is a barrier compared with 15.3% of the non-farmers. Conclusion: Long-held stereotypes of stoicism and self-reliance among farmers were somewhat supported, in the context of mental health. Mental health services and professionals in rural Australia might need to adapt their practices to successfully engage this population. Refereed/Peer-reviewed

Rural Australians are less physically active than their metropolitan counterparts, and yet very little is known of the candidate intervention targets for promoting physical activity in rural populations. As rural regions are economically, socially and environmentally diverse, drivers of regular physical activity are likely to vary between regions. This study explored the region-specific correlates of daily walking among middle age and older adults in rural regions with contrasting dominant primary industries. Participants were recruited through print and electronic media, primary care settings and community organisations. Pedometers were worn by 153 adults for at least four days, including a weekend day. A questionnaire identified potential intra-personal, social and environmental correlates of physical activity, according to a social ecological framework. Regression modelling identified independent correlates of daily walking separately in the two study regions. In one region, there were independent correlates of walking from all levels of the social ecological framework. In the other region, significant correlates of daily walking were almost all demographic (age, education and marital status). Participants living alone were less likely to be physically active regardless of region. This study highlights the importance of considering region-specific factors when designing strategies for promoting regular walking among rural adults. Refereed/Peer-reviewed

Objective: To explore perceptions of health among South Australian farmers. Design: Descriptive qualitative study, using semi-structured interviews. Setting: Two rural towns in the Riverland region of South Australia. Participants: Fifteen adults involved in farming within the Riverland region of South Australia, from a variety of farming industries; age range 23-70 years old; 53% male, 47% female. Main outcome measures: Perceptions and definitions of health.Results: Participants described an ecological understanding of health across individual, farm, and community domains. Participants perceived health as being able to function and complete farm work. Participants reported that farm work helped to maintain fitness, but the multiple stress and hazards associated with farming had a significant influence on health. Participants described how health was influenced by community activities and social support from friends and families. Women were reported to take a lead role in health. Conclusions: Health providers can frame interventions to resonate with the perceptions of health held by people, shaped and formed by the context of farming. Further research is needed to explore farmers'; perceptions of health in different locations, from different industries and from a range of age groups. Refereed/Peer-reviewed

Rural Australians have a higher likelihood of chronic disease than urban Australians, particularly male farmers. Chronic disease has been associated with occupational sedentary time. The aim was to validate the self-report of sedentary time in men in contrasting rural occupations. Farmers (n = 29) and office workers (n = 28), age 30–65 years, were recruited from the Riverland region of South Australia. Daily sedentary time and number of breaks in sedentary time were self-reported and measured objectively using body-worn inclinometers. Correlational analyses were conducted between self-reported and objectively measured variables, separately by occupation. There was a significant correlation between self-reported and objectively measured sedentary time in the whole sample (r = 0.44, P = 0.001). The correlation among office workers was significant (r = 0.57, P = 0.003) but not among farmers (r = 0.08, P = 0.68). There were no significant correlations between self-reported and measured number of breaks in sedentary time, for the whole sample (rho = −0.03, P = 0.83), office workers (rho = 0.17, P = 0.39) and farmers (rho = −0.22, P = 0.25). In conclusion, the validity of self-report of sedentary behaviours by farmers was poor. Further research is needed to develop better performing self-report instruments or more accessible objective measures of sedentary behaviour in this population. Refereed/Peer-reviewed

Purpose: Physical activity has been associated with improved outcomes for cancer survivors. Compared to their urban counterparts, rural Australians experience a health disadvantage, including poorer survival rates after diagnosis of cancer. The aim of this pilot feasibility study was to gain insight into the experiences of rural cancer survivors engaging in an online resource designed to increase regular walking. Conclusions: This online pedometer-based walking intervention is feasible and effectively increases motivation for walking and enhances health-related quality of life in South Australian rural cancer survivors. A randomized controlled trial of this intervention is warranted. Methods: A 6-week online lifestyle intervention was implemented among eight cancer survivors living in three rural regions of South Australia. Participants used a pedometer to monitor daily steps taken, reported daily steps using a specially designed website and were provided with daily step goals based on their affective state. Participants took part in semi-structured face-to-face interviews to gauge their impressions of the program. Data were analysed using qualitative description and content analysis to derive major themes from the interviews. Results: The program motivated participants to increase their walking and resulted in improvements in several self-reported physical and quality of life outcomes. The resource was clear and easy to navigate. The three-tiered step goal system reduced feelings of guilt if participants were unable to reach a goal. The step log and graph allowed participants to self-monitor their progress. The forum fostered social support; however, more interaction with intervention personnel was suggested. Refereed/Peer-reviewed

Objectives: While there is consistent evidence that rural adults in Australia are less active than their urban counterparts, studies relating geographical remoteness to activity patterns in Australian adolescents have yielded inconsistent results. The aim of this study was to describe objectively and subjectively measured patterns of physical activity and sedentary behaviours across remoteness categories in a representative sample of 9-16 year old Australians. Conclusions: Activity levels among Australian adolescents show contrasting patterns of geographical differences to those found in Australian adults. Higher levels of free play among rural Australian adolescents may be due to more available space and less fear of traffic and stranger risks. Design: Cross-sectional observational study. Methods: 2071 Australian adolescents provided self-report use of time data on four days and wore a pedometer for at least 6 days within the 2007 Australian National Children's Nutrition and Physical Activity Survey. Comparisons of activity patterns were made across four objectively-determined remoteness categories (Major City, Inner Regional, Outer Regional and Remote), adjusting for household income, parental education and age. Results: Adolescents living in major cities self-reported 11-29 min less moderate to vigorous physical activity each day than their counterparts living in geographically more remote areas, and took 150-850 fewer steps each day. While there were no differences in time spent in sport or active transport, differences in free play participation were significant. Males in major cities also reported higher levels of screen time. Differences were somewhat more marked among males than among females. Refereed/Peer-reviewed

Background Rural Australian adults are continually shown to be insufficiently active with higher prevalence of lifestyle-related diseases associated with physical inactivity compared to urban adults. This may, partly, be attributable to the challenges associated with implementing community-based physical activity programs in rural communities. There is a need for broadly accessible physical activity programs specifically tailored to the unique attributes of rural communities. The aim of the Rural Environments And Community Health (REACH) study is to evaluate the effectiveness of an online-delivered physical activity intervention for increasing regular walking among adults living in rural areas of South Australia. Methods/Design This is a randomised controlled trial. The intervention is 12-weeks with a 12-month follow-up. Participants will be insufficiently active, aged 18 to 70 years and randomly assigned to either Control or Intervention group. Participants receive a pedometer, but only the Intervention group will receive access to the purpose built REACH website where they will report steps taken, affect and ratings of perceived exertion during daily walking. These variables will be used to establish individualised step goals for increasing walking. Control participants will receive a paper diary to record their variables and generic incremental step goals. The primary outcome measures are time spent in sedentary, light and moderate-to-vigorous intensity physical activity, measured by accelerometry. Secondary outcomes include 1) health measures (anthropometric and physiological), 2) psychological well-being, 3) diet quality, and 4) correlates of physical activity (exercise self-efficacy and physical activity environments). Measures will be collected at baseline, post-intervention, 6-month and 12-month follow-up. Discussion This protocol describes the implementation of a trial testing the effectiveness of an online resource designed to assist rural Australians to become more physically active. The outcomes of this study will guide the efforts of health promotion professionals by providing evidence for a relatively inexpensive, widely accessible and effective method for increasing physical activity that can be utilized by anyone with access to the internet. Findings may indicate future directions for the implementation of physical activity and other health related interventions in rural communities. Trial registration Australian New Zealand Clinical Trials Registry: ACTR12614000927628 (registered 28 August 2014).