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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

Purpose: To assess trends in South Australian children’s physical activity between 1985 and 2003 and 2013 in the contexts of school active transport, organized sport, physical education, and school break times. Method: The 1985 Australian Health and Fitness Survey was administered in South Australian schools in 2004 (8 schools) and 2013 (9 schools) and was demographically matched to the 10 South Australian schools in the Australian Health and Fitness Survey. Ordinal logistic modeling was used to identify trends, stratified by older children (10–12 y) and early adolescent (13–15 y) subgroups. Results: School active transport generally declined for males and older female children (19 and 20 percentage points per decade, respectively), whereas early adolescent females increased in walking to school (11 percentage points per decade). School sport participation declined for early adolescents, and club sport participation declined in early adolescent females (23 percentage points per decade). Moderate to vigorous physical activity participation during school break times (particularly lunchtime) generally declined (16–26 percentage points per decade). Observed changes in most contexts occurred between 2004 and 2013. Conclusion: There was evidence of context-specific declines in children’s physical activity participation over this time span. Early adolescent females were the subgroup of most concern, experiencing declines in most contexts.

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

Background Physical activity has numerous associated benefits for cancer survivors. Compared with their urban counterparts, rural Australians experience a health disadvantage, including poorer survival rate after diagnosis of cancer. Objective The aims of this study were to test the effectiveness of an online 12-week walking intervention designed for cancer survivors and explore region-specific psychological predictors of behavior change. Methods This was a quasi-randomized controlled trial of an online resource designed according to Social Cognitive Theory and Self-determination Theory, based on individualized goal setting. Measures of habitual walking, motivation, and self-efficacy were taken at baseline, postintervention, and 3-month follow-up in an intervention group (n = 46) and active control group (n = 45). The control group was provided a pedometer but did not have access to the online program. Results An increase in steps/day at 12 weeks was observed in both groups, with a larger increase in the intervention group; these increases were not sustained at the 3-month follow-up. Psychological predictors of maintained change in steps per day (motivation, barrier self-efficacy, and relapse self-efficacy) did not differ between metropolitan and rural participants. Changes in steps per day among intervention participants were predicted by changes in relapse self-efficacy and barrier self-efficacy. Conclusions The intervention was successful in increasing physical activity postintervention; however, changes were not maintained at follow-up. There were no region-specific predictors of engagement in the intervention. Implications for practice Nurses are seamlessly positioned to promote health interventions like walking. Nurses should reframe physical activity with patients so that relapse is seen as common and possibly inevitable when adopting a regular physical activity habit.

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

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

Cancer survivors are at an increased risk of experiencing physical and psychological ill-effects following cancer treatment. Rural cancer survivors are at a greater risk of future health problems following a cancer diagnosis compared to their urban counterparts. Physical activity has been targeted as a health promotion priority in cancer survivors. Research indicates that a large portion of cancer survivors do not meet physical activity recommendations. The purpose of this quasi-randomized controlled trial was to test the effectiveness of an online 12-week walking intervention designed for cancer survivors, and to explore its impact on physical health indicators and quality of life outcomes. Steps Toward Improving Diet and Exercise among cancer survivors (STRIDE) is an online resource designed according to Social Cognitive Theory and Self Determination Theory, based on individualized step goal setting. Measures of physiology, physical fitness, and quality of life were taken at the baseline, post-intervention, and three-month follow-up in an Intervention group (n = 46) and active Control group (n = 45). The Control group was provided with a pedometer but did not have access to the online program. Three-factor repeated measures ANOVAs indicated that there were improvements in physical fitness (p &lt, 0.01), systolic blood pressure (p &lt, 0.01), diastolic blood pressure (p &lt, 0.01), waist girth (p &lt, 0.01), mental health (p &lt, 0.05), social functioning (p &lt, 0.01), and general health (p &lt, 0.01), but an increase in bodily pain (p &lt, 0.01), from the baseline to week 12 and the three-month follow-up, irrespective of group allocation. Pedometer interventions, delivered with or without online support and step goal setting, show promise for improving the overall health of cancer survivors, at least in the short term.

Rising youth obesity is a serious public health concern. There is a widespread view that declining physical activity is contributing to this trend. A total of 929 young South Australians (age=9-15 years) were surveyed in 1985 and 2004 on usual physical activity in several contexts, including attitudes to physical activity. Eight of 10 South Australian schools participating in the 1985 Schools Health and Fitness Survey were revisited in 2004. Comparisons were made on: organised sport, active transport, physical education (PE), playground activity, vigorous physical activity (VPA), total leisure-time physical activity (LTPA), and attitudes to PE and school sport. The questionnaire and method of administration were identical in both surveys. There were no differences between surveys in club and school sport participation, walking to school, and reported enjoyment of PE and school sport. In 2004 fewer children rode to school, but PE classes were more frequent. The percentage of children who 'sit and talk' during school breaks had increased, with a decreased percentage of older girls who 'run around' during school breaks. There was a significantly higher LTPA in MET.min in 2004 for boys, which was particularly evident at higher percentiles. There were no changes in mean or distribution of LTPA for the whole sample or girls. The percentage of respondents reporting >/=3 bouts of VPA in the previous week rose from 51% (1985) to 76% (2004). There is no consistent evidence of declining physical activity among South Australian youth. It is apparent that physical activity in some contexts has declined, while in other contexts levels are the same or higher than in 1985. This underscores the complex nature of physical activity and the influences on this behaviour.

Background: The purpose of this study was to identify the independent association of frequency of walking trips between home and school with daily physical activity in a sample of school-aged children. Methods: Participants were 109 children (mean age = 12.05 years [±0.71]) attending nine primary schools in Adelaide, South Australia. Physical activity was derived from accelerometers with total counts as the outcome variable. Transport patterns were self-reported for each of the previous five school days. Walking trips were summed for each day and across the school week. The relationship between the number of active transport journeys andindividual school day and school week physical activity was modelled separately in boys and girls using multiple linear regression. Results: Frequency of walking was positively associated with school day and school week accelerometer counts in boys, accounting for 6% and 12% of the explained variance in total counts, respectively. There were no significant associations among girls. Conclusion: Despite sex-specific differences in associations between active transport to school and total physical activity, active transport is likely to have important ancillary benefits for development of independence and physical activity habits, and should continue to be promoted. 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

Cancer survivorship rates have increased in developed countries largely due to population ageing and improvements in cancer care. Survivorship is a neglected phase of cancer treatment and is often associated with adverse physical and psychological effects. There is a need for broadly accessible, non-pharmacological measures that may prolong disease-free survival, reduce or alleviate co-morbidities and enhance quality of life. The aim of the Steps TowaRd Improving Diet and Exercise (STRIDE) study is to evaluate the effectiveness of an online-delivered physical activity intervention for increasing walking in cancer survivors living in metropolitan and rural areas of South Australia. This is a quasi-randomised controlled trial. The intervention period is 12-weeks with 3-month follow-up. The trial will be conducted at a university setting and community health services in South Australia. Participants will be insufficiently active and aged 18 years or older. Participants will be randomly assigned to either the intervention or control group. All participants will receive a pedometer but only the intervention group will have access to the STRIDE website where they will report steps, affect and ratings of perceived exertion (RPE) during exercise daily. Researchers will use these variables to individualise weekly step goals to increase walking. The primary outcome measure is steps per day. The secondary outcomes are a) health measures (anthropometric and physiological), b) dietary habits (consumption of core foods and non-core foods) and c) quality of life (QOL) including physical, psychological and social wellbeing. Measures will be collected at baseline, post-intervention and 3-month follow-up. This protocol describes the implementation of a trial using an online resource to assist cancer survivors to become more physically active. It is an innovative tool that uses ratings of perceived exertion and daily affect to create individualised step goals for cancer survivors. The research findings may be of relevance to public health policy makers as an efficacious and inexpensive online-delivered intervention can have widespread application and may improve physical and psychological outcomes among this vulnerable population. Findings may indicate directions for the implementation of future physical activity interventions with this population. Australian New Zealand Clinical Trials Registry: ACTRN12613000473763 .

Conclusions : Mixed results and inconsistent magnitudes of change were identified when exploring trends in different contexts of physical activity for children and adolescents over the last few decades. Taken overall, there is little evidence for a decrease in children's and adolescents' physical activity, although consistent declines in active transport highlight this context as a suitable intervention target. Design : A comprehensive literature search was completed to identify articles on the specific contexts of physical activity for inclusion in this review. Methods : Journal articles for inclusion in this narrative review were sourced from the various databases and reference lists. Most studies in this review employed self-report or proxy-report methodologies. Objectives : It is particularly important to measure trends in physical activity to identify specific contexts where physical activity may have declined and can be targeted for intervention. The aim of this review was to summarize overall physical activity trends based on objectively measured physical activity as well as trends in specific contexts (active transport, organized sport, school physical education and school play periods) using self- or proxy-reported physical activity. Results : There is limited research on temporal trends in children's and adolescents' physical activity. The few studies that employ objective measures to assess trends in physical activity indicate little change has occurred in the last 20 years. Other studies that employed self-report methods indicate organized sport trends are somewhat inconsistent across countries, however most studies reported an increase in participation. Within the limited physical education trend studies, inconsistent trends were noted. There have been consistent declines in active transport, particularly cycling. Few studies have investigated trends in physical activity and sedentary behaviour during school play periods, highlighting a need for further research. Refereed/Peer-reviewed

This study examined whether active commuting to and from school was associated with more frequent walking and cycling to other neighborhood destinations. Parents reported on free-time physical activity and frequency of active commuting among 1,643 South Australians (9–15 years), as well as their perceptions of risk associated with active commuting in the neighborhood. Groups were formed on the basis of active and motorized transport to and from school and compared on the frequency of walking and cycling to other neighborhood destinations. Those who actively commuted between home and school were approximately 30% more likely to actively commute to other neighborhood destinations, independent of age, free-time physical activity, and neighborhood risk. Active commuting to and from school is part of a broader habit of walking and cycling in the neighborhood among school age South Australians. The advantages of promoting active transport between home and school might extend beyond the energy expenditure of that journey alone.

It is not clear whether the global increase in weight problems in children is the result of excessive energy intake or decreasing energy expenditure. Methodological limitations have made it difficult to analyse. There is evidence that at least part of the problem may lie with increasing energy consumption, but it is important to examine the other side of the energy equation also. However, it is not possible to conclusively describe physical activity trends because of the absence of suitable baseline data. One solution is to summate all available evidence in as many areas of daily activities as possible and then draw tentative conclusions. This review summarises available trend data on direct representations of physical activity in a range of contexts, together with indirect measures such as sedentariness, fitness, and attitudes. The conclusions drawn are: physical activity in clearly defined contexts such as active transport, school physical education, and organised sports is declining in many countries; young people would like to be active but are often constrained by external factors such as school policy or curricula, parental rules in relation to safety and convenience, and physical environmental factors.

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).

Background Increases in chronic illness due to sedentary lifestyles and poor metabolic fitness have led to numerous intervention strategies to promote physical activity (PA). This paper describes the methodological strategies of two short-term PA interventions. Outcome measures reported are PA adherence and compliance rates during the intervention and at 3, 6 and 12-month follow-up. Methods The 40-day interventions were: a pedometer-based walking program (n = 251) and a group-based intensive program (n = 148). There was also an active control group (n = 135). Intervention subjects were prescribed PA each day and required to record all activity sessions (pedometer steps or energy expenditure from heart rate monitors). Results Compliance (≥ 150 min/wk PA) was highest post-intervention (81.1% and 64.5% for the group and pedometer subjects, respectively) and then progressively decreased across the 12-month follow-up period (final compliance rates were 53.5% and 46.6%, respectively) although they remained significantly higher than pre-intervention rates (zero %). There was significantly higher adherence to 6 months (75.0% and 64.9%), and compliance to 3 months (64.9% and 51.0%), for group versus pedometer subjects. The active control group maintained the highest adherence and compliance rates across the study. Conclusions The group-based program resulted in higher adherence and compliance rates post-intervention although both types of interventions showed long-term effectiveness to increase activity patterns.