What Sets Physically Active Rural Communities Apart from Less Active Ones? A Comparative Case Study of Three US Counties

Background: Rural US communities experience health disparities, including a lower prevalence of physical activity (PA). However, “Positive Deviants”—rural communities with greater PA than their peers—exist. The purpose of this study was to identify the factors that help create physically active rural US communities. Methods: Stakeholder interviews, on-site intercept interviews, and in-person observations were used to form a comparative case study of two rural counties with high PA prevalence (HPAs) and one with low PA prevalence (LPA) from a southern US state, selected based on rurality and adult PA prevalence. Interview transcripts were inductively coded by three readers, resulting in a thematic structure that aligned with a Community Capital Framework, which was then used for deductive coding and analysis. Results: Fifteen stakeholder interviews, nine intercept interviews, and on-site observations were conducted. Human and Organizational Capital differed between the HPAs and LPA, manifesting as Social, Built, Financial, and Political Capital differences and a possible “spiraling-up” or cyclical effect through increasing PA and health (Human Capital), highlighting a potential causal model for future study. Conclusions: Multi-organizational PA coalitions may hold promise for rural PA by directly influencing Human and Organizational Capital in the short term and the other forms of capital in the long term.