title: Engaging rural women in healthy lifestyle programs: insights from a randomized controlled trial.
abstract: BACKGROUND
  The obesity epidemic is well established, particularly in rural settings. Programs promoting healthy lifestyles for rural women are urgently needed; however, participant engagement is challenging. In the context of a large randomized controlled trial targeting the prevention of weight gain in rural women, we explored successful recruitment strategies and aimed to understand participants' barriers, enablers and reasons for program participation.
  
  
  METHODS
  We recruited women (aged 18-55 years) from the general rural Australian population. A mixed-methods approach was applied to explore factors that influenced program participation, including quantitative questionnaires for all participants (n = 649) and qualitative semi-structured interviews conducted for a subgroup of participants (n = 45). Data were collected at three time points: baseline, 6 and 12 months post program commencement.
  
  
  RESULTS
  We recruited 649 rural women through a community communication and partnering strategy, a program marketing campaign and mobilization of social networks. Program participants were diverse across education and income levels and were representative of the wider Australian regional population. Factors that influenced program engagement were divided into personal (perceived program benefits and program accessibility) and social (peer persuasion and support). Identified enablers included convenience of the program location, perceived program utility, such as weight management and optimization of lifestyle choices, as well as attending the program with peer support. Barriers to engagement, which are likely exacerbated in rural communities included lack of anonymity, self-consciousness and segregated social networks in rural settings. Participants reported that eliciting local support and maximizing publicity is fundamental to improving future program engagement.
  
  
  CONCLUSIONS
  Multiple program promotion strategies including communication, marketing and partnering, as well as mobilization of social networks and peer persuasion, enabled engagement of rural women into a healthy lifestyle program. These recruitment strategies are consistent with successful strategies utilized previously to recruit urban-dwelling women into lifestyle programs. Future engagement efforts in rural settings could be enhanced by hosting multiple sessions within existing socio-cultural networks and assuring participants that they will not need to share their personal health information with others in their community.
  
  
  BACKGROUND
  Australia & New Zealand Clinical Trial Registry. Trial number ACTRN12612000115831. Date of registration 24 January 2012.
authors.affiliation: Monash Centre for Health Research and Implementation, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia. samantha.kozica@monash.edu.
authors.forename: Samantha L
authors.initials: SL
authors.lastname: Kozica
authors.affiliation: Monash Centre for Health Research and Implementation, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia. cheryce.harrison@monash.edu.
authors.forename: Cheryce L
authors.initials: CL
authors.lastname: Harrison
authors.affiliation: Monash Centre for Health Research and Implementation, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia. helena.teede@monash.edu.|Diabetes and Vascular Medicine Unit, Monash Health, Victoria, Australia. helena.teede@monash.edu.
authors.forename: Helena J
authors.initials: HJ
authors.lastname: Teede
authors.affiliation: Monash Centre for Health Research and Implementation, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia. lisa.moran@adelaide.edu.au.
authors.forename: Sze
authors.initials: S
authors.lastname: Ng
authors.affiliation: Monash Centre for Health Research and Implementation, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia. nicole.ng@monash.edu.|The Robinson Institute, Discipline of Obstetrics and Gynaecology, University of Adelaide, Adelaide, Australia. nicole.ng@monash.edu.
authors.forename: Lisa J
authors.initials: LJ
authors.lastname: Moran
authors.affiliation: Monash Centre for Health Research and Implementation, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia. catherine.lombard@monash.edu.
authors.forename: Catherine B
authors.initials: CB
authors.lastname: Lombard
mesh_terms: D000293:Adolescent; D000328:Adult; D001315:Australia / Q000453:epidemiology; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007407:Interviews as Topic; D008019:Life Style; D008875:Middle Aged; D009042:Motivation; D009765:Obesity / Q000175:diagnosis / Q000453:epidemiology / Q000503:physiopathology / Q000517:prevention & control* / Q000523:psychology; D010342:Patient Acceptance of Health Care; D018579:Patient Selection; D035842:Research Subjects / Q000523:psychology*; D012307:Risk Factors; D040242:Risk Reduction Behavior; D012423:Rural Health; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires; D013997:Time Factors; D016896:Treatment Outcome; D015431:Weight Loss; D016387:Women's Health; D055815:Young Adult