More than 25 years ago, Ross Brownson, PhD, the Steven H. and Susan U. Lipstein Distinguished Professor at the School of Public Health at Washington University in St. Louis, helped build 40 miles of walking trails in southeastern Missouri to make it easier for people in the area to get exercise. While follow-up studies indicated that local residents used the trails, a 2017 study by the Prevention Research Center at WashU showed that only a quarter of residents used them regularly, and half had ever used them at all.
“You know the quote from the movie ‘Field of Dreams,’ ‘If you build it, they will come?’” asked lead author Alan Beck, PhD. “It turns out, if you build it, only half of them will come.” Now the manager of research resources at the School of Public Health (SPH), Beck led the study as a research manager in the school’s Prevention Research Center.
To boost usage of the walking trails, Brownson — director of SPH’s Prevention Research Center — Beck and colleagues designed a multipronged intervention that included text reminders five days a week. Analysis showed that people who received the intervention were nearly twice as likely to meet the guidelines for aerobic physical activity as those who did not receive the intervention.
“We showed that promoting physical activity in rural communities is possible,” said Dixie Duncan, who led implementation of the program as a research project coordinator at the Prevention Research Center. “There are local health champions in rural communities who can be really vital resources. Sometimes they’re city officials or health department workers, but sometimes they’re just individuals who are really passionate about health or physical activity, and they’re happy to help with the efforts. So finding and celebrating those people can go a long way.”
The study involved 14 rural communities in southeast Missouri that contained at least one public walking trail. Communities were paired on factors such as rurality, demographics and poverty rate, and one of each pair of communities was randomly assigned to receive the intervention. The original intervention plan called for a variety of strategies to promote physical activity at the individual, group and community levels. However, the COVID-19 pandemic started just as the program was about to be launched, forcing the team to quickly modify any plans that involved bringing people together. No longer could they encourage people to join walking groups to meet new friends; now they encouraged families to go for walks together. Large public events were out; instead, the team rented two billboards and plastered them with photos of local people enjoying walks with friends and family, turning them into temporary celebrities and ambassadors for healthy activity. Only the text messaging part went as planned.
“When COVID happened, I had just sent something like 85 accelerometers — devices for measuring motion — to people in southeast Missouri via mail,” Beck said. “At the time, St. Louis had a couple of cases of COVID-19, but that area still had zero, and nobody knew if the virus could be transmitted via objects. So people saw a package from St. Louis, and they wouldn’t even touch it. They just said, ‘Nope, get this off my front porch,’ and sent it right back.”
Duncan, who was born and raised in Southeast Missouri and lives in the area, ran the program. In each community, she identified and worked with local partners to determine existing resources, get input and feedback from residents, and execute the interventions. She led a physical activity promotion media campaign that included renting a billboard after people in one town reported that they got much of their health information from roadside signs.
“I moved away from here for about 10 years, and during that time I became very aware of the stark differences in health between rural areas and more urban or suburban areas,” Duncan said. “I became more aware of the limited access to resources and the health behaviors I didn’t see growing up in my town, and how they are linked to chronic diseases, substance use disorders, all the various health disparities that communities in our region face. It drove me to push for change. Working with Ross and the Prevention Research Center showed me you can have an impact on those outcomes.”
The pandemic disruptions made it difficult to assess the impact of the social- and community-level interventions, but the text messaging proved effective at increasing physical activity. Since the project wrapped up, some of the communities have continued promoting physical activity by supporting walking groups and hosting local events as part of Walktober, an international event to promote walking.
Beck AM, Serrano N, Duncan D, Eyler AA, Gilbert A, Naghiloo F, Reis R, Tabak RG, Brownson RC. “Cluster randomized multilevel intervention for promoting physical activity in rural communities.” Frontiers in Public Health. August 28, 2025. DOI: 10.3389/fpubh.2025.1577056.
This work was supported by the National Cancer Institute at the National Institutes of Health (NIH) (grant number R01CA211323), the Centers for Disease Control and Prevention (CDC)(grant number U48DP006395 to Washington University in St. Louis), and the Foundation for Barnes-Jewish Hospital. The clinical trial is registered at clinicaltrials.gov, identifier NCT03683173. The findings and conclusions are those of the authors and do not necessarily represent the official positions of the NIH or the CDC.
Writer
Tamara Schneider, MPH, PhD, is the senior science writer and assistant director of communications for WashU School of Public Health. She holds a bachelor’s degree in molecular biophysics & biochemistry and in sociology from Yale University, a master’s in public health from the University of California, Berkeley, and a PhD in biomedical science from the University of California, San Diego.