We identified 9,879 records through a search of PubMed, Psych Info, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Public Affairs Information Service, and Common Community Measures for Obesity Prevention references. Of these, 1,998 were identified as relevant. We identified 4 additional records through reference lists. Of 2,002 records screened, 1,514 duplicates were removed, and 488 records remained. When these 488 records were screened for eligibility, 443 records were excluded for various reasons: was not an intervention, was an abstract only, did not focus on physical activity, did not include policy or environmental focus, or did not specify rural results. The remaining 45 articles, representing 41 distinct studies, were assigned for data extraction. Fifteen articles were excluded during extraction: 5 were descriptive or formative studies not linked to intervention; 3 lacked sufficient detail; 2 were conducted outside United States or Canada; 1 did not have rural target population; 1 was not a primary source; 1 focused on instrument development; 1 had no policy or environmental strategy implemented; and 1 did not report results. Thus, 30 articles representing 26 distinct studies were included in the final synthesis.

Figure. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram for study inclusion in a systematic review of physical activity–related policy and environmental strategies for obesity prevention in rural communities. Abbreviations: CINAHL, Cumulative Index to Nursing and Allied Health Literature; PAIS, Public Affairs Information Service; COCOMO, Common Community Measures for Obesity Prevention (21).

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