Exploring the Facilitators and Barriers to Physical Activity among Adults Experiencing Food Insecurity During the Healthy Food First Trial: A Qualitative Study.

Background: Food insecurity (FI) is associated with lower physical activity (PA) and higher cardiometabolic risk. Food Is Medicine (FIM) interventions increasingly demonstrate improvements in diet quality and FI, yet little is known about perceived PA barriers and facilitators within these interventions. Objectives: To examine perceived barriers and facilitators to PA among adults experiencing FI during participation in a randomly assigned FIM intervention, with attention to the role of community health worker (CHW) coaching and factors shaping PA capacity. Methods: This qualitative study was embedded within the Healthy Food First randomized clinical trial among adults with hypertension and FI, in which participants were assigned to food support (produce delivery or grocery subsidy) with or without CHW lifestyle coaching. Semi-structured telephone interviews were conducted at 12 mo or 18 mo, depending on intervention duration. Transcripts were analyzed inductively using constant comparison. Themes were organized across 3 domains: PA engagement, CHW coaching experience, and health and PA context. Results: Interviews with 38 participants, most of whom were female (66%) and Black (53%), indicated that PA was important for health and quality of life. Motivation to remain active was common. Sustained engagement was constrained by time scarcity, fatigue, occupational demands, environmental safety concerns, weather, health complication history, and financial limitations. Social connection and access to PA-friendly environments were key facilitators. Occupational PA varied widely; physically demanding work often limited leisure-time PA. CHW support was viewed as encouraging, but a stronger emphasis on diet than PA constrained its influence on PA engagement. Participants also described bidirectional links between diet quality, energy, and capacity for PA. Conclusions: Among adults experiencing FI, motivation for PA was high, but engagement was constrained by contextual and capacity barriers. PA support within FIM interventions appears acceptable and warrants testing using more explicit, low-burden approaches delivered alongside nutrition-focused components.This trial was registered at clinicaltrials.gov as NCT05048836.