Multilevel determinants of physical activity in rural breast cancer survivors: a mixed-methods study

Abstract Background Rural breast cancer survivors are less likely to meet physical activity (PA) recommendations than those residing in urban areas. Ecologic frameworks account for multilevel factors related to PA and may be used to contextually adapt interventions to meet the needs of underserved cancer survivors. This study explored ecologic determinants of PA in rural breast cancer survivors to inform future intervention adaptations and implementation in rural communities. Methods An explanatory sequential mixed-methods design was used to explore determinants among breast cancer survivors who resided in a rural area. Surveys included measures of individual, social, and environmental factors that influence PA, and in-depth interviews expanded on multilevel determinants of PA and preferences. Results Rural cancer survivors ( N = 219) completed questionnaires. Of those, 67 were breast cancer survivors and included in quantitative analyses, and 38 completed an interview. Participants were in their early 60s ( M age = 62.0 ± 13.1) and were 7.2 ± 8.1 years post-diagnosis. Less than half (46.2%) were physically active and meeting PA recommendations. Regression models identified multilevel factors associated with greater PA, after adjusting for age and education, including motivational readiness, lower perceived stress and depressive symptoms, PA infrastructure, and aesthetic qualities of the environment. Interviews revealed additional factors that influence PA in rural breast cancer survivors, including their individual history and PA habits pre-diagnosis, how the shared experience within a cancer support group shapes their PA, and how residing in a rural community or area impacts their PA. Additionally, participants shared multilevel barriers to being physically active, including a lack of motivation and social support, cost, limited access to resources, and characteristics of the built environment. Congruencies and incongruencies between quantitative and qualitative findings were identified. Conclusions Mixed-methods findings from this study highlight the multilevel, interactive complexities that influence PA adoption and maintenance in rural breast cancer survivors. Findings enhance understanding of the unique needs of cancer survivors residing in rural communities and inform the adaptation of evidence-based interventions for implementation in rural communities.