Promoting Physical Activity in Rural Settings: Effectiveness and Potential Strategies : Translational Journal of the American College of Sports Medicine

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Original Investigation

Promoting Physical Activity in Rural Settings: Effectiveness and Potential Strategies

Smith, Whitney J.1; Martin, Michelle Y.2; Pisu, Maria3; Oster, Robert A.3; Qu, Haiyan4; Shewchuk, Richard M.4; Sheffield, Mary E.5; Minter, Alex5; Baumann, Ana A.6; Rogers, Laura Q.3

Author Information
Translational Journal of the ACSM 6(4):e000180, Fall 2021. | DOI: 10.1249/TJX.0000000000000180
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Cancer survivors who meet the recommended 150 min or more of moderate to vigorous physical activity per week experience improved energy levels, physical well-being, and overall quality of life along with reduced risk of cancer recurrence and mortality (1,2). Most cancer survivors do not participate in the above recommendations (3,4). Women cancer survivors are more likely than men to forego physical activity posttreatment, and rural survivors engage in less physical activity than their urban counterparts (5,6). As a result, it is necessary to promote increased physical activity in this at-risk population. This requires implementing evidence-based physical activity programs for cancer survivors by nonresearch staff in rural community settings (7).

One such evidence-based intervention is the Better Exercise Adherence after Treatment for Cancer (BEAT Cancer) program that involved supervised exercise sessions, independent exercise supported by individual physical activity counseling, and six group discussion sessions (8,9). This efficacious social cognitive theory-based physical activity behavior change intervention improves physical activity adherence, cardiorespiratory fitness, quality of life, and multiple patient-reported outcomes (8,10–14). Given this highly beneficial physical activity promotion program, evaluating its potential for delivery by community-based interventionists and management by community organizational staff is warranted. Doing so provides practical information for individuals interested in promoting physical activity interventions while also contributing research knowledge to the field of implementation science.

Evaluating the effectiveness of interventions when implemented in new settings is critical for improving public health through effective and broader adoption of efficacious interventions (14). This is particularly true for physical activity promotion programs for rural cancer survivors, an at-risk population for whom research related to physical activity translation is limited. Therefore, our study purpose was to evaluate the effectiveness of an evidenced-based physical activity promotion program (BEAT Cancer) for rural women cancer survivors and use program evaluation to explore strategies to improve the future implementation of BEAT Cancer.


Overview and Study Design

In collaboration with a rural community clinical care organization, a pre-post study design assessed proof-of-concept program effectiveness when delivered by nonresearch staff for rural women cancer survivors. Both interventionists and cancer survivors evaluated the program using survey and/or nominal group technique (NGT). Participating organizations obtained institutional review board approval, and written informed consent was obtained from cancer survivors and interventionists before initiating study activities.

Intervention Description and Adaptations during Implementation

BEAT Cancer is a 3-month evidenced-based physical activity promotion program that has been proven efficacious when delivered by research staff in a multicenter randomized controlled trial (8,10–13). It included 12 supervised in-person aerobic exercise sessions during the first 6 wk tapered to fully independent, unsupervised aerobic exercise by the last 6 wk. During the last 6 wk, participants also met biweekly with exercise staff to provide updates on adherence and receive physical activity counseling and recommendations. Participants also attended six discussion group meetings throughout the physical activity program during which they received education and counseling targeting self-efficacy, exercise barriers, goal setting, time management, etc. (8,9).

For this rural implementation, the community intervention delivery staff (identified by the community organization) were required to meet the following criteria for safety and logistical reasons: 1) possession of qualifications related to at least one of the intervention activities (i.e., exercise specialist, discussion group leader, or administrative staff [for logistical activities such as scheduling, printing materials, etc.]); 2) ≥19 yr old; 3) residency in site county or adjacent county; 4) English speaking; 5) intact hearing; 6) no history of dementia or organic brain syndrome; and 7) no medical, psychological, or social characteristic that would interfere with ability to properly transfer intervention information and adequately assess participants.

Several intervention adaptations were made when adapting BEAT Cancer for rural women cancer survivors in a community site. The participant education materials (e.g., text, worksheets) were simplified and adapted for application to any cancer type (rather than only breast cancer) by original efficacy study research team members using literature review and our previously published stakeholder input (15–17). The community interventionists were informed of the program core components and their intent as follows: 1) group sessions for support, encouragement, accountability, and behavioral capability; 2) participant education materials for facilitating learning and engagement; 3) supervised exercise sessions for individualization, accountability, behavioral capability, self-efficacy, overcoming barriers, and identifying personally important benefits; 4) unsupervised exercise for self-efficacy and overcoming barriers; and 5) update physical activity counseling sessions for support, encouragement, individualization, positive reinforcement, and overcoming barriers. As a result, the community interventionists made several adaptations that maintained the core components while improving fit with the community organization’s staffing and resources (e.g., simplifying logistics by scheduling group sessions or supervised sessions more evenly over time rather than strictly tapered; shortening group meeting duration; using exercise modes other than walking; supervising several cancer survivors during one session while providing the individualization as needed; shortening staff documentation formats). Interventionists were trained using a half-day in-person workshop, implementation toolkit, and ongoing access to intervention experts.

Cancer Survivors Receiving the Intervention: Eligibility Criteria and Recruitment

For intervention effectiveness and cancer survivors’ program evaluation components, 16 rural women cancer survivors who were postprimary treatment received BEAT Cancer implemented by a rural community cancer care organization. This site was located in or adjacent to counties with Rural–Urban Continuum Code (RUCC) classification of completely rural or <2500 urban population, adjacent [RUCC = 8] or not adjacent [RUCC = 9] to a metro area (18). Cancer survivors’ eligibility criteria included 1) adult women with a history of any cancer type (excluding skin cancer other than melanoma), stage, and years since diagnosis; 2) postprimary cancer treatment; 3) residents of site county or adjacent counties; 4) ambulatory without assistance; 5) English speaking; 6) intact hearing; 7) no contraindication to moderate intensity exercise; 8) physician clearance for participation in moderate intensity exercise; 9) no history of dementia or organic brain syndrome; and 10) no medical, psychological, or social characteristic that would interfere with ability to fully participate. Participants were recruited via personal invitation, flyers placed in waiting rooms, support groups, and media advertisements. All potential participants underwent telephone screening during which the study was described and eligibility determined. Participants were invited to an orientation during which study participation was explained and written informed consent obtained.

Intervention Effectiveness Evaluation


Cancer survivor and interventionist characteristics were assessed by self-administered survey before implementation. Program effectiveness was evaluated using accelerometer and self-administered survey pre- and postprogram receipt (cancer survivors only). Program evaluation was completed postprogram using self-administered survey (cancer survivors) and NGT (cancer survivors and intervention delivery staff).

Effectiveness outcome: physical activity

Physical activity was measured by accelerometer (worn at waist during waking hours) and self-report. Cancer survivors completed an accelerometer log recording when accelerometer was removed/replaced and start/end times for exercise done when not wearing the accelerometer. This was particularly important for imputing activity minutes because some cancer survivors chose to do pool exercises. Activity duration and intensity were calculated using the following accelerometer activity count cut points: 1) inactive (0–499 counts per minute, 2) light (500–1951 counts per minute), 3) moderate (1952–5724 counts per minute), and 4) vigorous (5725+ counts per minute) (19,20). Physical activity was also self-reported using the Godin Leisure Time Exercise Questionnaire, and the average weekly duration of light, moderate, and vigorous activity was calculated (21–23). Meeting recommendations of ≥150 min of weekly moderate to vigorous physical activity (an intervention goal) was also calculated by doubling vigorous minutes before adding to moderate minutes (24).

Effectiveness Secondary Outcomes

Psychosocial functionality

Health-related quality of life was measured by the Functional Assessment of Cancer Therapy—General (25), in which the sum of 5-point Likert scales (0 = not at all, 4 = very much) for 27 different items were categorized into physical, social/family, emotional, and functional well-being. Thus, summed items could range from 0 to 108, with higher scores indicating better quality of life. Because the cancer survivors had a history of mixed cancer types, additional concerns subscales were not obtained. In addition to health-related quality of life, global quality of life was measured with the Satisfaction with Life Scale (26). The 5-item Satisfaction with Life Scale uses a 7-point Likert response (1 = strongly disagree to 7 = strongly agree) with items summed for analysis (possible range of 7 to 35, with higher score indicating a better global quality of life). Fatigue intensity and interference over the past 7 d was measured with the 13-item multidimensional fatigue scale (i.e., Fatigue Symptom Inventory; possible range 1 to 10 with higher scores indicating greater fatigue) (27). Sleep dysfunction was measured subjectively using the Pittsburgh Sleep Quality Index with scoring according to published protocol (28). The Pittsburgh Sleep Quality Index global score is the sum of seven subscales (i.e., subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction) with a possible range of 0 to 21 and higher scores indicating greater sleep dysfunction. Anxiety and depression were measured using the Hospital Anxiety and Depression Scale (HADS) (29). HADS has seven items each for anxiety and depression with each item scaling from 0 to 3. Thus, total scores ranged from 0 to 21 for both anxiety and depression, with a total HADS score ranging from 0 to 42 (higher scores represent greater anxiety and depression symptoms).

Social cognitive theory constructs

Self-efficacy barriers (cancer survivor confidence in overcoming exercise barriers) were assessed using a nine-item scale previously used with cancer survivors (30). A walking task self-efficacy scale included six items to assess a cancer survivor’s confidence in her ability to walk at a moderately fast pace for several durations (5, 10, 15, 20, 25, and 30 min) (31). The Likert scale was used, and scale items were averaged to calculate both barriers and walking task self-efficacy with a possible range of 0% (not at all confident) to 100% (extremely confident). In addition to self-efficacy, barriers interference was assessed using 21 items and a 5-point Likert scale (1 = never to 5 = very often) to reflect how often barriers interfered with exercise (responses summed for total score; higher score indicates greater perceived exercise barriers interference) (32). Cancer survivors reported physical activity enjoyment on a 5-point Likert scale (range 1 to 5; higher score indicates greater enjoyment) (33). Exercise social support was assessed for friends, family, and both using four items and 5-point Likert scale (range of 0 to 8 for friends only or family only and range of 0 to 16 for both combined) (34).

Intervention effectiveness statistical analysis

Descriptive statistics were calculated. Pre- and postprogram mean and SD values were calculated and compared using a paired t-test for which 95% confidence intervals, P values, and effect sizes were reported. Within-group difference and corresponding SD values were also calculated and reported. Participants meeting versus not meeting recommendations from pre- to postprogram were compared using a McNemar test.

Program Evaluation

Self-administered survey (cancer survivors)

To garner feedback on the program and to improve future implementation efforts, cancer survivors completed a two-page self-administered program evaluation survey. Two items asked cancer survivors to indicate if their exercise increased during the program and would they recommend the program to others on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Similarly, cancer survivors were asked to provide an overall program ranking of poor, fair, good, very good, or excellent. Several yes/no questions asked the cancer survivors if they participated in another exercise program during the intervention or experienced improvements and/or worsening in problems or medical conditions as a result of the intervention. Open-ended questions were also provided to enable participants to offer feedback, which might not otherwise be accounted for in the scaled questions.

NGT (cancer survivors and interventionists)

NGT sessions were conducted postimplementation with cancer survivors who completed the BEAT Cancer program (three sessions) and interventionists (one session). The NGT obtains and prioritizes responses to one specific question from a group of individuals following a well-established, published protocol (35). Procedures were as follows: 1) the BEAT Cancer intervention was reviewed, 2) the NGT question was stated in verbal and written format, 3) participants silently wrote down as many responses as possible on a worksheet, 4) a round-robin approach was used to allow participants to state the responses (one at a time) until no more new items were generated (responses were recorded on a board that all could see during this process), 5) nonevaluative discussion of responses for clarification, and 6) anonymous written votes were completed by each participant (i.e., top three responses ranked from 3 = most important to 1 = third most important were written on an index card, which was collected by the group leader). An initial tabulation of the voting results was presented to the group for closure and to allow the opportunity for members to share additional information. Three groups of cancer survivors with four to five participants in each group completed this procedure with the following NGT question: “What about the BEAT Cancer program is helpful in regard to providing healthy lifestyle support for cancer survivors?” The same groups repeated this procedure with the following question: “What improvements in the BEAT Cancer program could be made to better help rural breast cancer survivors incorporate activity into their lifestyle?” Group 3 was unable to vote on the second question because of lack of time. Finally, one group of five interventionists completed this procedure with the following question: “What can be done to prepare an organization or facility to implement a program for cancer survivors such as the BEAT Cancer program?” For each question, the sum of all votes per response and voting percentage per response were calculated.


Cancer Survivors and Interventionists

Program recipients included 16 women cancer survivors with characteristics summarized in Table 1. Mean age was 58 ± 12 yr with 62% being White, 31% reporting annual household income ≤ $20,000, and 31% having ≤12 yr of education. Mean months since cancer diagnosis was 54 ± 72 (median = 35; range = 11–300) with 69% reporting a history of breast cancer. All 16 cancer survivors completed the intervention (i.e., participated in any of the program activities and completed a postprogram evaluation). A preintervention survey was missing on one participant, and three cancer survivors did not participate in the postprogram NGT group program evaluation session. No adverse events were reported.

TABLE 1 - Women Cancer Survivors Participating in a Proof-of-Concept Implementation Pilot Study.
Variable Women Cancer Survivors (N = 16) a
Age (yr) 58 ± 12 (37–83)
 Not Hispanic/Latino 11 (100)
 White/Caucasian 10 (62)
 Black/African American 6 (38)
 ≤$20,000 5 (31)
 >$20,000 to <$50,000 4 (25)
 ≥$50,000 6 (38)
 Missing 1 (6)
 ≤12 yr 5 (31)
 13–16 yr 6 (38)
 >16 yr 5 (31)
Mean number of comorbidities 2.5 ± 1.6 (0–5)
Marital status
 Married 11 (69)
 Not married or partnered 5 (31)
Current smoker (yes) 0 (0)
Alcohol (yes) 3 (19)
Cancer type
 Breast 11 (69)
 Other (melanoma, lung, leukemia, uterine, cervical) 5 (31)
Cancer stage
 0 or 1 4 (25)
 2 7 (44)
 3 2 (12)
 Missing or unknown 3 (19)
Months since cancer diagnosis 54 ± 72 (11 to 300)
Prior cancer surgery (yes) 14 (88)
Prior radiation therapy (yes) 11 (69)
Prior chemotherapy (yes) 10 (63)
Distance from home to implementation site b 10 ± 10 (3–35)
Distance from job to implementation site b, c 11 ± 15 (0–40)
a Values are presented as mean ± SD (range) or n (%).
b Distance from home and job to the implementation site reported in miles.
c Participants who were used (n = 7).

The five interventionists implementing the program and completing the postprogram NGT had a mean age of 42.5 ± 15.6 yr (range 40 to 70) and education of 16.6 ± 0.9 yr. All were non-Hispanic White with four being women (80%) and four reporting an annual household income ≥ $50,000. Three were fitness instructors, and the remaining included a wellness director and health educator.

Cancer Survivor Adherence to Program Activities

Of the 12 supervised exercise sessions offered to each participant throughout the physical activity program, mean attendance was 10 ± 1.6 sessions per participant with 88% of participants attending ≥75% of the 12 sessions. Of the six discussion group meetings offered, mean attendance was 4.9 ± 1.0 sessions per participant with 94% attending at least four of the six groups. Adherence to update physical activity counseling sessions was not tracked by the implementing site.

Intervention Effectiveness

Effectiveness data are summarized in Table 2. Statistically significant within-group differences were noted for weekly minutes of self-report moderate physical activity (mean within-group difference [M] = 94 ± 106, P = 0.005), self-report moderate to vigorous physical activity (M = 146 ± 186, P = 0.009), weekly minutes of accelerometer moderate physical activity (M = 74 ± 88, P = 0.015), HADS anxiety subscale (M = −1.3 ± 1.8, P = 0.016), HADS depression subscale (M = −2.1 ± 2.0, P = 0.001), and HADS total score (M = −3.4 ± 3.1, P = 0.001). Significant changes were also found for walking task self-efficacy (M = 20.9 ± 30.5, P = 0.019), perceived barriers interference (M = −15.0 ± 14.1, P = 0.001), friend social support (M = 2.7 ± 3.7, P = 0.015), and total social support (M = 5.0 ± 7.4, P = 0.02). The remaining outcomes were not statistically significant. The percent meeting physical activity recommendations of ≥150 weekly minutes of moderate to vigorous intensity physical activity increased from 13% to 47% based on self-report (P = 0.125) and from 50% to 75% (P = 0.25) based on accelerometer.

TABLE 2 - Changes in Physical Activity, Patient-Reported Outcomes, and Social Cognitive Theory Constructs during the Implementation of an Evidence-Based Physical Activity Program by a Rural Community Cancer Care Organization.
Variable Preprogram Postprogram Within-Group Change 95% Confidence Interval P Value Effect Size
Mean SD Mean SD Mean SD Lower Upper
Physical activity (weekly minutes)
Self-report moderate intensity 18 44 112 88 94 109 33 155 0.005 0.86
Self-report vigorous intensity 6 23 32 56 26 61 −8 60 0.121 0.43
Self-report moderate to vigorous intensity a 30 77 176 159 146 186 43 249 0.009 0.78
Accelerometer b moderate intensity 158 96 232 96 74 88 18 130 0.015 0.84
Accelerometer b vigorous intensity 21 64 1 3 −20 65 −66 27 0.361 −0.31
Accelerometer b moderate to vigorous a 193 148 234 99 41 135 −44 127 0.313 0.30
Quality of life (FACT-General) 87.2 17.0 90.0 15.9 2.8 6.7 −1.1 6.7 0.141 0.42
Physical well-being 23.6 4.4 22.3 5.9 1.3 3.4 −0.6 3.1 0.170 0.37
Social well-being 21.3 5.6 21.2 6.8 0.0 2.6 −1.5 1.4 0.948 −0.02
Emotional well-being 21.7 3.0 22.0 2.1 0.3 3.0 −1.4 2.0 0.725 0.10
Functional well-being 21.1 5.5 22.3 5.7 1.1 3.6 −0.8 3.1 0.238 0.32
Satisfaction with life 24.4 8.4 23.6 8.4 −0.8 5.1 −3.6 2.0 0.556 −0.16
Fatigue intensity 4.4 2.8 3.9 2.0 −0.6 2.5 −2.0 0.8 0.400 −0.22
Fatigue interference 3.6 2.6 3.0 2.0 −0.6 2.1 −1.8 0.6 0.279 −0.29
Sleep dysfunction (PSQI global) 7.9 4.0 7.7 4.7 −0.2 2.7 −1.7 1.3 0.774 −0.08
 Anxiety 5.7 3.9 4.5 3.3 −1.3 1.8 −2.3 −0.3 0.016 −0.71
 Depression 4.8 3.5 2.7 2.4 −2.1 2.0 −3.2 −1.0 0.001 −1.07
 Total 10.5 6.8 7.1 5.5 −3.4 3.1 −5.1 −1.7 0.001 −1.10
Barriers self-efficacy 51.2 23.8 50.4 18.5 −0.7 27.9 −16.2 14.7 0.920 −0.03
Task self-efficacy 49.4 26.2 70.3 31.3 20.9 30.5 4.0 37.8 0.019 0.68
Perceived barriers interference 55.9 12.1 40.9 13.3 −15.0 14.1 −22.8 −7.2 0.001 −1.06
Physical activity enjoyment 3.9 1.2 4.4 0.8 0.5 1.2 −0.2 1.2 0.151 0.41
Social support
 Family 2.0 2.6 2.0 4.4 2.3 5.0 −0.4 5.1 0.092 0.47
 Friends 2.8 3.0 2.8 2.8 2.7 3.7 0.6 4.7 0.015 0.72
 Total 4.8 5.3 4.8 6.3 5.0 7.4 0.9 9.1 0.020 0.68
FACT-General, Functional Assessment of Cancer Therapy—General; PSQI, Pittsburgh Sleep Quality Index.
a Vigorous minutes doubled before adding to moderate intensity minutes.
b Accelerometer data imputed due to nonwear activities such as swimming.

Program Evaluation (Self-Administered Survey Completed by Cancer Survivors)

Program evaluation data are summarized in Table 3. The majority of cancer survivors reported increased exercise during the program (88%), would recommend the program to others (88%), rated the program very good or excellent (94%), and experienced program benefits (94%). Qualitative comments from participants less likely to recommend the program indicated a desire for more pool exercises and more exercise meetings with the group. Cancer survivors reporting participating in another exercise program listed classes outside the program (e.g., yoga, Zumba, etc.) and walking on their own outside.

TABLE 3 - Cancer Survivor Self-Administered Program Evaluation Survey.
n (%)
My exercise increased during the program
 Agree 14 (88)
 Neutral 2 (12)
 Disagree 0 (0)
I would recommend the BEAT Cancer program to others
 Agree 14 (88)
 Neutral 1 (6)
 Disagree 1 (6)
How would you rank the BEAT Cancer program?
 Poor/fair 0 (0)
 Good 1 (6)
 Very good 4 (25)
 Excellent 11 (69)
Participated in another exercise program in the past 3 months (yes) 2 (12.5)
Experienced benefits as a result of the exercise program (yes) 15 (94)
Experienced problems as a result of the exercise program (yes) 0 (0)
Program improved medical problems (yes) 9 (56)
Program worsened medical problems (yes) 0 (0)

Nine cancer survivors stated improvements in medical problems during the program that were specified as follows: reduced blood pressure, increased energy, increased joint flexibility and reduced joint pain, strength to better endure medical issues, arm lymphedema improved, and weight loss. Responses to the remaining open-ended questions are summarized as follows:

  • What part of the program was most helpful?
    • o The exercise, other participants (role models), trainer compassion and motivation, encouragement, group exercise, water exercises, increased awareness of exercise benefits related to cancer recurrence, exercise knowledge (what to do, how to progress, how to use equipment), accountability
  • What would you change about the program?
    • o Add nutrition, obtain insurance coverage (perhaps through physician prescription), better exercise log sheet, faster exercise progression, reduce cost for individuals with limited income, more group meetings, more water classes
  • List benefits you experienced as a result of the program
    • o Better attitude and mood, obtained a workout plan, increased muscle strength and cardiorespiratory fitness, motivation (to do more, work out, and be healthy), exercise knowledge, felt better, met new people, more energy, less pain, weight loss, better sleep, increased self-confidence
  • Do you have other comments for us?
    • o “Before cancer I could carry 50 lbs of dog food—gone through treatment—not carrying any. Then I went to 14 lbs, 25 lbs, 31 lbs. After the 2.5 months in BEAT I’m back carrying 50 lbs! Why is this important—I live alone and have 7 dogs.”
    • o “I am a fan of this program! It has made a big difference in my life! More than I had hoped or expected.”

Program Evaluation (NGT with Cancer Survivors and Interventionists)

The postprogram NGT cancer survivor group data for responses receiving a vote are provided in Tables 4 and 5 with data for the interventionists’ NGT session provided in Table 6. Of note, a low vote ranking does not indicate the suggestion is not important but rather indicates prioritization of all items of sufficient importance to receive at least one vote.

TABLE 4 - Cancer Survivors’ NGT Scores Weighted by Ranking in Response to the Question: “What about the BEAT Cancer Program Is Helpful in Regard to Providing Healthy Lifestyle Support for Cancer Survivors?”
Response No. Votes Votes Assigned a Sum of Votes No. Votes
Cancer survivor NGT group 1 (n = 5)
 Support from staff and other participants 3 3, 3, 1 7 23
 Shared experience 3 2, 3, 2 7 23
 Individualized exercise prescription 2 3, 2 5 17
 Accountability 2 1, 2 3 10
 Provides opportunity for progress 1 3 3 10
 Caring staff and environment 1 2 2 7
 Increased energy 1 1 1 3
 Importance of exercise value 1 1 1 3
 Distraction (cleared mind) 1 1 1 3
 Total 15 30 100
Cancer survivor NGT group 2 (n = 4)
 Individualized plan/personal 2 3, 3 6 25
 Motivation/commitment/meeting expectations 2 2, 3 5 21
 Produced results; improved overall health 2 2, 2 4 17
 Free 3-month (gym) membership 1 3 3 13
 Social interaction with other participants 2 1, 1 2 8
 Shared experience 1 2 2 8
 Exercise knowledge/instruction 1 1 1 4
 Variety of exercises 1 1 1 4
 Total 12 24 100
Cancer survivor NGT group 3 (n = 4)
 Personalized exercise plan 3 1, 1, 3 5 21
 Instruction (on how to exercise) 2 2, 2 4 17
 Social group support 1 3 3 12.5
 Motivation (work harder in a group) 2 2, 1 3 12.5
 Accountability 1 3 3 12.5
 Encouragement 1 3 3 12.5
 Self-evaluation of health 1 2 2 8
 Exercise frequency 1 1 1 4
 Total 12 24 100
a Participants voted for three responses in order of importance, with 3 being the most important and 1 being the third most important.

TABLE 5 - Cancer Survivors’ NGT Scores Weighted by Ranking in Response to the Question: “What Improvements in the BEAT Cancer Program Could be Made to Better Help Rural Breast Cancer Survivors Incorporate Activity into Their Lifestyle?”
Response No. Votes Votes Assigned a Sum of Votes No. Votes
Cancer survivor NGT group 1 (n = 5)
 More supervised exercise classes 6 3, 3, 1, 3, 2, 3 15 50
 Facility issues/privacy in locker room 4 1, 2, 2, 3 8 27
 Provide guides for home exercise 3 1, 2, 2 5 17
 Variety of exercises 2 1, 1 2 7
 Total 15 30
Cancer survivor NGT group 2 (n = 4)
 Nutrition education 3 3, 3, 2 8 33
 Share more resources (Web site s, recipes, etc.) 3 1, 2, 3 6 25
 Expand content (sleep diet, stress, etc.) 3 1, 3, 2 6 25
 Healthy environment (healthier options in vending machine) 2 2, 1 3 13
 Dedicated space 1 1 1 4
 Total 12 24 100
Cancer survivor NGT group 3 (n = 4) N/A
a Participants voted for three responses in order of importance, with 3 being the most important and 1 being the third most important.

TABLE 6 - Interventionists’ NGT Scores Weighted by Ranking in Response to the Question: “What Can be Done to Prepare an Organization or Facility to Implement a Program for Cancer Survivors such as the BEAT Program?”
Response No. Votes Votes Assigned a Sum of Votes No. Votes
Interventionists’ NGT group (n = 5)
Organization—setup, logistics, time, date, etc. 3 3, 2, 2 7 23
Required staff knowledge of exercise/training 3 2, 1, 3 6 20
Create certification standards for staff and site 2 3, 3 6 20
Follow-up—continued support for participants 2 2, 3 5 17
Providing flexibility in programs 2 1, 2 3 10
Cost information 2 1, 1 2 7
Identify necessary resources—minimum, optimal 1 1 1 3
Total 15 30 100
a Participants voted for three responses in order of importance, with 3 being the most important and 1 being the third most important.


A physical activity promotion program for rural women cancer survivors demonstrated potential effectiveness when implemented by a rural site based on this proof-of-concept study. Moderate to vigorous physical activity increased significantly from pre- to postprogram. The retention of BEAT Cancer efficacy when implemented in a rural setting is also supported by an absolute pre- or postintervention within-group mean change in several outcomes that met or exceeded that reported in the efficacy study (e.g., self-reported physical activity, physical well-being, fatigue, anxiety, depression, barriers self-efficacy, perceived barriers interference) (8,10,36). Also, the absolute before or after mean change exceeded the minimal important difference for HADS depression and total scores (37). The outcomes demonstrating a change similar to original efficacy are notable given that our inclusion criteria (e.g., any physical activity level at baseline) were broader than that of the efficacy study (e.g., only enrolled women who were insufficiently physically active).

Similar to the original BEAT Cancer efficacy study (8), the self-reported physical activity was less than the accelerometer activity and is most likely due to the accelerometer measuring all movement while self-report measure only asks about intentional leisure activity. Also, the decrease in vigorous accelerometer physical activity from pre- to postprogram most likely occurred because a single participant was active at baseline but very inactive during the postprogram accelerometer monitoring week due to a respiratory illness. If that single participant is excluded from our analysis, then our outcomes improve with mean change in weekly minutes of accelerometer vigorous exercise reversing to 0.71 (P = 0.60) and moderate to vigorous increasing to a statistically significant change of 132 (P = 0.028).

With regard to physical activity promotion programs testing efficacy and focused specifically on rural cancer survivors, our improvement in the proportion of survivors meeting recommendations (based on self-report) is similar to that reported for a health coaching intervention in rural Australia for mixed cancer types (men and women) (38). In a 6-month weight loss program for rural breast cancer survivors, the intervention group increased their accelerometer moderate to vigorous physical activity by 46.9 weekly minutes, which is also similar to our findings (39).

Studies reporting the implementation of exercise programs for cancer survivors by nonresearch staff in clinical or community settings have demonstrated that effectiveness is usually smaller than efficacy benefits and implementation has rarely focused on rural cancer survivors. Pinto et al. (40) implemented a telephone-based physical activity intervention for breast cancer survivors (Northeastern United States) using peer counselors; the pre- or postincrease in self-report moderate to vigorous physical activity was 118.93 weekly minutes in the efficacy study and 97.7 weekly minutes when the program was delivered by the peer counselors (40,41). Leach et al. (42) implemented an academic center-based intervention using staff within an urban YMCA (Canada) with similar improvements in the 6-min walk test (compared with efficacy), but quality of life benefits were not statistically significant. Similarly, Beidas et al. (43) implemented a resistance exercise intervention for breast cancer survivors using physical therapists at a large, urban cancer center with statistically significant benefits that were smaller than the original efficacy study. Hence, our data reported here supports BEAT Cancer as achieving physical activity effectiveness similar to the efficacy of other programs for rural cancer survivors while also demonstrating limited attenuation of efficacy commonly reported by others. Moreover, additional research focused on how to best implement physical activity programs for rural cancer survivors specifically is an emerging field warranting further study.

The vast majority of our participants rated the program as very good or excellent. Most cancer survivors found the program helpful because of individualized exercise plans, instruction and support from staff, shared experiences, and results produced. These findings suggest program “core components” potentially important to maintain as the intervention is adapted to new settings. The future implementation of BEAT Cancer should also consider suggested improvements such as program flexibility, more supervised exercise classes, and expanding content to include sleep, diet, stress, etc.

Few implementation studies of evidence-based physical activity programs for cancer survivors have reported program evaluation data. Beidas et al. (43) focused on program evaluation from an interventionist standpoint and reported that interventionists believe individualized exercise training is better than group training when resistance training is provided by physical therapists. This finding is consistent with our participants’ endorsement of the individualized exercise prescription and staff support. Leach et al. (42) focused on participant program evaluation and reported findings comparable to our program evaluation (i.e., emphasized the importance of group activities for support and encouragement). Taken as a whole, these studies along with our data reported here support the inclusion of both individualized exercise training and group elements in physical activity promotion programs for rural cancer survivors when feasible.

With regard to preparing organizations for program implementation (e.g., organizational readiness), the interventionists identified several important implementation strategies primarily focused on logistics and ensuring staff expertise. These data suggest design features to consider when practitioners and researchers develop and implement similar physical activity programs for rural cancer survivors (e.g., staff certification, longer participant follow-up, financial support, etc.). Little data exist regarding other implementation strategies for improving organizational readiness for exercise and cancer programming. During preimplementation focus groups (i.e., done before the BEAT Cancer implementation reported here) (17), specific readiness strategies such as “cheat sheets,” training modules, and expert facilitation were mentioned. Our postimplementation NGT extends this work by confirming their importance and prioritizing readiness needs among interventionists who had experience implementing the program.

Strengths and Weaknesses

This study possesses several notable strengths, including its focus on an understudied, underserved population (rural cancer survivors) and important implementation science knowledge gap (translating evidenced-based physical activity programs to rural communities). Our data are strengthened by the inclusion of the interventionists’ perspectives on increasing readiness for intervention implementation, an organizational factor critical to evidence-based intervention implementation success (44). Although our study is limited by its small sample size and single implementation site, the resultant proof-of-concept data support further testing with a larger sample size, randomized controlled design, and multiple rural nonresearch sites. Other limitations should be considered. The P values were not adjusted based on multiple tests. However, the magnitude of several absolute before or after within-group mean changes and the effect sizes (regardless of P value) satisfy the goals of this proof-of-concept study by justifying testing effectiveness in a larger trial. Moreover, we have previously reported that the intervention implementation cost to our community organizational partner was $350 per participant, yet additional research is needed to elucidate cost to the participant (e.g., exercise clothes, time, etc.) (17). With regard to staff training, our implementation effort used an in-person workshop, implementation toolkit, and access to intervention experts, yet research is needed to identify and test additional useful training strategies suggested in a prior publication (e.g., online educational modules with posttests, etc.) (17).


In conclusion, results suggest that evidence-based physical activity promotion programs can be effective when implemented by rural organizations and nonresearch staff. Participants experienced statistically significant improvements in physical activity, psychosocial outcomes (i.e., anxiety and depressive symptomatology), and several exercise-related social cognitive theory constructs. Overall, participants enjoyed the BEAT Cancer program and would recommend it to others. Participants found the program most helpful due to individualized, effective exercise plans and provision of exercise knowledge coupled with staff and group support. Interventionists identified several factors important to consider when preparing organizations for program implementation, including but not limited to addressing organizational logistics, staff training, and creation of certification standards.


Taken as whole, our data and that of others support the effectiveness of evidence-based physical activity promotion programs when implemented by nonresearch staff, the value of obtaining program evaluations from program recipients and interventionists, and the need for physical activity promotion programs that provide individualized assistance and opportunities for group support. Broader dissemination and implementation of physical activity programs should continue to be pursued to benefit rural cancer survivors. Further research informed by multilevel perspectives (cancer survivors, interventionists, and other stakeholders) that also tests effectiveness and determines optimal implementation strategies is warranted. It is also essential that future studies include implementation science frameworks (e.g., RE-AIM [45]) to plan and evaluate the translation of physical activity promotion programs for cancer survivors living in rural communities.

This project was supported by the National Cancer Institute (grant nos. R21CA182601 and R25CA76023). Dr. Baumann is supported by 3U01HL133994-02S1, R01HG009351, U24HL136790, and UL1TR00234.

All authors declare that no conflicts of interest exist. The views of this article do not constitute endorsement by the American College of Sports Medicine.


1. Campbell KL, Winters-Stone KM, Wiskemann J, et al. Exercise guidelines for cancer survivors: consensus statement from International Multidisciplinary Roundtable. Med Sci Sports Exerc. 2019;51(11):2375–90. doi:10.1249/MSS.0000000000002116.
2. Patel AV, Friedenreich CM, Moore SC, et al. American College of Sports Medicine roundtable report on physical activity, sedentary behavior, and cancer prevention and control. Med Sci Sports Exerc. 2019;51(11):2391–402. doi:10.1249/MSS.0000000000002117.
3. LeMasters TJ, Madhavan SS, Sambamoorthi U, et al. Health behaviors among breast, prostate, and colorectal cancer survivors: a US population-based case-control study, with comparisons by cancer type and gender. J Cancer Surviv. 2014;8(3):336–48. doi:10.1007/s11764-014-0347-5.
4. Thraen-Borowski KM, Gennuso KP, Cadmus-Bertram L. Accelerometer-derived physical activity and sedentary time by cancer type in the United States. PLoS One. 2017;12(8):e0182554.
5. Littman AJ, Tang MT, Rossing MA. Longitudinal study of recreational physical activity in breast cancer survivors. J Cancer Surviv. 2010;4(2):119–27. doi:10.1007/s11764-009-0113-2.
6. Meit M, Knudson A, Gilbert T, et al. The 2014 Update of the Rural–Urban Chartbook. Bethesda (MD): Rural Health Reform Policy Research Center; 2014.
7. Phillips SM, Alfano CM, Perna FM, et al. Accelerating translation of physical activity and cancer survivorship research into practice: recommendations for a more integrated and collaborative approach. Cancer Epidemiol Biomarkers Prev. 2014;23(5):687–99. doi:10.1158/1055-9965.EPI-13-1355.
8. Rogers LQ, Courneya KS, Anton PM, et al. Effects of the BEAT cancer physical activity behavior change intervention on physical activity, aerobic fitness, and quality of life in breast cancer survivors: a multicenter randomized controlled trial. Breast Cancer Res Treat. 2015;149(1):109–19. doi:10.1007/s10549-014-3216-z.
9. Rogers LQ, McAuley E, Anton PM, et al. Better exercise adherence after treatment for cancer (BEAT Cancer) study: rationale, design, and methods. Contemp Clin Trials. 2012;33(1):124–37. doi:10.1016/j.cct.2011.09.004.
10. Rogers LQ, Courneya KS, Anton PM, et al. Effects of a multicomponent physical activity behavior change intervention on fatigue, anxiety, and depressive symptomatology in breast cancer survivors: randomized trial. Psychooncology. 2017;26(11):1901–6. doi:10.1002/pon.4254.
11. Rogers LQ, Courneya KS, Carter SJ, et al. Effects of a multicomponent physical activity behavior change intervention on breast cancer survivor health status outcomes in a randomized controlled trial. Breast Cancer Res Treat. 2016;159(2):283–91. doi:10.1007/s10549-016-3945-2.
12. Rogers LQ, Courneya KS, Oster RA, et al. Physical activity and sleep quality in breast cancer survivors: a randomized trial. Med Sci Sports Exerc. 2017;49(10):2009–15. doi:10.1249/MSS.0000000000001327.
13. Ehlers DK, Rogers LQ, Courneya KS, et al. Effects of BEAT cancer randomized physical activity trial on subjective memory impairments in breast cancer survivors. Psychooncology. 2018;27(2):687–90. doi:10.1002/pon.4438.
14. Brownson RC, Colditz GA, Proctor EK. Dissemination and Implementation Research in Health: Translating Science to Practice. Oxford University Press; 2017.
15. Adams JL, Martin MY, Pisu M, et al. Determining patient needs to enhance exercise program implementation and uptake in rural settings for women after a cancer diagnosis. Support Care Cancer. 2021;29:4641–9. doi:10.1007/s00520-021-05990-8.
16. Qu H, Shewchuk R, Hu X, et al. Input from multiple stakeholder levels prioritizes targets for improving implementation of an exercise intervention for rural women cancer survivors. Implement Sci Commun. 2020;1(1):97. doi:10.1186/s43058-020-00061-1.
17. Rogers LQ, Goncalves L, Martin MY, et al. Beyond efficacy: a qualitative organizational perspective on key implementation science constructs important to physical activity intervention translation to rural community cancer care sites. J Cancer Surviv. 2019;13(4):537–46. doi:10.1007/s11764-019-00773-x.
18. USDA Economic Research Service. Rural–Urban Continuum Codes. Washington (DC): USDA Economic Research Service; 2013.
19. Freedson PS, Melanson E, Sirard J. Calibration of the computer science and applications, Inc. accelerometer. Med Sci Sports Exerc. 1998;30(5):777–81. Epub 1998/05/20. doi:10.1097/00005768-199805000-00021.
20. Sirard JR, Melanson EL, Li L, et al. Field evaluation of the Computer Science and Applications, Inc. physical activity monitor. Med Sci Sports Exerc. 2000;32(3):695–700. doi:10.1097/00005768-200003000-00022.
21. Godin G, Jobin J, Bouillon J. Assessment of leisure time exercise behavior by self-report: a concurrent validity study. Can J Public Health. 1986;77(5):359–62.
22. Godin G, Shephard RJ. A simple method to assess exercise behavior in the community. Can J Appl Sport Sci. 1985;10(3):141–6.
23. Jacobs DR Jr., Ainsworth BE, Hartman TJ, et al. A simultaneous evaluation of 10 commonly used physical activity questionnaires. Med Sci Sports Exerc. 1993;25(1):81–91. doi:10.1249/00005768-199301000-00012.
24. Piercy KL, Troiano RP, Ballard RM, et al. The Physical Activity Guidelines for Americans. JAMA. 2018;320(19):2020–8. doi:10.1001/jama.2018.14854.
25. Cella DF, Tulsky DS, Gray G, et al. The Functional Assessment of Cancer Therapy scale: development and validation of the general measure. J Clin Oncol. 1993;11(3):570–9. doi:10.1200/JCO.1993.11.3.570.
26. Diener E, Emmons RA, Larsen RJ, et al. The Satisfaction with Life scale. J Pers Assess. 1985;49(1):71–5. doi:10.1207/s15327752jpa4901_13.
27. Hann DM, Denniston MM, Baker F. Measurement of fatigue in cancer patients: further validation of the Fatigue Symptom Inventory. Qual Life Res. 2000;9(7):847–54. doi:10.1023/a:1008900413113.
28. Buysse DJ, Reynolds CF 3rd, Monk TH, et al. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193–213. doi:10.1016/0165-1781(89)90047-4.
29. Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand. 1983;67(6):361–70. doi:10.1111/j.1600-0447.1983.tb09716.x.
30. Rogers LQ, Courneya KS, Verhulst S, et al. Exercise barrier and task self-efficacy in breast cancer patients during treatment. Support Care Cancer. 2006;14(1):84–90. doi:10.1007/s00520-005-0851-2.
31. McAuley E, Mihalko SL. Advances in Sports and Exercise Psychology Measurement. Morgantown (WV): Fitness Information Technology, Inc.; 1998.
32. Rogers LQ, McAuley E, Courneya KS, et al. Correlates of physical activity self-efficacy among breast cancer survivors. Am J Health Behav. 2008;32(6):594–603. doi:10.5555/ajhb.2008.32.6.594.
33. Rogers LQ, Shah P, Dunnington G, et al. Social cognitive theory and physical activity during breast cancer treatment. Oncol Nurs Forum. 2005;32(4):807–15. doi:10.1188/05.ONF.807-815.
34. Sallis JF, Grossman RM, Pinski RB, et al. The development of scales to measure social support for diet and exercise behaviors. Prev Med. 1987;16(6):825–36. doi:10.1016/0091-7435(87)90022-3.
35. Van de Ven AH, Delbecq AL. The nominal group as a research instrument for exploratory health studies. Am J Public Health. 1972;62(3):337–42. doi:10.2105/ajph.62.3.337.
36. Rogers LQ, Courneya KS, Anton PM, et al. Social cognitive constructs did not mediate the BEAT cancer intervention effects on objective physical activity behavior based on multivariable path analysis. Ann Behav Med. 2017;51(2):321–6. doi:10.1007/s12160-016-9840-6.
37. Puhan MA, Frey M, Buchi S, et al. The minimal important difference of the Hospital Anxiety and Depression Scale in patients with chronic obstructive pulmonary disease. Health Qual Life Outcomes. 2008;6:46. doi:10.1186/1477-7525-6-46.
38. Ristevsk E, Trinh T, Vo N, et al. I.CAN: health coaching provides tailored nutrition and physical activity guidance to people diagnosed with cancer in a rural region in West Gippsland, Australia. J Cancer Surviv. 2020;14(1):48–52. doi:10.1007/s11764-019-00818-1.
39. Fazzino TL, Fabian C, Befort CA. Change in physical activity during a weight management intervention for breast cancer survivors: association with weight outcomes. Obesity (Silver Spring). 2017;25(Suppl 2):S109–15. doi:10.1002/oby.22007.
40. Pinto BM, Stein K, Dunsiger S. Peers promoting physical activity among breast cancer survivors: a randomized controlled trial. Health Psychol. 2015;34(5):463–72. doi:10.1037/hea0000120.
41. Pinto BM, Frierson GM, Rabin C, et al. Home-based physical activity intervention for breast cancer patients. J Clin Oncol. 2005;23(15):3577–87. doi:10.1200/JCO.2005.03.080.
42. Leach HJ, Gainforth HL, Culos-Reed SN. Delivery of an exercise program for breast cancer survivors on treatment in a community setting. Transl J Am Coll Sports Med. 2017;2(24):153–61.
43. Beidas RS, Paciotti B, Barg F, et al. A hybrid effectiveness-implementation trial of an evidence-based exercise intervention for breast cancer survivors. J Natl Cancer Inst Monogr. 2014;2014(50):338–45. doi:10.1093/jncimonographs/lgu033.
44. Weiner BJ. A theory of organizational readiness for change. Implement Sci. 2009;4:67. doi:10.1186/1748-5908-4-67.
45. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89(9):1322–7. doi:10.2105/ajph.89.9.1322.
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