Understanding how to reach the hard to reach in cancer rehabilitation

Jenna Smith-Turchyn PT, PhD1,2*; Madison F Vani MSc, PhD(c)1; Catherine M Sabiston PhD1

1Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada.
2School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada.

Introduction: Regular exercise helps manage side effects of cancer treatment, however, less than 30% of survivors participate in regular exercise. Exercise-related barriers, facilitators, and needs of general populations of cancer survivors are described in the literature. No information exists describing this information for hard to reach populations.

Purpose: To determine the barriers, facilitators, and exercise needs of hard to reach cancer survivors.

Materials and Methods: Research design: Descriptive qualitative study. Population: Hard to reach cancer survivors, including young adults (18-39 years), those living in rural communities, and those living in areas of low socioeconomic status. Data collection: Semi-structured interviews were conducted with participants. Interviews were audio recorded and transcribed verbatim. Transcripts were coded independently by two researchers. Coded data was aggregated into nodes and grouped into themes.

Results: Five themes were identified that influence exercise participation in hard to reach survivors: accessibility of exercise programs, appropriateness of exercise programs, social support, personal factors, and exercise information. Young adults described a lack of appropriate exercise programs for their age group, those in rural settings described availability issues, and those in areas of low SES described cost and social support as barriers to exercise.

Conclusion: This project identified unique exercise-related barriers, facilitators, and needs of hard to reach cancer survivors. Results can be used by researchers and clinicians when creating exercise interventions for cancer survivors. Interventions must be tailored to the specific needs of each individual in order to facilitate accessible participation in regular exercise and facilitate sustained behaviour change.

Keywords: Exercise, physical activity, neoplasms, survivorship, hard to reach populations, barriers and facilitators

Free Full-text PDF

How to cite this article:
Jenna Smith-Turchyn, Madison F Vani; Catherine M Sabiston. Understanding how to reach the hard to reach in cancer rehabilitation. Global Journal of Nursing , 2020; 3:18. DOI: 10.28933/gjn-2020-10-3005


1. Canadian Cancer Statistics Advisory Committee. (2019). Canadian cancer statistics 2019. Toronto, ON: Canadian Cancer Society. https://www.cancer.ca/Canadian-Cancer-Statistics-2019-EN. Accessed June 22, 2020.
2.Canadian Cancer Society’s Advisory Committee on Cancer Statistics. (2017). Canadian cancer statistics 2017. Toronto, ON: Canadian Cancer Society. https://www.cancer.ca/~/media/cancer.ca/CW/can-cer% 20information/ cancer%20101/Canadian%20can-cer%20statistics/Canadian-Cancer-Statistics-2017-EN.pdf. Accessed June 22, 2020.
3. Cella D, Fallowfield LJ. Recognition and management of treatment-related side effects for breast cancer patients receiving adjuvant endocrine therapy. Breast Cancer Res Treat. 2008; 107(2): 167-180. doi:10.1007/s10549-007-9548-1
4. Ewertz M, Jensen AB. Late effects of breast cancer treatment and potentials for rehabilitation. Acta Oncol. 2011; 50(2):187-193. doi:10.3109/0284186X.2010.533190
5. Brown JC, Huedo-Medina TB, Pescatello LS, et al. The efficacy of exercise in reducing depressive symptoms among cancer survivors: A meta-analysis. Plos One. 2012; 7(1): e30955.doi:10.1371/journal.pone.0030955
6. Dennett AM, Peiris CL, Shields N, Prendergast LA, Taylor NF. Moderate-intensity exercise reduces fatigue and improves mobility in cancer survivors: A systematic review and meta-regression. J Physiother. 2016; 62(2):68-82.doi:10.1016/j.jphys.2016.02.012
7. Juvet LK, Thune I, Elvsaas IKO, et al. The effect of exercise on fatigue and physical functioning in breast cancer patients during and after treatment and at 6 months follow-up: A meta-analysis. Breast. 2017;33:166-177.doi:10.1016/j.breast.2017.04.003
8. Cormie P, Zopf EM, Zhang X, Schmitz KH. The impact of exercise on cancer mortality, recurrence, and treatment-related adverse effects. Epidemiol Rev. 2017;39(1):71-92. doi:10.1093/epirev/mxx007
9. Lahart IM, Metsios GS, Nevill AM, Carmichael AR. Physical activity, risk of death and recurrence in breast cancer survivors: A systematic review and meta-analysis of epidemiological studies. Acta Oncol. 2015; 54(5):635-654.doi:10.3109/0284186X.2014.998275
10. Campbell K, Winters-Stone K, Wiskemann J, et al. Exercise guidelines for cancer survivors: Consensus statement from international multidisciplinary roundtable. Med Sci Sports Exerc. 2019;51(11):2375. doi:10.1249/MSS.0000000000002116
11. Segal R, Zwaal C, Green E, et al. (2015) Exercise for people with cancer. Toronto, ON: Cancer Care Ontario. https://www.cancercareontario.ca/sites/ccocancercare/files/guidelines/full/pebc19-5f_2.pdf
12. Courneya KS, Katzmarzyk PT, Bacon E. Physical activity and obesity in Canadian cancer survivors: Population-based estimates from the 2005 Canadian Community Healthy Survey. Cancer. 2008; 112(11):2475-2482.
13. Fernandez S, Franklin J, Amlani N, DeMilleVille C, Lawson D, Smith J. Physical activity and cancer: A cross-sectional study on the barriers and facilitators to exercise during cancer treatment. CONJ. 2015;42(1):37-48.doi:10.5737/236880762513742
14. Shaghaghi A. Approaches to recruiting ‘hard-to-reach’ populations into re-search: A review of the literature. Health Promot Perspect. 2011;1(2):86-94. doi:10.5681/hpp.2011.009
15. Ahmed S, Shahid R. Disparity in cancer care: A Canadian perspective. Curr Oncol. 2011;19(6): e376-e382. doi:10.3747/co.19.1177
16. Truant T, Varcoe C, Gotay C, Thorne S. Toward equitable high-quality cancer survivorship care. CONJ. 2019;29(3):156-162.
17. Clifford B, Mizrahi D, Sandler C, et al. Barriers and facilitators of exercise experienced by cancer survivors: A mixed methods systematic review. Support Care Cancer. 2018; 26(3): 685-700. doi:10.1007/s00520-017-3964-5
18. Sandelowski M. Focus on research methods: Whatever happened to qualitative description? RINAH. 2000; 23:334-340.
19. Sandelowski M. What’s in a name? qualitative description revisited. RINAH. 2010; 33:77-84.
20. Statistics Canada. (2019). Dictionary, census. rural area. https://www12.statcan.gc.ca/census-recensement/2016/ref/dict/geo042-eng.cfm. Accessed June 25, 2020.
21. Given L (2016) 100 questions (and answers) about qualitative research. Thousand Oaks: Sage.
22. Saunders B, Sim J, Kingstone T, et al. Saturation in qualitative research: Exploring its conceptualization and operationalization. Qual Quant. 2018;52(4):1893-1907.
23. Sabiston CM, Fong AJ, O’Loughlin EK, Meteris-sian S. A mixed-methods evaluation of a community physical activity program for breast cancer survivors. J Transl Med. 2019;17(1):206.doi:10.1186/s12967-019-1958-4
24. Curran K, Drust B, Murphy R, Pringle A, Richardson D. The challenge and impact of engaging hard-to-reach populations in regular physical activity and health behaviours: An examination of an English premier league ‘football in the community’ men’s health programme. Public Health. 2016;135:14-22.
25. Wu YP, Yi J, McClellan J, et al. Barriers and facilitators of healthy diet and exercise among adolescent and young adult cancer survivors: Implications for behavioral interventions. J Adolesc Young Adult Oncol. 2015;4(4):184-191.
26. Ajzen I. The theory of planned behaviour. Organizational Behaviour and Human Decision Process. 1991;50:179-211.
27. Bandura A (1986) Social foundations of thought and action: A social cognitive theory. Prentice Hall.
28. Fan JX, Wen M, Kowaleski-Jones L. Rural-urban differences in objective and subjective measures of physical activity: Findings from the national health and nutrition examination survey (NHANES) 2003-2006. Prev Chronic Dis. 2014; 11: E141.
29. Martin SL, Kirkner GJ, Mayo K, Matthews CE, Durstine JL, Hebert JR. Urban, rural, and regional variations in physical activity. J Rural Health. 2005;21(3):239-244.
30. Eberhardt MS, Pamuk ER. The importance of place of residence: Examining health in rural and nonrural areas. Am J Public Health. 2004; 94(10):1682-1686.
31. Reis JP, Bowles HR, Ainsworth BE, Dubose KD, Smith S, Laditka JN. Nonoccupational physical activity by degree of urbanization and U.S. geographic region. Med Sci Sports Exerc. 2004; 36(12):2093-2098.
32. Barnidge EK, Radvanyi C, Duggan K, et al. Understanding and addressing barriers to implementation of environmental and policy interventions to support physical activity and healthy eating in rural communities. J Rural Health. 2013; 29(1):97-105.
33. Cleland V, Hughes C, Thornton L, Venn A, Squibb K, Ball K. A qualitative study of environmental factors important for physical activity in rural adults. PLoS ONE. 2015;10(11): e0140659.
34. Gilbert AS, Duncan DD, Beck AM, Eyler AA, Brownson RC. A qualitative study identifying barriers and facilitators of physical activity in rural communities. J Environ Public Health. 2019: 7298692.
35. Becker M. The Health belief model and personal health behavior. Health Education Monographs.1974; 2:324-508.
36. Foster C, Hillsdon M, Thorogood M, Kaur A, Wedatilake T. Interventions for promoting physical activity. Cochrane Database Syst Rev. 2005; (1): doi:10.1002/14651858.CD003180.pub2
37. Withall J, Jago R, Fox KR. Why some do but most don’t. Barriers and enablers to engaging low-income groups in physical activity programmes: A mixed methods study. BMC Public Health. 2011;11:507.
38. Rockliffe L, Chorley AJ, Marlow L, Forster AS. It’s hard to reach the “hard-to-reach”: The challenges of recruiting people who do not access preventative healthcare services into interview studies. Int J Qual Stud Health Well-Being. 2018;13(1): doi:10.1080/17482631.2018.1479582