Considerations for Adapting Evidence-Based Health Behavior Interventions for Older, Rural Cancer Survivors

Abstract

BACKGROUND: Older cancer survivors living in rural areas are more likely to experienceaccelerated aging, difficulty with physical functionality, and chronic pain or fatigue. One likely contributor to poor health outcomes in this population of survivors is low adherence to lifestyle recommendations, such as a healthy diet and increased physical activity. Rural cancer survivors face several challenges to engaging in healthy lifestyle behavior change programming such as access to care, transportation, and health literacy. Though telehealth has been a promising avenue for engaging rural living individuals with health care and lifestyle programming, older cancer survivors may have additional challenges to accessing digital devices and tools that have not yet been described. Survivors at the intersection of older age and rurality face several challenges to behavior change that must be addressed to improve long-term health outcomes. OBJECTIVES: This dissertation is composed of three studies that aim to address the gaps in knowledge about lifestyle behavior adherence among older, rural cancer survivors by: (1) synthesizing the literature related to lifestyle behavior change interventions conducted with rural survivor populations, (2) examining the prevalence of digital technology use for health-related activities among older cancer survivors in both rural and urban settings, and (3) exploring the acceptability of digital technology as a tool for lifestyle behavior change in this population. METHODS: To address aim 1, a systematic review of five databases identified randomized controlled trials and controlled clinical trials that targeted diet, physical activity, alcohol consumption, or tobacco use change in adult cancer survivors living in rural areas of the world. Narrative synthesis was completed to describe eligible studies. A cross-sectional analysis of the Health Information National Trends Survey was completed for aim 2 to examine the prevalence of digital technology use among older cancer survivors. Logistic regression models were used to assess the association between rurality and digital health tool use. A mixed-methods approach was utilized for aim 3 to explore the acceptability of using digital technology for lifestyle behavior change. Phase 1 included a quantitative online survey, followed by semi-structured interviews in phase 2 to explore the findings. RESULTS: Eight studies met inclusion criteria for aim 1. Most studies were conducted in either Australia or the United States, included survivors at least 6-weeks post-treatment, and half included only breast cancer survivors. No articles addressed changes in alcohol or tobacco behavior, and none were prospectively aimed at implementation for older, rural-dwelling survivors. Seven utilized a fully remote or hybrid delivery model. For aim 2, there were few differences in digital technology use among older cancer survivors by rural-urban status and prevalence of use for health-related activities was high overall. Findings from the mixed-methods study completed for aim 3 showed both quantitatively and qualitatively that acceptability of digital technology as a tool for lifestyle behavior change is high. Survivors identified five key features they would like to see incorporated in future digital technology-delivered lifestyle behavior change intervention including accountability, feedback, gamification, socialization, and tracking. CONCLUSION: Few studies have been conducted to implement and evaluate the effectiveness of lifestyle behavior change interventions among older, rural survivors of cancer. The findings from this dissertation provide the critical preliminary proof-of-concept information necessary to adapt evidence-based lifestyle interventions for older cancer survivors living in rural areas using a digital technology-based approach.