Background
Over 15.5 million American children and adults were living with a history of cancer on January 1, 2016, and 5-year survival rates have risen to 69% for all cancers diagnosed between 2005 and 2011 [
1]. Evidence supports important health benefits of regular physical activity for cancer survivors, including increased strength, quality of life, and self-esteem; fewer negative treatment-related side-effects; and reduced fatigue, anxiety, recurrence, and mortality [
2‐
5]. Additionally, poorer health indicators (e.g., poorer physical functioning, physical health, and general health), greater fatigue, and lower health-related quality of life are associated with increased sedentary behaviors seen among cancer survivors, independent of physical activity participation [
5‐
7]. In fact, physical inactivity among cancer survivors has been suggested to contribute to increased risk of second primary malignancies [
8]. However, physical activity participation among cancer survivors remains low [
7,
9,
10], with evidence indicating that up to 88% of cancer survivors are inactive. Additionally, cancer survivors report spending the majority of their waking time in sedentary behaviors [
7,
11].
Cancer organizations, like the LIVE
STRONG Foundation, provide various kinds of resources and support for cancer survivors, including emotional, instrumental, informational, and appraisal support in the forms of online communities, in-person events, and educational information on topics ranging from prevention to treatment. Another way cancer organizations support the cancer community is through hosting for-cause physical activity events, providing opportunities for anyone (including cancer survivors) to engage in physical activity and “help”/support those living with cancer while building community and fundraising for the cause. Examples of for-cause physical activity events include 5 k–10 k runs or walks, marathons, triathlons, and cycling rides to raise awareness of and/or financial support for the identified cause. Recent research examining relationships between participation in large physical activity events (e.g., cycling events, triathlons, 5 k, 8 k, half marathons, marathons, etc..), which could include for-cause physical activity events, demonstrates an increase in physical activity for many participants during training months leading up to the event, and maintenance of or increase in physical activity after an event concludes [
12,
13]. The combination of promoting notions of helping others while being physically active provides a unique context in which to encourage multiple health-enhancing behaviors: physical activity and helping others.
The concept of
helping others has been examined in the fields of volunteerism, spirituality, and work in the broader umbrella-area of pro-social behavior (intentional actions undertaken to help or benefit others) [
14,
15]. Collectively, helping others has been associated with multiple health-enhancing behaviors, positive wellbeing, social support, confidence, enriched life purpose, and physical, mental, and emotional health-related benefits for individuals across age ranges [
14‐
26]. Additionally, previous work also supports mental, emotional, and social health related benefits of helping others for those living with a disease or chronic physical condition [
27‐
29].
To summarize, helping others seems to benefit the wellbeing of helpers, including helpers with cancer and other illnesses, although mechanisms that facilitate these benefits are not often examined or well understood. Additionally, training for and participating in for-cause physical activity events is related with participants engaging in regular physical activity during training and continuing afterwards, promoting regular physical activity participation [
12,
13]. One mechanism with the potential to positively impact regular physical activity and associated benefits, including quality of life, is the idea that people, including cancer survivors, want to help others through physical activity by using their physical bodies [
30]. While this has not been empirically examined, to some degree it is practically supported when looking at the number of for-cause physical activity events sponsored by for-cause organizations [
30] and theoretically supported through the historical lens of muscular Christianity, which heavily influenced modern sport and physical activity ideals, and includes a core tenant of “doing good for others” (to help others) using our physical “God-given” bodies to do so [
31,
32]. While this historical socio-theological movement and its associated ideologies is often cursorily discussed in modern sport contexts [
33], sports historians, sport sociologists, and religious sport scholars highlight the influence muscular Christianity had in shaping sporting ideals, and posit that these can be observed more broadly in social ideals, health, physical activity, and contemporary physical activity in education [
32,
34‐
39].
The core ideals of muscular Christianity can be found in the writings of British Victorian authors and clergymen, namely Charles Kingsley and Thomas Hughes. In his popular novel
Tom Brown at Oxford (1861) Hughes states that muscular Christians are “to have strong and well-exercised bodies…that a man’s body is given to him to be trained and brought into subjection, and then used for the protection of the weak, the advancement of all righteous causes, and the subduing of the earth which God has given to the children of men” (p. 82) [
31]. While the term muscular Christianity is relegated to historical discussions of sport and physical activity, the tenants of the historical movement are found in sport and physical activity ideals today [
40].
Related to the focus of this current study, existing research parallel’s tenants of muscular Christianity, demonstrating its relevance today in various sport and health related areas. For example, Hoverd and Sibley (2007) identified how “conceptions of health use moral discourses derived from Christianity” (p. 391) [
41], and recent empirical studies have focused on identifying muscular Christian themes among various populations with relation to place attachment and prescription drug misuse [
40]. Additional research has discussed the ways in which moral conversations about bodies have been shaped by Christian ideals since the nineteenth century [
41]. For example, Townsend (2009) describes “the moralized understanding of obesity,” and explores how media perpetuates these moralistic ideas associated with obesity, often ignoring the “structures which create ill health” (p. 172) [
42]. Gerber (2009) also addresses moral components of health and physical activity, identifying how formatively religion influenced norms of weight loss and contributed to “moral discourses on fat” (p. 406) [
43].
Research has also identified Christian moral ideals among community soup kitchen volunteers, an example of attaching religious aspects of helping others in secular contexts [
44]. Additionally, Christian-founded values and ideals have been examined and continue to perpetuate our culture, with recent work identifying media representations of Christian football and soccer players in the United States and Germany [
45]. Christian themes have also recently been explored within CrossFit settings where participants describe gym spaces and compare them to church [
46]. Critics of such moral language surrounding body, health, and physical activity, such as Hoverd and Sibley (2007) state, “the haphazard application of Christian moral discourse in everyday contexts to evaluate the body and health behaviors is generalized, nontheologically coherent and…reflects a morally loaded discourse in health” (p. 391) [
41]. This current paper acknowledges the history and contemporary influence of religious ideals in constructing meaning for participants at LIVE
STRONG for-cause physical activity events. While other motives for participation in for-cause physically activity events by cancer survivors may exist, this research focused on the idea of helping others, derived from the nineteenth century muscular Christian movement, and seen in other fields.
To further examine and describe the potential role of using our physical bodies as a means to “help others” and as a mechanism to improve overall physical activity engagement and general wellbeing for people with cancer, we developed a path model to examine relationships between cancer survivors’ (1) desire to help others with cancer, (2) physical activity participation in LIVESTRONG to help others with cancer, (3) regular physical activity engagement, and (4) quality of life.
Discussion
Our results suggest that cancer survivors can personally benefit from participating in for-cause physical activity events, and that participating in this way could be a gateway to regular physical activity for these individuals, resulting positively on their quality of life. However, relatively few cancer survivors participate in for-cause physical activity events (11.4% in the present sample), and similar to non-cancer survivors participating in LIVE
STRONG [
65] and research examining physical activity engagement in the U.S. [
66], more cancer survivors participating in for-cause physical activity events were men, self-identified as White, and reported higher income as compared to cancer survivors not participating in for-cause physical activity events. LIVE
STRONG and many other cause-related organizations promote physical activity to help others, which links back to muscular Christian ideology, as early proponents advocated that the core ideology of muscular Christianity focuses on the transformation of society [
37]. Original muscular Christian ideals of using one’s God-given body to help others was tied to the broader cultural push for social welfare in nineteenth century England. These ideals continue to persist within for-cause physically active philanthropy and health efforts today. Other popular examples of such physical activity related health efforts can be observed in the programs created by professional sport organizations in the United States, including
NFL Play 60,
NBA Cares, and the myriad of affiliates listed with
MLBcommunity.org, including cancer and health related organizations. These professional sport organizations’ quality of life programs reflect underlying cultural desires and discourses around health and physical activity which are based on muscular Christian ideals. While we acknowledge there are many reasons cancer survivors may be motivated to participate in for-cause physical activity events, including regaining a sense of physical control or desire for community [
67], we identified within this sample of cancer survivors that the desire to help others, a central tenant of muscular Christianity, was significantly related with this engagement, suggesting that this may be one reason cancer survivors are motivated to be physically active. As a social theology, muscular Christianity set forth the notion that sport and physical activity could make “good” out of the “bad” in society [
37], and proponents of the movement believed that Christian moral values, learned through sport and physical activity, transferred to life beyond the playing fields [
39,
68]. While making the “bad of society good” is a strong statement [
34], this idea of doing good by helping others through using one’s physical body in physical activity or sport aligns with the rising movement of for-cause physical activity events, recently termed “physical philanthropy” [
65].
Evidence supports the health benefits of physical activity and helping others for people who have been diagnosed with cancer and other diseases. There seems to exist important and overlapping personal benefits that have been experienced through both of these behaviors, including fewer or improved depressive symptoms, positive life engagement/purpose, lower anxiety, positive mental health, improvements in various physical health indicators, and greater quality of life [
2‐
5,
20,
27,
29,
69,
70]. The present study examined how combining these two behaviors impacts both regular physical activity behavior and quality of life and concludes by suggesting that health-enhancing benefits can be gained through combining these efforts.
The LIVE
STRONG Foundation and other cancer organizations should continue to encourage cancer survivors to help others through
physical philanthropy, being physically active in these events. These organizations should also work to increase the number of cancer survivors participating in these events given the associated positive benefits of this type of participation for survivors themselves, specifically tailoring opportunities for those reporting less engagement (e.g., cancer survivors reporting a shorter survivorship length, women, Black or African Americans, and those reporting a lower income). Organizations that implement for-cause physical activity events should consider offering shorter distance events that might be more appealing and accessible to more people, including all cancer survivors and those less engaged as listed above. These shorter distance events would be more inclusive for participants of all physical health and those less comfortable/familiar with being active, while also providing “stepping stones,” as supported in hierarchical goal setting approaches, for cancer survivors and others to use as they strive to achieve goals of completing incrementally longer distance events in the future [
71]. This would be especially beneficial for cancer survivors since reports suggest most are not meeting physical activity guidelines, reemphasizing the need for short-term, long-term, and incremental goals to increase physical activity engagement [
72].
Researchers have emphasized that the complex nature of behavior change and sustaining positive behavior change, including physical activity, often requires a multi-faceted ecological approach [
73,
74]. Aspects of for-cause physical activity events may be viewed through a social ecological lens and provide a translatable model for researchers and practitioners to use when promoting behavior change in a community. For example, for-cause physical activity events may have the potential to influence individual-level factors related with physical activity, such as self-efficacy, goal setting, intention, enjoyment, and motivation towards physical activity [
53,
75,
76]. Due to the large numbers of participants in these events, individuals will also benefit through social support and forming relationships with members and leaders in the community [
53,
77,
78]. As participation and interest in these organizational events continues to grow, guidelines and regulations of city centers and towns could potentially be adapted to support a physically active community (e.g., policies mandating investments in physical activity resources, for hosting physical activity events, open streets policies, or planning regulations to improve active transportation and/or leisure physical activity infrastructure [
53,
79]).
Limitations
Despite the encouraging findings suggested from the present study, several limitations need to be acknowledged. Given the cross-sectional design of data collection used for this analysis, causation could not be examined; and it is possible that more physically active cancer survivors were more likely to participate in physically active ways. Future research should use study designs that allow for temporality and causation of the variables of interest to be examined. Variables of interest were also measured using self-report, which includes inherent bias. Future research should also consider including objective measures of physical activity and more robust measures of helping others from other areas of research such as volunteerism and muscular Christianity to better understand the role of helping others when it comes to cancer survivors’ engagement in for-cause physical activity events, overall physical activity behaviors, and quality of life. Future work should aim to measure helping others with a multi-faceted scale, versus a single-item. And while informative, using a single-item physical activity measure was also not ideal; future research should employ more robust self-report measures capturing intensity, frequency, and duration where objective measures are not possible. It should also be noted that the data analyzed in this study was collected in 2010. While research continues to grow in the area of cancer survivorship and physical activity, the variables and pathways examined in the present study remain relevant today. Future work should confirm this in current data and further explore these relationships for people in various lengths of survivorship, those diagnosed with different types of cancers, and those seeking or who have experienced various treatment options. Additionally, these findings should be limited to the current sample given the low number of minority participants and the relatively young age of the sample (compared to overall survivorship age). Future researchers should intentionally recruit minority participants and older survivors to ensure representativeness. While the focus of the present study was to examine the presented relationships among cancer survivors, it is also possible that these same relationships exist for people never diagnosed with cancer. Thus, future research should examine the proposed relationships in a general adult population to further examine and understand these proposed relationships within our culture and how these relationships might be similar or dissimilar in these two groups. Physical activity history and physical activity levels prior to enrollment in the for-cause physical activity event should also be measured and considered as potential moderators in future work examining relationships presented in this study.
Conclusions
Since this is the first study we are aware of that examines the proposed pathways between a desire to help others and positive health outcomes through using one’s physical body to do so, further research is needed to better understand these mediating relationships, as well as how to best address these relationships through intervention strategies. As discussed above, future research needs to include more detailed and robust measures of these constructs. It is also possible that qualitative approaches could help us better describe why these pathways are relevant to cancer survivors participating in physical philanthropy events. Researchers should consider conducting interviews and/or focus groups with physical philanthropy participants to examine the “whys” of their engagement. Finally, given that muscular Christian ideals are apparent in many facets of our culture today, and are posited to influence people’s everyday lives, it is plausible that the desire to help others is a determinant of many types of physical activity engagement, not just for-cause physical activity engagement. Future research should explore this possibility among cancer survivors and other populations, potentially comparing the relationships between desire to help others and physical activity among for-cause physical activity participants and other physical activity intervention participants. If there is a culturally solidified desire to help others through using our physical bodies, as suggested by muscular Christian ideology, then efforts toward understanding how to best harness these ideals for all physically philanthropic activities and incorporate them into future physical activity interventions should be explored. Finally, while our study suggests that helping others may be one motivator for cancer survivors to engage in physical activity, further research is needed to identify and better understand additional reasons why all cancer survivors, and specific subgroups of cancer survivors reporting less engagement (e.g., women, recent survivors, Black or African Americans, etc.), are or are not motivated to be physically active, and subsequently how to incorporate these factors into interventions and/or tailor intervention approaches.
To conclude, our results suggest that cancer survivors benefit from participating in for-cause physical activity events hosted by cancer organizations, including more regular physical activity and higher quality of life. Researchers need to further investigate the role of helping others, and cancer organizations should continue to encourage cancer survivors to help others in a multitude of ways including participation in for-cause physical activity events.