The postpartum period presents a critical window for maternal health promotion yet remains one of the most neglected phases in the continuum of care [1]. Physical activity during this period offers substantial benefits including accelerated physical recovery, weight management, reduced postpartum depression risk, improved cardiovascular health, and enhanced quality of life [2,3]. International guidelines recommend postpartum women engage in at least 150 minutes of moderate-intensity aerobic activity weekly, with gradual resumption based on individual recovery and mode of delivery [4]. However, global evidence consistently shows low postpartum physical activity rates, particularly in low- and middle-income countries (LMICs) where estimates range from 15-35% [5,6].

Understanding why postpartum women do not engage in physical activity despite knowing its benefits the knowledge-practice gap requires moving beyond descriptive epidemiology to explore the complex, interconnected factors shaping health behaviors [7]. The socioecological model provides a useful framework, recognizing that behavior is influenced by factors operating at multiple levels: individual (knowledge, attitudes, physical capacity), interpersonal (family, social networks), healthcare system (provider counseling, service availability), and community/cultural (norms, beliefs, physical environment) [8,9]. Barriers and facilitators at each level interact to either constrain or enable physical activity engagement.

Previous qualitative research in high-income countries has identified common barriers including time constraints, fatigue, lack of childcare, fear of injury, and social isolation [10,11]. However, in African contexts, additional culturally-specific factors emerge. Traditional postpartum practices often prescribe extended rest periods, restrict maternal movement, and emphasize infant care over maternal self-care [12,13]. In Zambia, cultural practices such as "kukaya" (postpartum seclusion and rest) reflect deeply-held beliefs about protecting maternal and infant health [14]. Understanding how these cultural contexts intersect with modern health recommendations is essential for designing acceptable and effective interventions.

Moreover, healthcare systems in many LMICs struggle with resource constraints, workforce shortages, and competing priorities, often resulting in postpartum care focusing primarily on infant health with minimal attention to maternal wellness beyond complications management [15,16]. The role of healthcare providers in counseling and supporting postpartum physical activity remains underexplored in sub-Saharan African settings.

Mixed methods of research, integrating quantitative measurement of prevalence and associations with qualitative exploration of lived experiences and meanings, offers comprehensive insights needed for implementation science and intervention design [17,18]. While our companion paper documented the prevalence and predictors of postpartum physical activity in Zambia, the current study deepens this understanding by exploring the "why" and "how" examining the multilevel barriers and facilitators that explain observed patterns and identifying actionable intervention targets.

Study Aims and Objectives

This study employed an explanatory sequential mixed methods design to comprehensively examine barriers and facilitators to postpartum physical activity among Zambian women. Specific objectives were to:

• Quantitatively identify the prevalence of postpartum physical activity practice and key associated factors
• Qualitatively explore women's lived experiences, beliefs, and perceptions regarding postpartum exercise
• Examine barriers to physical activity operating at individual, interpersonal, healthcare system, and community/cultural levels
• Identify facilitators and strategies women use to overcome barriers
• Integrate quantitative and qualitative findings to develop a comprehensive understanding of factors influencing postpartum physical activity in the Zambian context
• Generate evidence-based recommendations for multi-level intervention development

Study Design and Philosophical Approach

This study employed an explanatory sequential mixed methods design [19], conducted in two phases:

Phase 1 (QUAN): Cross-sectional survey to establish prevalence, patterns, and quantitative associations

Phase 2 (QUAL): Focus group discussions and in-depth interviews to explore meanings, experiences, and context

The design followed a pragmatist philosophical paradigm, valuing both objective measurement and subjective understanding, with priority given to practical utility for intervention development [20]. Integration occurred through purposive sampling (using quantitative findings to guide qualitative participant selection), joint display analysis, and interpretation using the socioecological framework.

Study Setting

The study was conducted in first level one hospitals Lusaka District, Zambia, between November 2024 and September 2025. Lusaka, the capital city with approximately 2.5 million inhabitants, represents Zambia's most urbanised area while retaining strong traditional cultural practices. Four public health facilities were selected for quantitative recruitment: [Facility 1], [Facility 2], [Facility 3], and [Facility 4]. These facilities serve diverse socioeconomic populations and provide comprehensive antenatal and postnatal services. Qualitative data collection occurred at facilities and in community settings accessible to participants.

Participants and Sampling

The quantitative phase recruited 420 postpartum women through consecutive sampling at the four study facilities. Inclusion criteria: women aged 18-45 years, 6 weeks to 6 months postpartum, singleton pregnancy/delivery, residents of Lusaka District, and provided informed consent. Exclusion criteria: medical contraindications to exercise (severe postpartum complications, cardiovascular disease, uncontrolled hypertension), mental health conditions impairing questionnaire completion, or pregnancy complications requiring ongoing specialized care.

Sample Size Calculation

The sample size was calculated using the single proportion formula: n = Z²p (1-p)/d² (Z=1.96 for 95% CI; p=25% estimated prevalence; d=5% margin of error), yielding 289. Adjusting for 10% non-response and design effect of 1.5, final sample was 420, allocated proportionally across facilities.

Data Collection

A structured questionnaire assessed: (1) sociodemographic and obstetric characteristics; (2) knowledge of postpartum physical activity (15 items, scored as good/moderate/poor); (3) attitudes using Likert scales (10 items); (4) physical activity practice (type, frequency, duration, intensity, timing of initiation); (5) barriers (structured list with multiple selection); (6) healthcare provider interaction regarding exercise. The questionnaire was adapted from validated instruments and our team's previous pregnancy exercise research. Eight trained research assistants with healthcare backgrounds conducted 25-30 minute face-to-face interviews in English or local languages.

Analysis

Data were analyzed using SPSS version 26. Descriptive statistics summarized participant characteristics, knowledge/attitude scores, exercise practices, and barriers. Chi-square tests examined bivariate associations between sociodemographic/obstetric factors and physical activity practice. Variables significant at p<0.25 entered multivariable logistic regression. Results included adjusted odds ratios (AOR) with 95% confidence intervals, significance at p<0.05.

Sampling Strategy and Participants

Following quantitative data analysis, purposive maximum variation sampling was employed to select Phase 2 participants, ensuring diverse representation across:

• Exercise practice status (regular exercisers, sporadic exercisers, non-exercisers)
• Mode of delivery (vaginal, caesarean section)
• Parity (primiparous, multiparous)
• Socioeconomic status (varied education/employment levels)
• Postpartum timing (early: 6 weeks-3 months; late: 3-6 months)

Qualitative data collection comprised:

Focus Group Discussions (FGDs): 8 groups of 6-10 women each (total n=64)

• 3 groups: women who exercise regularly
• 3 groups: women who do not exercise
• 2 groups: women post-caesarean section (mixed exercise practice)

In-Depth Interviews (IDIs): 20 individual interviews purposively selected to explore unique perspectives, sensitive experiences (e.g., postpartum complications), and achieve data saturation. Included women from diverse backgrounds not captured in FGDs.

Data Collection Procedures

FGDs and IDIs were conducted by the principal investigator and two trained qualitative researchers fluent in English, Nyanja, and Bemba. Sessions occurred in private, comfortable community spaces or facility rooms, lasted 60-90 minutes (FGDs) or 45-60 minutes (IDIs), and were audio-recorded with participant consent.

Semi-structured guides covered:

• Understanding and perceptions of postpartum exercise
• Personal experiences with physical activity postpartum
• Barriers encountered at different levels (prompts: physical, social, cultural, healthcare, environmental)
• Facilitators and enabling factors
• Cultural beliefs and practices related to postpartum period
• Healthcare provider interactions regarding exercise
• Suggestions for promoting postpartum physical activity

Probing questions explored unexpected themes emerging during discussions. Data collection continued until thematic saturation was achieved-when no new themes emerged across three consecutive FGDs/IDIs [21].

Data Management and Analysis

Audio recordings were transcribed verbatim in the language spoken, with non-English transcripts translated to English by bilingual team members. Translation accuracy was verified through back-translation of 20% of transcripts. Transcripts were de-identified, imported into NVivo 14 software, and analyzed using Braun and Clarke's six-phase thematic analysis framework [22]:

Phase 1: Familiarization - Researchers repeatedly read transcripts, noting initial ideas

Phase 2: Generating initial codes - Systematic coding of meaningful data segments

Phase 3: Searching for themes - Collating codes into potential themes

Phase 4: Reviewing themes - Checking themes against coded data and entire dataset

Phase 5: Defining and naming themes - Refining theme specifics and developing clear definitions

Phase 6: Producing the report - Selecting compelling examples and relating analysis to research questions

Analysis was both inductive (data-driven) and deductive (informed by socioecological framework). Three researchers independently coded 5 transcripts, then met to develop a unified coding framework, ensuring inter-coder reliability. Regular team meetings discussed emerging themes, alternative interpretations, and theoretical connections.

• Integration occurred at three points:
• Study Design: Quantitative findings informed qualitative sampling and refined interview guide focus areas
• Analysis: Joint display matrices connected to quantitative results (prevalence of specific barriers, ORs for factors) with illustrative qualitative quotes and themes

Interpretation: Socioecological framework synthesized findings across methods, identifying where quantitative and qualitative data converged, diverged, or expanded understanding

Trustworthiness and Rigor

Quantitative rigor: validated instruments, adequate sample size, appropriate statistical methods, and control for confounders

Qualitative rigor: prolonged engagement, purposive maximum variation sampling, triangulation (FGDs+IDIs), member checking (summary validation with 5 participants), peer debriefing, audit trail, reflexive journaling

Mixed methods rigor: transparent integration procedures, joint displays, resolution of discrepancies between methods

Ethical Considerations

Ethical approval: UNZAHSREC (Protocol number: 2023270503). Permissions: Lusaka District Health Management Team and facility administrators. Written informed consent obtained after detailed explanation. Confidentiality maintained through de-identification, secure data storage. Participants received no compensation but obtained health education materials on postpartum self-care.

The results are presented in three sections: (1) Quantitative findings overview; (2) Qualitative themes by socioecological level; (3) Integrated findings through joint display.

Table 1: Participant Characteristics - Quantitative and Qualitative Phases.

Table 1 presents the characteristics of participants in both quantitative and qualitative phases, demonstrating the representativeness of the qualitative sample.

Among 420 participants (mean age 28.4±5.6 years), only 24.3% (n=102) engaged in regular postpartum physical activity (≥150 minutes moderate-intensity weekly). Mode of delivery significantly influenced practice: 35.4% of vaginal delivery women vs. 11.0% post-caesarean exercised regularly (AOR=2.34, 95%CI: 1.45-3.78, p<0.001). Other significant predictors: tertiary education (AOR=2.87), healthcare provider counseling (AOR=3.21), good knowledge (AOR=2.15), positive attitudes (AOR=1.98), primiparity (AOR=1.76). [Detailed quantitative results in companion paper]

Top reported barriers (quantitative):

• Lack of time due to childcare (68.3%)
• Fatigue and lack of energy (62.1%)
• Lack of healthcare provider guidance (55.7%)
• Cultural beliefs about needing rest (54.8%)
• Belief that exercise reduces breast milk (48.3%)

Table 2: Barriers Comparison by Physical Activity Practice Status.

Eight major themes emerged, organized by socioecological framework levels.

Table 3: Summary of Qualitative Themes by Socioecological Level.

Theme 1: Physical Constraints Post-Caesarean Section

Women who delivered via caesarean section described prolonged physical limitations extending well beyond the 6-8-week medical recommendation for activity restriction.

"The cut [caesarean scar] pains me even now at 4 months. I am scared if I move too much it will open. The doctor said 6 weeks is okay, but my body tells me no." (IDI-14, 28 years, CS delivery, not exercising)

"I wanted to start walking, but climbing stairs makes the scar pull. It's like a burning feeling. So I just stay home and rest." (FGD-6, Participant 4, CS delivery)

Pain, fear of wound dehiscence, and altered body image created psychological barriers beyond physical limitations.

Theme 2: Profound Fatigue and Energy Depletion

Fatigue emerged as a pervasive, multidimensional barrier encompassing physical exhaustion, sleep deprivation, and emotional drain.

"I am tired all the time. The baby feeds every 2 hours, even at night. When will I exercise? During the day I just want to sleep when the baby sleeps." (FGD-3, Participant 7, primiparous)

"People who exercise have help. Someone to watch the baby. For me, it's just me. By evening I cooked, cleaned, and cared for the baby. I have no energy left." (IDI-8, 32 years, multiparous, unemployed)

Women differentiated between "good tired" from activity and "bad tired" from constant demand without recovery, viewing exercise as an additional burden rather than energizing.

Theme 3: Knowledge Gaps Despite Information

Even among women with moderate survey-measured knowledge, qualitative data revealed gaps in practical understanding specifically how to safely progress exercise, what warning signs require stopping, and exercises for specific concerns.

"I know walking is good, but what about my stomach? It's still so soft and loose. What exercises fix that? Nobody tells me these things." (FGD-5, Participant 3)

"The pamphlet says 'start slowly' but what does that mean? How slow? How do I know if I'm overdoing?" (IDI-12, 25 years, CS delivery) This "knowing but not knowing how" reflects the gap between declarative knowledge (facts about exercise benefits) and procedural knowledge (skills to implement safely).

Theme 4: Lack of Partner and Family Support

Women described partners and family members either actively discouraging exercise or providing no practical support enabling it.

"My husband says, 'Why do you want to exercise? Stay home with the baby.' He thinks I want to go out and look good for other men." (IDI-17, 29 years, married)

"My mother-in-law tells me, 'You young women and your modern ideas. We just rested and our bodies recovered fine.' She doesn't support it." (FGD-2, Participant 5)

Lack of childcare support from partners was particularly constraining:

"If my husband could just watch the baby for 30 minutes, I could walk. But he says childcare is my job. He worked, now he rests." (IDI-6, 27 years, multiparous)

Some women described tension between self-care and expectations of selfless motherhood:

"As a mother, you're supposed to sacrifice everything for your child. If I take time for myself, people say I'm selfish." (FGD-7, Participant 8)

Theme 5: Social Isolation and Lack of Exercise Companions

Postpartum women often experienced social isolation, with traditional postpartum practices reinforcing this, and lacking peers for group exercise.

"I used to exercise with friends before pregnancy. Now they are all working, and I'm home with the baby. It's lonely." (IDI-11, 26 years, primiparous)

"If there was a group where mothers exercise together with babies, I would go. But I don't feel comfortable going to a gym alone with all these young people." (FGD-4, Participant 6).

Theme 6: Absence of Postpartum Exercise Counseling and Fragmented Care

Healthcare provider interaction was minimal regarding postpartum physical activity, with care focusing primarily on danger signs, family planning, and infant immunizations.

"At the 6-week check, the nurse asked if I'm bleeding, if family planning is okay. Nothing about exercise. When I asked, she said, 'You can start if you want,' but no advice how." (IDI-4, 30 years, multiparous)

"The physiotherapists are there, but only for women who had complications or can't walk. Normal women like us, they don't see us." (FGD-1, Participant 3)

Women perceived this silence as tacit messaging that exercise was not important or possibly unsafe:

"If it was important, the doctors would tell us, right? Since nobody talks about it, maybe it's not necessary or even dangerous postpartum." (IDI-18, 24 years, primiparous)

When counseling occurred, it was often vague and non-specific:

"The midwife just said, 'Stay active.' But what does that mean? What activities? How much?" (FGD-6, Participant 2)

Theme 7: Lack of Postpartum Exercise Programs and Resources

Women identified absence of structured, accessible postpartum exercise programs as a barrier, contrasting with some facilities offering antenatal classes.

"There is exercise class for pregnant women, but after delivery, nothing. Why do they forget us?" (IDI-9, 31 years, multiparous)

"I don't know where to go. Gyms are expensive and don't allow babies. Home is too small. The neighborhood isn't safe to walk alone." (FGD-8, Participant 4).

Theme 8: Traditional Postpartum Practices and Cultural Beliefs

The most deeply embedded barriers related to cultural practices and beliefs about the postpartum period, particularly "kukaya" (traditional seclusion and rest).

"In our culture, after birth you stay inside for at least 6 weeks. You rest, you are cared for, you don't go outside. Exercise that's for later, much later." (FGD-2, Participant 8, multiparous)

"My grandmother says the womb needs to settle back. If you move too much, it can shift or not heal properly. Our ancestors knew these things." (IDI-15, 33 years, grand multiparous)

Subtheme 8a: Protecting the Womb and Facilitating "Closure"

Women described beliefs about the womb needing protection and time to "close" properly, with activity perceived as interfering with this process.

"Your insides are still open after birth. If you exercise too soon, things can come out or go wrong." (FGD-5, Participant 7)

Subtheme 8b: Breastfeeding Concerns

Despite quantitative data showing 48.3% concerned about exercise affecting milk supply, qualitative exploration revealed nuanced, culturally rooted fears.

"If you get too hot from exercising, the milk becomes 'hot' and can upset the baby's stomach. My mother warned me about this." (IDI-7, 25 years, primiparous)

"When you are sweaty, you shouldn't breastfeed. The baby can refuse the breast or get sick." (FGD-3, Participant 5)

These beliefs, while not evidence-based, were deeply held and reinforced by elder women's authority.

Subtheme 8c: Prioritizing Infant Care over Maternal Self-Care

Cultural norms positioned maternal self-care, including exercise, as secondary to infant care even selfish.

"People will say, 'Look at her, exercise instead of caring for her baby.' It's shameful." (FGD-7, Participant 3)

"A good mother focuses on her child. Your body can wait. The baby needs you now." (IDI-16, 29 years, multiparous).

Theme 8: Traditional Postpartum Practices and Cultural Beliefs

The most deeply embedded barriers related to cultural practices and beliefs about the postpartum period, particularly "kukaya" (traditional seclusion and rest).

"In our culture, after birth you stay inside for at least 6 weeks. You rest, you are cared for, you don't go outside. Exercise that's for later, much later." (FGD-2, Participant 8, multiparous)

"My grandmother says the womb needs to settle back. If you move too much, it can shift or not heal properly. Our ancestors knew these things." (IDI-15, 33 years, grand multiparous)

Subtheme 8a: Protecting the Womb and Facilitating "Closure"

Women described beliefs about the womb needing protection and time to "close" properly, with activity perceived as interfering with this process.

"Your insides are still open after birth. If you exercise too soon, things can come out or go wrong." (FGD-5, Participant 7)

Subtheme 8b: Breastfeeding Concerns

Despite quantitative data showing 48.3% concerned about exercise affecting milk supply, qualitative exploration revealed nuanced, culturally rooted fears.

"If you get too hot from exercising, the milk becomes 'hot' and can upset the baby's stomach. My mother warned me about this." (IDI-7, 25 years, primiparous)

"When you are sweaty, you shouldn't breastfeed. The baby can refuse the breast or get sick." (FGD-3, Participant 5)

These beliefs, while not evidence-based, were deeply held and reinforced by elder women's authority.

Subtheme 8c: Prioritizing Infant Care over Maternal Self-Care

Cultural norms positioned maternal self-care, including exercise, as secondary to infant care even selfish.

"People will say, 'Look at her, exercise instead of caring for her baby.' It's shameful." (FGD-7, Participant 3)

"A good mother focuses on her child. Your body can wait. The baby needs you now." (IDI-16, 29 years, multiparous).

Despite numerous barriers, some women successfully engaged in postpartum exercise by leveraging facilitators and employing creative strategies.

Table 4: Facilitators among Regular Exercisers.

Facilitator 1: Prior Positive Exercise Experiences

Women who exercised during pregnancy found postpartum resumption easier.

"I walked throughout pregnancy and felt good. After birth, I knew my body could handle it, so I continued." (IDI-1, 26 years, regular exerciser)

Facilitator 2: Healthcare Provider Endorsement and Specific Guidance

When providers gave specific, personalized advice, women felt empowered and safe.

"The physiotherapist showed me pelvic floor exercises and explained exactly when I could add more activities. That confidence helped me start." (IDI-5, 28 years, CS delivery, exercising)

Facilitator 3: Partner and Family Encouragement

Supportive partners and families enabled exercise through encouragement and practical help.

"My husband takes the baby every morning for one hour so I can walk. He says he wants me healthy and happy." (FGD-1, Participant 6)

Facilitator 4: Visible Role Models and Social Support

Seeing other postpartum women exercise normalized the behavior.

"My neighbor started walking with her baby 8 weeks. I saw her looking happy and healthy, so I joined her. Now we walk together every day." (IDI-19, 30 years, regular exerciser)

Facilitator 5: Integration of Exercise with Infant Care

Women who found ways to incorporate babies into activity overcame childcare barriers.

"I put the baby in a chitenge [traditional cloth wrap] on my back and walk to the market. It's exercise and I get errands done." (FGD-4, Participant 2)

"I do floor exercises while the baby plays on a blanket next to me. It works." (IDI-20, 27 years, regular exerciser).

Strategy 1: Reframing Household Activities as Exercise

Women validated their activity by recognizing household tasks as physical activity.

"I sweep, wash clothes by hand, carry water. That's exercise, isn't it? Even if it's not 'exercise-exercise.'" (FGD-8, Participant 5)

Strategy 2: Creating Peer Support Networks

Some women formed informal walking groups with neighbors or fellow mothers from antenatal class.

"We were three mothers living nearby who all had babies the same month. We started walking together. It helped so much-we motivated each other." (IDI-3, 29 years)

Strategy 3: Negotiating Cultural Expectations

Women navigated traditional practices by timing exercise after the culturally acceptable confinement period.

"I respected kukaya for 6 weeks. After that, I started gently. My mother accepted because I had honored the tradition first." (IDI-10, 32 years)

Strategy 4: Starting Slow and Building Gradually

Women who successfully sustained exercise described patience and gradual progression.

"I didn't start with big goals. Just 10 minutes walking at first. Each week a little more. Now I walk 30 minutes five times a week." (IDI-2, 27 years, regular exerciser)

Table 5 presents the comprehensive joint display, integrating quantitative and qualitative findings across socioecological levels.

Table 5 presents the comprehensive joint display integrating quantitative and qualitative findings.

Table 5: Comprehensive Joint Display - Integration Matrix.

Table 1. Joint Display of Integrated Quantitative and Qualitative Findings (Abbreviated)

Note: Complete joint display with all factors available in supplementary materials

Key integrated insights:

• Mode of Delivery Impact: Quantitative data showed CS women 2.34 times less likely to exercise; qualitative revealed this reflects not just physical pain but psychological fear, lack of specific guidance, and family reinforcing rest.
• Healthcare Counseling Gap: Only 32.1% received counseling but it had strong effect (OR=3.21); qualitatively, counseling was vague, non-specific. The power of counseling when done well highlights the missed opportunity.
• Cultural Beliefs: Quantitatively, 54.8% cited cultural beliefs; qualitatively, kukaya emerged as deeply embedded practice with complex meanings, not simply a "barrier" to overcome.
• Knowledge-Practice Gap: Even among women with "good knowledge" (41.4% practicing), qualitative data showed distinction between knowing "that" exercise is good vs knowing "how" to do it safely.

This mixed methods study provides comprehensive, contextually grounded understanding of barriers and facilitators to postpartum physical activity in Zambia, with implications for intervention design and implementation across similar LMIC settings.

Multilevel Barriers and the Socioecological Perspective

Findings confirm that postpartum physical activity is not simply a matter of individual choice or knowledge but is constrained and enabled by interconnected factors across multiple socioecological levels [23,24]. While individual-level barriers like fatigue and pain are important, they occur within social, cultural, and systemic contexts that amplify or mitigate their impact.

Individual Level: Beyond Knowledge to Practical Skills

The knowledge-practice gap, where women with good knowledge still did not exercise, aligns with health behavior theories emphasizing that knowledge is necessary but insufficient [25]. Qualitative findings refined understanding: women needed not just information but practical skills (how-to knowledge), confidence (self-efficacy), and problem-solving abilities. This distinction between declarative and procedural knowledge has direct implications interventions must include demonstrations, supervised practice sessions, and progressive skill-building rather than information provision alone.

The profound impact of caesarean section delivery (AOR=2.34) extended beyond the medical 6–8-week recovery window, with women experiencing pain, fear, and lack of clear guidance at 3-4 months postpartum. This finding resonates with international literature showing CS as a major determinant [27,28] but adds cultural dimensions in Zambian settings where CS rates are rising but physiotherapy access is limited, women receive minimal post-surgical rehabilitation guidance.

Interpersonal Level: Support Systems and Social Norms

The absence of partner and family support emerged as a critical barrier, reflecting gender dynamics and maternal role expectations. International studies consistently identify lack of support [29,30], but cultural contexts shape its manifestation. The power of peer support as a facilitator suggests community-based group interventions may be particularly effective.

Healthcare System Level: The Critical Role and Missed Opportunity

The finding that healthcare provider counseling tripled the likelihood of exercise (AOR=3.21), yet only 32.1% received counseling, represents a critical gap and opportunity. Postnatal care in many African settings focuses narrowly on danger signs and family planning [32,33], with maternal wellness neglected. However, qualitative data revealed counseling quality matters vague advice provided little actionable guidance, while specific recommendations empowered women.

Community/Cultural Level: Navigating Tradition and Modernity

The most complex barriers related to cultural beliefs and practices, particularly kukaya. Rather than viewing these as obstacles to overcome, findings suggest the need for respectful engagement that acknowledges the valid protective functions of traditional practices while finding synergies with beneficial physical activity [37].

Kukaya serves important functions: providing maternal rest, protecting mother and infant during vulnerable period, facilitating breastfeeding establishment, and maintaining cultural identity. Simply dismissing these practices risks cultural insensitivity and ineffectiveness. Instead, interventions might acknowledge the rest period while providing guidance on gentle movement appropriate during and after kukaya.

The belief that exercise affects breastfeeding has been repeatedly disproven [39,40]. However, the belief's cultural roots require culturally appropriate responses addressing specific concerns (body heat, sweat) while correcting misinformation.

Facilitators and Strategies: Resilience and Agency

Despite multiple barriers, women who exercised demonstrated remarkable resilience and creativity. These strategies provide valuable insights:

• Leverage existing behaviors by recognizing household activities
• Integrate infant care and exercise (mother-baby approaches)
• Build peer support through existing networks
• Engage supportive family members as "exercise champions"

Provide progressive, feasible programs starting with brief activities

Implications for Multi-Level Interventions

Table 6: Multi-Level Intervention Recommendations.

These findings inform evidence-based, contextually appropriate, multi-level interventions addressing:

Individual Level: Practical skill-building workshops, CS-specific guidelines, progressive protocols, home-based videos

Interpersonal Level: Partner education, peer support groups, mother-baby classes, training "exercise champions"

Healthcare System Level: Provider training, standardized counseling protocols, simple job aids, community program linkages

Community/Cultural Level: Community engagement with traditional leaders, culturally sensitive messaging, myth-busting campaigns, safe accessible spaces.

Study Limitations

Limitations include urban setting (limiting generalizability to rural areas), potential social desirability bias, cross-sectional quantitative design, and qualitative sampling from facility attendees. The study did not include healthcare provider or family member perspectives. Future research should address these gaps, particularly rural-urban comparative studies.

This mixed methods study reveals that postpartum physical activity in Zambia is constrained by multilevel, interconnected barriers operating at individual, interpersonal, healthcare system, and cultural levels. The profound impact of caesarean section delivery, the critical yet underutilized role of healthcare provider counseling, and the complex influence of traditional postpartum practices emerge as key findings with direct implications for intervention design.

Rather than viewing traditional practices like kukaya simply as barriers, this study demonstrates the need for culturally sensitive approaches that respect protective postpartum customs while integrating evidence-based activity recommendations. Women who successfully engage in postpartum exercise demonstrate remarkable resilience, employing creative strategies including infant-integrated activities, peer support networks, and negotiation of cultural expectations.

The integration of quantitative prevalence data with rich qualitative exploration of lived experiences provides actionable insights unavailable from either method alone. The knowledge-practice gap reflects not just information deficits but gaps in practical skills, procedural knowledge, and enabling support systems. Healthcare provider counseling, when provided, powerfully influences exercise engagement yet many postpartum women receive no guidance.

Healthcare System Interventions

• Integrate standardized postpartum exercise counseling into routine postnatal care protocols
• Develop provider training programs on postpartum exercise guidelines, counseling techniques, and behavior change principles
• Create simple counseling job aids with mode-of-delivery-specific recommendations
• Establish referral pathways to community-based exercise programs

Caesarean Section-Specific Interventions

• Develop progressive exercise protocols for post-CS women with clear timelines and safety indicators
• Provide physiotherapy consultations or group education sessions for CS women at 6-week postpartum visits

Address psychological barriers (fear, body image) alongside physical recovery

Community-Based Interventions

• Pilot mother-baby exercise classes at health facilities or community centers
• Train community health workers to provide basic postpartum exercise guidance during home visits
• Facilitate peer support groups leveraging existing maternal and child health platforms
• Create safe, accessible spaces for postpartum women to exercise together

Culturally Tailored Interventions

• Engage community leaders, traditional birth attendants, and respected elders in intervention design and delivery
• Develop culturally appropriate messaging that respects kukaya while promoting safe activity
• Address breastfeeding concerns through evidence-based, culturally sensitive education

Frame maternal exercise as enabling better infant care rather than competing with it

Family-Focused Interventions

• Include partners in antenatal and postnatal education about supporting maternal physical activity
• Develop materials specifically for family members emphasizing their supportive role
• Promote shared childcare responsibilities enabling maternal self-care time

Digital Health Innovations

• Explore mobile health interventions providing progressive exercise videos, reminders, and peer support via platforms accessible to Zambian women

Develop simple, illustrated guides for home-based postpartum exercises

Future Research Directions

Several research priorities emerge from this study:

• Implementation of research testing multi-level intervention packages addressing identified barriers
• Cost-effective analysis of different intervention approaches in resource-limited settings
• Longitudinal studies examining trajectories of postpartum physical activity and long-term health outcomes
• Rural-urban comparative studies exploring how barriers and facilitators differ by geographic context

Studies including male partners, extended family members, and healthcare providers to understand their perspectives and roles.

This study provides essential evidence for designing contextually appropriate, multi-level interventions to promote postpartum physical activity in Zambia and similar LMIC settings. Moving from evidence to action requires collaboration among healthcare systems, communities, families, and women themselves recognizing that sustainable behavior change emerges not from individual willpower alone but from supportive environments enabling healthy choices.

We express deep gratitude to all the postpartum women who generously shared their experiences and time. We thank the Lusaka District Health Management Team and the participating health facilities for their support. Special thanks to our research assistants and qualitative research team for their dedication. We acknowledge the traditional birth attendants and community leaders who facilitated community engagement.

Author Contributions

OLB and LAN conceptualized an    d designed the mixed methods study, led quantitative and qualitative data collection, conducted thematic analysis, performed data integration, drafted and revised the manuscript. LAN contributed to qualitative data collection and analysis, assisted with data interpretation, and revised the manuscript. MM and GM provided expertise in mixed methods design, contributed to integration analysis, and revised the manuscript critically. All authors read and approved of the final manuscript.

Funding

This research was not supported by any agencies or organizations.

Competing Interests

The authors declare that they have no competing interests.

Data Availability Statement

The quantitative datasets generated during this study are available from the corresponding author on reasonable request. Qualitative data (interview and FGD transcripts) are not publicly available to protect participant confidentiality but may be available in anonymized form from the corresponding author with appropriate ethical approvals and data sharing agreements.

Ethics Approval and Consent to Participate

This study was approved by the [Ethics Committee Name] (Protocol Number: 2023270503,). All participants provided written informed consent prior to participation in both quantitative and qualitative phases. The study was conducted in accordance with the Declaration of Helsinki and followed ethical guidelines for qualitative research including confidentiality, voluntary participation, and right to withdraw.

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