Exploration of helpful elements contributing to engage in physical activity in patients with cancer

Purpose Although there are many reported benefits of physical activity for patients with cancer (e.g., improving quality of life), many patients with cancer do not meet the recommendations of physical activity guidelines. The amount of physical activity declines after diagnosis of cancer. This study aimed to clarify the elements that contribute engagement in regular moderate-or-higher-level intensity of physical activity (MHPA), based on the Health Action Process Approach (HAPA), among patients with cancer. Methods Two web surveys were conducted among cancer outpatients, asking them to respond to a questionnaire. Participants provided information regarding their demographics, physical activity, purpose, advantages, disadvantages, barriers, triggers, and need for support for regular MHPA. Results Categories were obtained for purposes, advantages, disadvantages, barriers, triggers, and support needs for regular MHPA. For example, the support they considered necessary to regularly engage in MHPA were developed 9 categories, such as Improving the environment, Support for the implementation of PA (interpersonal), and Reducing the burden. Women and younger patients provided more statements about reducing their burden; younger patients also mentioned on improving the environment more among those who did not engage in MHPA. Additionally, patients with cancer who provided statements about interpersonal support reported higher barriers to physical activity. Conclusions These findings will contribute to the development of a scale to measure the components of the HAPA on physical activity in patients with cancer. In addition, it will help develop a support system that promotes engagement in regular MHPA. Supplementary Information The online version contains supplementary material available at 10.1007/s00520-024-08647-4.


Introduction
Increasing attention has been paid to the promotion of physical activity (PA) in patients with cancer.Many benefits of PA have been reported in these patients.Examples include decreasing depression and stress levels [1][2][3], improving physical function and strengthening muscles [4], reducing the side effects of treatment [5], and maintaining or improving the quality of life [4,6,7].A reduction in mortality has also been reported for some types of cancers [8].Guidelines for PA in patients with cancer have also been reported, including recommended standards for PA [9][10][11].
Nevertheless, many patients with cancer do not meet the recommendations of PA guidelines [12,13].In addition, the amount of PA decreases after cancer diagnosis [14].Therefore, several studies have been conducted to promote PA in patients with cancer.
According to one study [15], previous experience with PA influenced the amount of current level of PA.Therefore, especially for those who have not been physically active previously, it is not difficult to assume that regardless of how much they know that PA is good, it is difficult to implement.Studies that have focused on barriers to PA in patients with cancer have also found that during and after treatment patients with cancer have similar content regarding facilitators and discouragements related to PA as the general population, as well as content related to their cancer experiences [16,17].Factors contributing to promoting PA have been reported, including those related to the effects and benefits of PA and psychosocial aspects such as improving well-being and support [18,19].Common barriers to PA, such as bad weather, have been reported, as well as cancer and treatment-related barriers, such as fatigue and pain, and barriers related to beliefs about the safety of PA and fear of worsening symptoms [16,18,19].
Many studies have applied behavioral change theories, such as the theory of planned behavior [20], social cognitive theory [21], and the transtheoretical model (TTM) [22], to promote PA in patients with cancer.Theory-based behavioral interventions have been suggested as useful, but their effects are not large, depending on the theory [23,24].Studies that partially or completely utilize the Health Action Process Approach (HAPA) [25,26], to promote PA in patients with cancer are being reported [3,[27][28][29][30].The HAPA state that self-efficacy, outcome expectancy, and risk perception influence behavioral intentions, which promote health behaviors through planning [25,26].There is still a lack of knowledge in studies that especially examine the application of the HAPA to explain the engagement in PA among people with cancer [29,30].Additionally, in this model, resources, including social support, are considered to contribute to certain components such as behavior and intention.Although not a study on patients with cancer, one study using the HAPA reported that social support was positively associated with action planning, suggesting its importance in promoting PA [31].Understanding what kind of support is needed for people with specific characteristics will give us a more helpful insight into developing interventions that are more acceptable to patients with cancer.
This study investigated barriers, advantages, disadvantages, purpose, triggers, and support needs of engaging in moderate-or-higher-level intensity of physical activity (MHPA) to extract the items that contribute to the components of the HAPA [25,26] among patients with cancer.Then, the relationship between the content of the need and characteristics of the participants was examined to identify the characteristics of their support needs.

Participants and procedure
Web surveys were conducted, and participants were asked to respond to a questionnaire through INTAGE HOLDINGS, Inc.The participants were patients with cancer who met the following criteria: 1) not currently hospitalized, 2) within five years of their cancer diagnosis, and 3) during or within six months of completing treatment for cancer.A screening survey was conducted to a panel that consisted of people who have received medication from a doctor for "cancer" within the last year.This survey for making the panel was conducted in advance and managed by INTAGE HOLDINGS, Inc.
Survey 1(S1): The former survey for making the panel was conducted in August 2019.The screening and main surveys were conducted in March 2020.Thirteen hundred and twenty-six members of this panel were asked to participate in the screening, of whom 577 participated.Of them, 311 met the screening criteria and responded to the survey.
Survey 2 (S2): The former survey for making the panel was conducted in August 2020.The screening and main surveys were conducted in January 2021.Fifteen hundred and eighty-eight members of this panel were asked to participate in the screening, of whom 1011 participated.Of them, 355 met the screening criteria and responded to the main survey.

Demographics (S1, S2)
Participants were asked about their age, sex, treatment information, time since initial diagnosis, and information on their disease.The responses obtained from a survey conducted in advance by the company were used to identify the types of cancer (S2).The participants subjectively responded to the Karnofsky Performance Scale (KPS) [32] from eight options (Table S1).

Engaging in PA (S1, S2)
The status of regularly engaging in MHPA was asked based on the TTM [22] and previous study [15].The options are shown in Table S1.Regular PA means about three times a week for about 30 min each time.

Thoughts on engaging in regular MHPA (S1)
Participants were asked about the barriers, advantages, disadvantages, triggers, and purpose of regular MHPA.For barriers and advantages, we used each 10 items from the previous study [33] and asked them to select all ones that applied and to answer freely (barriers: "What are the reasons that you do not regularly engage in MHPA?Or, when you have difficulty engaging in MHPA, what are the reasons?"; advantages: "What do you think are the benefits of engaging in MHPA regularly?").For the other components, respondents were asked to answer freely.Regarding disadvantages, participants were asked, "What do you think are the disadvantages of not regularly engaging in MHPA?"In the context of purpose, respondents were asked the following questions: "If you regularly engage in MHPA, what is your purpose for engaging in it?"and "For those who do not regularly engage in MHPA, if you do so, what is its purpose?"Regarding triggers, respondents who did not engage in MHPA regularly were asked, "What kind of triggers do you think would enable you to engage in regular MHPA?".

Thoughts on engaging in regular MHPA (S2)
This consisted of 23 items, including those from Ishii et al. [33], and was considered specific to patients with cancer that were extracted based on S1.For each item, respondents were asked to choose from "1: I do not think so at all" to "5: I really think so." Those who did not engage in regular MHPA were asked about the support they required to engage in such PA.Implementors of such PA were asked about the necessary support for those who did not engage in the PA to do so.

Analysis
Descriptive statistics were calculated.Qualitative data were analyzed with reference to content analysis.The author classified the responses, generated categories, and assigned category names.Two graduate students majoring in health psychology independently determined whether the category names and data contents were consistent.Items that did not match were discussed by the authors until they agreed.Other responses regarding barriers and advantages were analyzed by applying the responses to the items of the existing scale or the methods above.Additionally, a variable was created by assigning age to two groups: < 65 years and ≥ 65 years, which were assigned values of 0 and 1, respectively.For the sex variable, males were assigned 0 and females were assigned 1.For the developed categories on need, the author assigned a rating of 1 if the participants mentioned it and a rating of 0 if they did not.Using these binary variables, chi-square tests were performed to examine the associations with demographic variables using S2 data.T-tests were also conducted to examine the association between the support need and barrier items.

Ethical considerations
This study was approved by the Ethics Committee of Waseda University (reference number: 2020-093).In both surveys, INTAGE HOLDINGS Inc. explained the purpose of the surveys on the web and participants were considered to have granted consent by responding.

Participants and status of PA (S1) (Table S1)
A total of 301 effective responses were received.Regarding the time since the diagnosis of cancer, the most frequent response was "2 to less than 3 years" (n = 84, 27.9%).The most common cancer type was breast cancer (n = 150, 49.8%).Among those currently undergoing treatment or within six months of treatment, hormonal therapy was the most common (n = 185, 61.5%), followed by chemotherapy (n = 119, 39.5%).The responses to the KPS scale showed about 80% of all respondents answered better than to be able to carry on normal activities.A total of 125 respondents (41.5%) were regularly engaging in MHPA, but the most common answer was "I have not done it regularly since before I had cancer (n = 104, 34.6%)."

Participants and status of PA (S2) (Table S1)
Data from 303 patients with cancer were analyzed.The most frequent response on the time since the diagnosis was "1 to less than 2 years" for 98 respondents (32.3%).The most common cancer type was breast cancer (n = 148, 48.8%).Hormonal therapy was the most common type of treatment currently undergoing or within 6 months after treatment, with 175 (57.8%) of the respondents, followed by chemotherapy (n = 124, 40.9%).Regarding the KPS scale, more than 80% of all respondents answered better than to be able to carry out normal activities.While the most common answer was "I have not done it regularly since before I had cancer (n = 107, 35.3%), 141 respondents (46.5%) were currently engaging in regular MHPA.

Purpose of regular MHPA (Table 4)
Three hundred and thirty responses were obtained and classified into seven categories: Preventing cancer recurrence or worsening (n = 7, 2.3%), Staying healthy (n = 84, 27.9%), Maintaining and improving physical strength and physical function (n = 100, 33.2%), Preventing or improving mental health problems and preventing cognitive decline (n = 25, 8.3%), Engaging in physical activity,

Triggers for engaging in regular MHPA (Table 5)
The 199 responses were classified into ten categories:   For those who were not engaging in regular MHPA, Support for the implementation of PA (interpersonal) (n = 27, 16.7%), Reducing the burden (n = 26, 16.0%), Improving the environment (n = 25, 15.4%) were commonly mentioned.For those who were engaging in regular MHPA, Support for the implementation of PA (interpersonal) (n = 38, 27.0%) was most reported, followed Motivational support (n = 30, 21.3%), and Improving the environment (n = 24, 17.0%).

Relationships between support need categories and demographic and barriers variables
We conducted chi-square tests and t-tests using the support need categories and variables of barriers and demographics (age and sex) among those who did not engage in such PA (n =162) (Table S2

Discussion
This study investigated and clarified the thoughts or support needed to engage in regular MHPA among patients with cancer, based on the HAPA model [25,26].

Status of PA among patients with cancer
Approximately 80% of the participants in this study (S1, S2) had some symptoms but little difficulty in performing daily activities, it is assumed that most of them were capable of engaging in MHPA.However, less than half of the participants engaged in regular MHPA.More than 70% of those who currently engaged in regular MHPA had been doing so since before they developed cancer (S1, S2), suggesting the importance of considering past experiences, similar to a previous study [15].

Contents of thoughts regarding MHPA
To understand the components of the HAPA model [25,26], respondents were asked about the following items: barriers and advantages of regular MHPA, disadvantages of not engaging in it, purpose and triggers for it, and support needs for it.As a result, as in previous studies [16][17][18][19], both general and cancer-related contents were reported in this study.Participants more reported the general items presented based on previous studies [33]; for instance, Being slothful (28.6%) and Not enough time (15.0%) in barriers; most of contents in advantages; Decline in physical strength and physical function in disadvantages of not engaging (46.5%); and Staying healthy (27.9%) in purpose.For some questions, items that could be considered cancer specific were reported, although the number of reports was small.For example, Changing appearance (0.3%) in barriers; Preventing recurrence and Reducing swelling (0.3%) in advantages; Cancer-specific information on cancer recurrence and side effects (2.3%) in disadvantages of not engaging; and Preventing cancer recurrence or worsening (2.3%) in purpose.Information about benefits that are specific to patients with cancer, such as the reduction of side effects of treatment [5] and mortality in some types of cancer [8], may not have been prevalent.At the time of the survey, there were no PA guidelines for Japanese patients with cancer.Additionally, even if the respondents intended to answer as cancer-related or specific to patients with cancer, it is possible that such respondents were encompassed by the word "health."Fewer reports have been made; however, these detailed results, which contain the remarks of the participants, would be valuable resources.As for the triggers for engaging in regular MHPA, categories such as Understanding the positive changes from engaging in MHPA, which constitute the HAPA model [25,26] were obtained.Additionally, the participants mentioned hopeful situational improvements as a trigger.In the case of patients with cancer, such improvements sometimes may not be possible.Thus, it may also be important to increase self-efficacy and support that they need.Meanwhile, the importance of planning for regular MHPA implementation was rarely perceived among them.
The HAPA [25,26] is considered beneficial for explaining the promotion of PA among people with cancer, but there are insufficient reports on its applicability [3,[27][28][29][30].In the future, for example, by utilizing the content obtained in this study, psychological scales that measure the components of the HAPA model [25,26] specific to Japanese people with cancer and examining the fit of the model to them can be developed.This contributes to gaining a more accurate understanding of and promoting the physical activity practices.

Support needed to engage in regular MHPA
Nine categories were developed in this study.The categories in which the most frequent comments were provided differed between those who were currently engaged in regular MHPA and those who were not.Those who implemented regular MHPA tended to focus on motivation, while those who did not appear to focus on behavior, with relatively more statements related to interpersonal support and burden reduction.In considering support measures, it is important not only to intervene with individuals, but also to adjust the environment and reduce their daily burdens.For example, setting up an intervention program that utilizes the strength of peers, as reported in previous studies [34], may satisfy the need of Improving the environment and Support for the implementation of PA (interpersonal).
Additionally, the last two categories, Difficulties due to social situations and physical conditions and None, can hardly be called "support."It is assumed that these results were obtained because this study asked about support-targeting engagement in the MHPA.Engaging in regular MHPA have often been recommended and studied in this field.However, in recent years, the effectiveness of light-intensity physical activity (LPA) has attracted attention because of the complex physical conditions of patients with cancer, fatigue, and the low rate of PA [35].For example, LPA is positively associated with depressive symptoms, physical function, and quality of life [2,36].For those who have made statements in these categories, it may be acceptable to encourage LPA.

Relationship between support needs and individual characteristics
This study showed that patients with cancer who provided a statement about interpersonal support for the implementation of PA reported higher barrier levels to regular MHPA, female and younger patients provided more statements about reducing their burden, and younger patients also more mentioned improving the environment.Given that support needs differ depending on the participants' characteristics, it is necessary to take these into account when considering support strategies.
Additionally, the implementation of PA may be addressed as a problem-solving therapy for patients with cancer [37].In such cases, the list of support needs obtained in this study can be used to develop a solution, and the results of this study have the potential for use in clinical situations.Furthermore, a healthcare provider's recommendation was associated with higher levels of PA among cancer survivors [38].The results of this study may be utilized by healthcare providers to recommend PA to their patients.

Limitation
This study had several limitations.First, it was conducted as an online survey; therefore, there may have been a selectivity bias.Therefore, caution should be exercised when generalizing this study.Second, some components, such as support needs, were answered in an open-ended format; therefore, it is possible that items that were not brought to the participants' attention were not captured.Furthermore, as this study was conducted during the COVID-19 pandemic, its impact should be considered.For example, in the category of difficulties, the difficulty of not being able to engage in PA until the COVID-19 outbreak was mentioned.Despite these limitations, it is useful to provide a comprehensive description of thoughts on support strategies and other components for patients with cancer to engage in PA, especially MHPA.

Conclusion
This study enabled us to obtain a comprehensive understanding of the thoughts of patients with cancer on engaging in regular MHPA.Developing a scale for measuring the HAPA components for patients with cancer in terms of psychology and examining the application of the HAPA [25,26] to explain engagement in the MHPA is expected.
This study suggests that it is necessary to devise support strategies tailored to participants' characteristics.It is also important not only to intervene with individuals but also to adjust the environment.It is expected that our results will be utilized, and that interventions or support will be provided by local governments and medical institutions in the future.

Table 3
Disadvantages of not engaging in regular MHPA (N = 301)

Table 4
Purpose of regularly engaging in MHPA among patients with cancer (N = 301)

Table 5
Triggers for engaging in regular MHPA (N = 176)