Evaluating Wall-Mounted Prompts to Facilitate Physical Activity-Related Discussion between Individuals with Cancer and Oncology Health Care Providers: A Pre-post Survey Study

Abstract

Purpose:

To evaluate the use of wall-mounted prompts in facilitating physical activity (PA)-related discussions between individuals with cancer and oncology care providers.

Methods:

Individuals with cancer were approached to participate in a survey-based pre-post study. Half of participants (n = 100) completed a survey prior to installation of wall-mounted prompts in clinic while the other half (n = 100) completed a survey following installation of the prompts. Survey questions included content of PA-related discussion, satisfaction with PA education across treatment, and current PA level. The post-prompt survey also asked questions related to the prompt. Survey responses were analyzed using descriptive statistics. Chi-squared tests were performed to determine significance between timepoints.

Results:

One hundred participants completed the survey at each timepoint. A significant difference was found pre and post-prompt in the number of PA discussions occurring overall during care (p = 0.03). Some participants (53%) were satisfied with the PA education received during treatment. There was no significant difference in occurrence of PA discussion (p = 0.36) pre and post-prompt and no difference in PA behaviour was observed (p = 0.130).

Conclusions:

Wall-mounted prompts may be effective in increasing the frequency of PA-related discussions between individuals with cancer and their oncology team across treatment. Additional strategies, such as easy referral to rehabilitation professionals, are also needed to facilitate safe and effective PA behaviour during and after cancer treatments.

Over 1.5 million Canadians are living with or beyond cancer.¹ Many of these Canadians are living with debilitating physical and psychological side effects of their cancer diagnosis and its related treatments.^2,3 Physical activity (PA) is defined as any bodily movement produced by skeletal muscles that requires energy expenditure⁴ and includes exercise (purposeful and structured physical activity⁴) and leisure time activity (activity people engage in freely during their disposable time⁵). It is a feasible and cost-effective strategy to manage the side effects of cancer and its treatments given its many physical (e.g., increased cardiovascular functioning and reduced fatigue^6–10), psychological (e.g., improved mood, decreased self-reported anxiety, and depressive symptoms^6–8,11), and social (e.g., improved interaction, feelings of belonging, quality of life^6,12) benefits for individuals living with a current or past diagnosis of cancer. However, approximately 70% of individuals with cancer are not meeting currently recommended guidelines needed to garner health benefits (i.e., 90–150 minutes of moderate-to-vigorous PA per week^13–15). Therefore, strategies are needed to encourage more individuals with cancer to become active across the survivorship trajectory.

Greater PA engagement may occur in individuals with cancer if more guidance is offered by oncology health care providers (OCPs; e.g., medical, radiation and surgical oncologists, nurses). Individuals with cancer highly value the opinion of their OCPs during and after treatment.^16–18 However, researchers have found that OCPs may not be aware of current exercise guidelines^19,20 and do not consistently offer PA counseling to their patients.^17,21–23 PA discussions are a type of health promotion, and involves conversations where OCPs and individuals with cancer discuss current PA levels, PA guidelines, and PA opportunities in the community.²⁴ Barriers to PA promotion by OCPs include: (1) institutional barriers, such as a lack of time and defined role for who should discuss exercise,^20,25 (2) health professional barriers, such as low exercise knowledge and low self-efficacy related to exercise promotion,^20,25 and (3) perceived patient barriers, such as perceived physical side effects of individuals with cancer and a perceived lack of desire to receive PA education.²⁰

PA prompts are tools that help to communicate messages which remind and help motivate people to change their PA behaviour.²⁶ They are strategies that aid memory and assist information recall.²⁷ Prompts can include wall-mounted signs and messages delivered using technology.²⁶ Prompts posted in public locations facilitate, inform, and motivate people to make an active choice in specific environments (e.g., to take the stairs instead of the elevator).²⁸ PA prompts are effective in solidifying knowledge of health promoting behaviours in general populations.²⁸ Further, they have shown small-to-moderate improvements to facilitate referrals to community-based exercise programs in primary care settings for general populations.²⁹

Rehabilitation professionals design and implement interventions to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment.³⁰ Rehabilitation professionals, including physiotherapists, are not a standard part of the health care team within cancer centres across Canada.³¹ Therefore, the burden is placed on patients and other OCPs to initiate the conversation on the benefits of PA and encourage PA participation with the hopes that they will seek rehabilitation services to meet any unmet needs after this initial conversation has occurred. Together, there is a need to develop a support system which prompts individuals with cancer and OCPs to discuss PA during interactions. We hypothesize that wall-mounted PA prompts (e.g., images) could be a low-burden strategy implemented within cancer centres to prompt patients and OCPs to discuss PA. Therefore, the aim of this study was to implement and evaluate a simple and innovative wall-mounted prompt to facilitate PA conversations between individuals with cancer and OCPs. Results of this study can be used to help determine the preliminary effectiveness of this type of messaging strategy for individuals with cancer and will be used to determine the use of wall-mounted prompts in future research and clinical practice to start the conversation on PA-related behaviour for individuals with cancer.

Methods

Study design

This was a pre-test, post-test study. Survey data were collected at two timepoints [before (pre) and 12-weeks after (post) posting PA prompts in two different groups of participants] at a single cancer centre in Ontario, Canada. The Strength of Reporting of Observational Studies in Epidemiology (STROBE) guidelines³² were used to guide the writing of this manuscript. The study was approved by the Hamilton Integrated Research Ethics Board (ID# 10572).

Participants

Participants in this study were: (1) English-speaking, (2) adults (>18 years) with a diagnosis of cancer (any stage/type), (3) treated (any phase of treatment) at the Juravinski Cancer Centre (JCC), who (4) had a pre-scheduled appointment with their OCP. The JCC is a cancer care facility serving holistic cancer treatments to a wide geographic region in south-western Ontario. OCPs working at the JCC include oncology surgeons, medical and radiation oncologists, oncology nurses, social workers, dieticians, and psychologists.

Procedure

Potential participants were approached in-person by a research assistant after a regularly scheduled in-person appointment with their OCP. Potential participants were only made aware of the survey topic after their appointment to explore what PA-related discussion occurred naturally. Further, OCPs were aware of the presence of the research team outside of the clinic; however, to decrease bias were blinded to the contents of the survey, did not receive notice about the prompt placement in the clinic, and the research team members collecting data were not previously known to the OCPs. After participants consented to take part in the study, they independently completed a demographic questionnaire asking about age, sex, cancer type, cancer stage, and then a short (5–10 minute) survey in-person. Surveys were completed by participants outside of “Clinic D” at the JCC at two time points: pre-intervention (timepoint 1: before prompts were posted [July–September 2021]) and 12 weeks after prompts had been posted (timepoint 2: post-prompt [November 2021–March 2022)). Once baseline data collection was complete, the PA prompts were placed in two locations in Clinic D (one patient facing: Figure 1a and one OCP facing: Figure 1b) and remained in place for 12 weeks. This time frame was chosen as previous prompt-based research found that interventions that are 12-weeks in length are efficacious for prolonged behaviour change.³³ Further, this timeframe allowed continued exposure to the prompt and discussion of PA at weekly appointments for participants in order to assess change in PA level between the two timepoints. All participants were given a $5 coffee gift card after completing the survey.

Figure 1.

Wall-mounted prompts: a) patient facing, b) OCP facing.

Physical activity prompt

The PA prompt was developed in two parts. First, an environmental scan of cancer clinics including the JCC occurred to identify common PA-related features between clinics (see Fong et al.³⁴). Two raters independently walked through the clinics at each cancer centre to identify clinic features where a prompt could be implemented (e.g., blank wall space, examination table, chairs, empty desk space). An inventory checklist adapted from previous environmental scans in community locations was used along with photos.^35–37 Second, a 1-day workshop with experts in graphic design (n = 1), behaviour change (n = 1), knowledge translation (n = 2), cancer care (n = 4), and general practice medicine (n = 1), along with individuals with cancer who were post active treatment (n = 2), was held to design the prompt. Using the common clinic features identified in Part 1, a preferred target was chosen (blank wall space). The prompt was designed including prompt message, font size, and printing location. Prompt prototypes were generated by the graphic design company. Feedback on prototypes was sought from a convenience sample of 14 OCPs in Toronto, ON who were asked to complete an online questionnaire rating the innovation prototypes to identify the preferred prompt design. There was no overlap in these OCPs providing protype feedback and the OCPs working at the study location where the surveys were collected. The chosen prompt design included a wall-mounted decal promoting PA including three quotes and five running shoe decals. See Figure 1.

Survey

Survey questions were developed based on items that have previously been used in the evaluation of prompts in a clinical setting³⁸ and were formatted as multiple-choice questions, scaling questions, multi-select questions, or written response questions. Questions at both survey timepoints asked about (1) the content of discussion regarding PA (e.g., Did you discuss physical activity or exercise with your oncology care provider at today's appointment?; scored by selecting “Yes” or “No”; If yes, what did they discuss?; scored by checking the appropriate topic from a pre-specified list or writing open ended responses for other content), (2) satisfaction with PA education across treatment (Please rank your satisfaction with the education you have been provided on physical activity / exercise throughout your cancer treatment; scored on 7-point Likert scale from 1: “Extremely Dissatisfied” to 7: “Extremely Satisfied”), and (3) current PA level (via the Godin Leisure Time Exercise Questionnaire³⁹ which has been validated in individuals with cancer⁴⁰). In addition, the post survey asked question about the posted prompts (Did you notice the wall stickers in the Clinic D waiting room encouraging physical activity? If yes, did they facilitate physical activity-related discussion with your healthcare team?). Fourteen questions were included in the pre-prompt survey and 16 questions were included in the post-prompt survey. See Appendix 1 for the survey used.

Data analysis

All survey data were uploaded into a secure Microsoft Excel spreadsheet by a research assistant. Demographic data and a summary of results was calculated using descriptive statistics (e.g., number [percentage], means [standard deviation]) where appropriate. Chi-square tests were used to compare the pre-intervention group's scores to the post-intervention group's score, accounting for exposure to PA prompt. All quantitative analysis was conducted in STATAv15 with significance set at p < 0.05. Open ended survey questions were iteratively reviewed and grouped into topics by two reviewers (JST and BN) guided by qualitative content analysis.⁴¹

Sample size

Sample size was calculated using G*Power for two independent groups and two measurements (pre and post prompt) with one-tail (assuming an effect in one direction), an estimated effect size of 0.2, alpha of 0.05, and power of 0.80. A total sample size of 150 participants was required (n = 75 at each time point), with over-sampling to account for possible missing data. For pragmatic reasons and differences in treatment and follow-up appointment schedules, each data collection time point assessed a different group of individuals.

Results

Two hundred participants completed surveys across the two timepoints (n = 100 at each time point) and recruitment was ceased. Most participants were female (74%) diagnosed with breast cancer (58%). Many participants reported having stage 4 cancer (27%) and the majority (68%) were currently on treatment. No significant differences were found between cancer characteristics of participants at the two timepoints; however, significantly more participants post-prompt were at a follow-up appointment compared to those completing the survey at the pre-prompt timepoint. See Table 1 for participant characteristics for the pre-prompt and post-prompt study. Results of the pre-prompt survey, highlighting the frequency and content of PA-related discussions at a single timepoint have previously been published.²³

Table 1.

Participant Characteristics

Characteristics	Pre-prompt survey (N = 100) n (%)	Post-prompt survey (N = 100) n (%)	p-value
Age (years): mean, (SD)	61.2, (13.5)	60.7, (12.6)	0.76
Sex:
Female	76 (76)	72 (72)	0.73
Male	23 (23)	26 (26)
Did not specify	1 (1)	2 (2)
Cancer Type:
Breast	61 (61)	55 (55)	0.58
Other:	39 (39)	45 (45)
Melanoma	9	2
Prostate	5	3
Pancreatic	3	1
Colon	3	9
Esophageal	3	4
Squamous cell carcinoma	2	4
Liver	2	2
Rectal	2	0
Ovarian	1	0
Bone	1	0
Neuroendocrine	1	2
Goblet cell carcinoma	1	0
Soft tissue carcinoma	1	0
Thyroid	1	0
Head and Neck	0	8
Lung	0	6
Testicular	0	1
Did not answer	4	3
Cancer stage:
0	1 (1)	2 (2)	0.60
1	14 (14)	9 (9)
2	22 (22)	15 (15)
3	12 (12)	15 (15)
4	25 (25)	29 (29)
Did not answer	26 (26)	30 (30)
Type of appointment:
First appointment	18 (18)	5 (5)	0.004 †
Follow up appointment	82 (82)	94 (94)
Did not answer	0	1 (1)
Treatment status:
On treatment	64 (64)	72 (72)	0.34
Completed treatment	35 (35)	28 (28)
Did not answer	1 (1)	0
Current treatment type: *
Chemotherapy	28 (44)	35 (49)	0.18
Radiation Therapy	8 (13)	11 (15)
Hormone Therapy	19 (30)	23 (32)
Other	21 (33)	23 (32)
Not applicable (i.e., completed treatment)	36 (36)	28 (28)

^* (%) totals more than 100 as those who selected “on treatment” as some participants were on more than one treatment

^† Bolded values demonstrate significant difference between groups

Evaluation of the PA prompt

Forty-one percent of participants at the post-prompt survey said they noticed the prompts posted on the wall of the Clinic D waiting room. Twelve percent said it facilitated them to discuss PA with their OCP. Table 2 provides information on survey results between timepoints.

Table 2.

Survey Results

Variable	Pre-prompt survey Frequency (Yes) (N = 100) n (%)	Post-prompt survey Frequency (Yes) (N = 100) n (%)	p-value
PA discussion occurred in interaction between individual with cancer and oncology care provider	41 (41)	47 (47)	0.36
PA discussion occurred at some point during care between individual with cancer and oncology care provider	66 (66)	80 (80)	0.026 †
Satisfied with PA education throughout treatment (answered ≥5/7 on the satisfaction scale)	54 (54)	52 (52)	0.78
Considered sufficiently active	37 (37)	48 (48)	0.13
OCP discussing PA:* (n = 41 pre-prompt; n = 47 post-prompt)
Medical oncologist	32 (78)	36 (77)	0.87
Radiation oncologist	3 (7)	3 (6)
Oncology nurse	14 (34)	11 (23)
Other	5 (12)	4 (9)
Not applicable (i.e., did not discuss PA)	59 (59)	53 (53)
Content discussed*: (n = 41 pre-prompt; n = 47 post-prompt)
Current PA level	34 (83)	32 (68)	0.75
Benefits of exercise	25 (61)	21 (45)
Type of exercise	21 (51)	18 (38)
Strategies to become more active	16 (39)	23 (49)
Exercise frequency and/or duration	14 (34)	15 (32)

^* (%) totals more than 100% as some participants may have had discussion with multiple OCPs or discussed a variety of content

^† Bolded values demonstrate significant difference between groups

Frequency of PA-related Discussions

No significant difference was found for frequency of PA-related discussion between the two timepoints (pre-prompt: 41%, post-prompt: 47%; p = 0.36). However, a significant difference was found between timepoints for the number of PA discussions occurring at some point during care (66% vs. 80%; p = 0.026). Stage of cancer (early stage 0–3 vs. advanced disease (stage 4)) did not affect frequency of PA-related discussions (pre-prompt: p = 0.45; post-prompt: p = 0.95). There was also no significant difference in frequency of discussion by current PA level at either timepoint (pre-prompt: p = 0.66; post-prompt p = 0.60), or by treatment status at either timepoint (pre-prompt: p = 0.52; post-prompt p = 0.31). Across both timepoints, discussions occurred most frequently with medical oncologists (78% of discussions across both timepoints), followed by oncology nurses (29%).

A sub-analysis was also performed for frequency of discussion for those at follow-up appointments only. The significant difference between timepoints in occurrence of discussion at some point during treatment was maintained between timepoints for those at a follow up appointment only (67% vs. 81%; p = 0.037).

Content of PA-related discussions

Current PA level was the most common topic discussed during interactions between individuals with cancer and their OCP at both timepoints (83% vs. 68% respectively). At the pre-prompt timepoint other commonly reported discussion topics included the benefits of exercise (61%) and types of exercise to perform (51%). At the post-prompt timepoint, other commonly reported discussion topics included strategies to become more active (49%) and the benefits of exercise (45%). No significant differences were found between timepoints based on the content of PA-related discussions (p = 0.75).

Participants were also asked to report additional PA-related content discussed in the interaction with their OCP in an open response box. For those who did discuss PA during the interaction with their OCP, results at both timepoints found that discussion occurred related to healthy lifestyle activities (i.e., general weight and diet planning), complications of cancer treatment (i.e., pain, fatigue) that limited PA, and how to manage these complications during PA. Participants who said they did not discuss PA, but would have liked to, highlighted that they wanted more information on types of exercise to perform, how often to exercise, the benefits of exercise during and after treatment, and proper exercise intensity.

Satisfaction

Only half of participants were satisfied with the PA education they had received across timepoints (54% answered ≥5/7 on the 7-point Likert scale at the pre-prompt survey vs. 52% at the post-prompt survey) with no significant difference being found post-prompt (p = 0.78). The median satisfaction score across timepoints was 6/7; range 1–7.

Physical activity level

While PA-related discussions were more frequent post-prompt, the number of those considered “sufficiently active” was not statistically different between timepoints (p = 0.13), yet higher post-prompt (37% vs. 48%).

Discussion

This unique study evaluated the use of a wall-mounted PA prompt for individuals with cancer. Although no significant difference was found post-prompt for occurrence of PA discussion between individuals with cancer and their OCP at a single interaction, a significant difference was found in the number of PA discussions occurring overall during care. The 41% discussion rate of OCPs with their patient's found pre-prompt is higher than in previous findings^17,19,21 and while these discussions seemed to be happening even more often post-prompt, no change in exercise behaviour was found between timepoints. Overall, PA prompts may be effective in increasing the frequency of PA-related discussions between individuals with cancer and their oncology health care team across treatment; however, the results from our study suggest that wall prompts should not be used in isolation when trying to change PA-related behaviour. Additional strategies, such as easy referral to rehabilitation professionals, education for OCPs, availability of rehabilitation services and professionals within the cancer institution, are also needed to facilitate safe and effective PA prescription during and after cancer treatments.

In community settings, prompts, including signs or reminders, are used to motivate people to make an active choice.²⁶ They are often posted in transit stations, worksites, shopping malls, and airports.²⁶ A systematic review published in 2009²⁸ examined the effectiveness of periodic prompts and reminders in health promotion and health behaviour interventions targeting weight loss, PA, and diet. The review found that prompts were most effective when they were frequent, given in a personal manner, and were supplemented with additional contact from a ‘counsellor’ regarding the behaviour it was prompting.²⁸ Further, while we used wall-mounted prompts in this study, current literature is using technology to prompt health behaviours²⁸ (i.e., within app prompts or targeted emails), and suggests that prompting individuals at the “right time” is important to facilitate motivation to change behaviour.^42,43 Recent literature on the use of prompts to facilitate PA in those with chronic conditions demonstrates a significant increase in PA levels 3 days following a prompt.⁴³ Assessing intention to take part in PA after seeing the prompt was not assessed in this study and is a more congruent outcome to assess at the same timepoint as prompt exposure in future studies. Determining how (i.e., mode), when, how often, and what information to prompt to promote PA behaviour for individuals with cancer is an area of future research. Also, considering and evaluating who to prompt to discuss PA behaviour with individuals with cancer (i.e., an oncology professional, general health professional, peer, or family member) to facilitate successful behavioural motivation has not been explored and is an area of future research for this population.

A number of subgroups of individuals with cancer, such as those with metastatic disease and those currently receiving chemotherapy treatment, could benefit from discussion with OCPs but are often ignored. Interestingly in our study, the participants often reported stage 4 cancer, or metastatic disease. Research demonstrates that individuals with advanced cancer express an interest in receiving information on exercise,^44–46 however, face increased and unique barriers to exercise during and after treatment, such as more severe physical side effects and depressive symptoms, and lack of motivation.^47,48 Further OCPs may be less likely to recommend exercise to those with metastatic disease due to perceived risk of potential complications such as increased risk for fracture.^44,49,50 The fact that there was no significant difference in frequency of discussion between those with metastatic disease and those with lower stage cancer in this study is promising, as tailored exercise strategies have been found to be needed, safe and effective at managing side effects for individuals with metastatic cancer^48,51,52 when performed appropriately. Additionally, several studies suggest that regular moderate intensity exercise may decreased the risk of cancer recurrence, possibly through key biological mechanisms such as normalizing angiogenesis and cancer cell apoptosis, reducing numbers of circulating tumor cells, and decreasing endothelial cell permeability^53–55 – heightening the importance of promoting PA for individuals with metastatic cancer. Based on the current evidence, a recent consensus statement on exercise for those living with bone metastases⁴⁴ demonstrated that exercise is safe and beneficial for those with bone metastases when proper precautions are taken. In addition to having a large proportion of respondents with metastatic disease, most of our participants were also receiving chemotherapy treatment – another period of increased apprehension to promote exercise by OCPs and a time of lower exercise behaviour in individuals with cancer.^56,57 Overall, our results demonstrate promising findings for these less-researched sub-groups of individuals with cancer and highlight the need for future research to include males and those with other forms of cancer when evaluating the effectiveness of exercise prompts for cancer populations.

Past research on the barriers to exercise participation for individuals with cancer demonstrates a lack of knowledge on the benefits of exercise and safe exercise prescription during and after treatment.^21,58–60 Further, barriers to PA promotion by OCPs has been found to include both institutional and personal barriers including a lack of exercise knowledge as well as time to discuss exercise, and simply “forgetting” to discuss exercise during busy clinical appointments.^20,25 The use of prompts, used as a simple reminder to OCPs to discuss exercise, is an easy-to-install and low burden strategy for health providers to promote this behaviour. We know that individuals with cancer rely heavily on the opinion and advice of their OCP during and after treatment,^16–18 therefore, facilitating this continued discussion is important for future clinical practice. Easy to implement referral strategies to qualified rehabilitation professionals should also be implemented and prompted for OCPs in order to facilitate safe and effective exercise prescription during and after cancer treatments.^61,62 While this study explored the perspective of individuals with cancer on the use of exercise prompts, future research will explore OCPs feedback and perspective on the need, use, and effectiveness of exercise prompts to facilitate PA-discussion with their patients and further needs to optimize the referral process to rehabilitation professionals for those in need.

The inclusion of qualified rehabilitation professionals, including physiotherapists, in cancer care has repeatedly shown physical and psychological benefit for individuals with cancer^11,12,63 and has been endorsed by many provincial and national organization,^14,62 however, referral is still low.⁶⁴ Overall, the passive strategy of wall-mounted PA prompts was an easy way to promote the sharing of knowledge and facilitate PA-related discussions in a clinical setting to start the process of survivorship care to optimize physical functioning. But these results also demonstrate that we should not use this strategy in isolation. Future research and clinical practice could incorporate PA prompts as part of a more robust strategy to facilitate PA behaviour for individuals with cancer. Future research should consider how to best link this strategy with other PA implementation strategies and focus on what content is prompted; trying to make the information as specific and useable as possible for individuals with cancer.

Limitations

The results of this study should be reviewed with an understanding of its limitations. Firstly, the study was conducted at a single institution in Ontario, Canada which may limit the generalizability to other institutions within and outside of Canada. Further, the wall-mounted prompt and survey were only administered in English. This limits collection of data on the experiences of individuals with cancer who do not read the English language. Additionally, this study was conducted during the various waves of the COVID-19 pandemic in Canada. Within this timeframe, lockdowns and stay at home orders were implemented by the government, which led to a longer period of data collection than would have occurred in pre-pandemic days. Further, while all interactions within this study were done in-person, some appointments during this period were conducted using tele-communication (i.e., phone), especially for those who were not undergoing active treatment. This may have led to bias in that those who were surveyed at the cancer centre were in more acute phases of treatment, had more severe disease (i.e., metastatic cancer), and/or were more comfortable in communication with research staff during this time. Finally, the heterogeneity of our sample, and inclusion of individuals attending both first and follow-up appointments may be viewed as a limitation, as initial appointments are often overwhelming and include many forms of information. To overcome this, we did perform sub-analysis based solely on those at a follow-up appointment and found that differences in the frequencies of discussion were maintained across timepoints, however, readers should be aware of this limitation.

Conclusions

This study demonstrated preliminary evidence of benefit of wall-mounted prompts to facilitate PA discussions between individuals with cancer and their OCP. These findings provide the foundation for a larger intervention, focusing on a variety of disease sites and additional oncology clinics across Ontario and Canada. This study addresses an important need to help individuals with cancer become more physically active, which may offer an effective strategy for promoting long-term health benefits and well-being among individuals with cancer. Additionally, this information can be used to inform similar interventions to be tested in primary care settings to enhance the use of PA for primary prevention of cancer.

Key Messsages

What is already known on this topic

Many Canadians live with side effects of cancer and its associated treatments. Regular PA participation can help mitigate side effects of cancer treatment. However, many survivors are not meeting PA guidelines and barriers to regular PA participation and promotion exist at both the survivor and health professional level. PA prompts are effective in solidifying knowledge of health promoting behaviour in general populations.

What this study adds

Wall mounted PA prompts are easily implemented in the cancer care setting and may help to facilitate PA discussion between individuals with cancer and their OCP. However, PA-related wall-prompts alone do not lead to a significant change in PA behaviour within this population and therefore should not be used in isolation. Additional strategies are needed in a clinical setting, such as referral strategies to rehabilitation professionals, education for OCPs, and increased availability of rehabilitation services and professionals within the cancer institution, to facilitate sustained change in PA behaviour during and after cancer treatment.

Jenna Smith-Turchyn PT, PhD, is a physiotherapist and Assistant Professor in the School of Rehabilitation Science at McMaster University. She is also an Associate Member in the Centre for Discovery in Cancer Research at McMaster University and co-chair for the Canadian Physiotherapy Association's Oncology Division. Jenna has an active research program at the Juravinski Cancer Centre in Hamilton, Ontario. Her research focuses on exercise oncology, self-management, and implementation strategies to promote rehabilitation for individuals living with or beyond a cancer diagnosis, with the goal of maximizing participation and physical functioning.

Appendix 1

Exercise Prompt/Physical Activity Survey

Date: ______

Please answer these questions about yourself:

1. What is your month and year of birth? ___________________________

2. Are you male or female? ___________________________

3. What type of cancer have you been diagnosed with? ___________________________

4. What stage of cancer have you been diagnosed with?___________________________

5. Was this your first appointment or a follow up appointment?

• □First appointment
• □Follow-up appointment

6. Are you currently undergoing treatment?    □    Yes    □    No

□ If YES, please describe the type of treatment you are currently receiving (check all that apply):

• □Chemotherapy
• □Radiation
• □Hormonal Therapy
• □Other (please describe):______________________________

Please answer the following questions regarding your interaction with your oncology care provider today.

7. Did you discuss physical activity or exercise with your oncology care provider at today's appointment?:

• □Yes
• □No

8. If YES to question #7, who was this discussion with? (check all that apply)

• □Medical Oncologist
• □Radiation Oncologist
• □Oncology Nurse
• □Other (please list): ____________________

9. If YES to question #7, what did the discussion include?

• Did they discuss your current exercise level?	□ Yes	□ No
• Did they discuss the benefits of exercise for cancer survivors?	□ Yes	□ No
• Did they discuss how you can become more active?	□ Yes	□ No
• Did they discuss what types of exercise you can do?	□ Yes	□ No
• Did they discuss how often you should exercise or how long you should exercise for?	□ Yes	□ No

What else did you discuss (related to exercise or physical activity)?

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

10. If NO to question #7, have you discussed physical activity or exercise with your oncology care provider in the past?

• □Yes
• □No
• □Not applicable

11. If NO to question #7, would you have liked to discuss this topic (exercise / physical activity) with your healthcare team today?

• □Yes
• □No

12. If YES to question #11, what would you have liked to discuss?

_________________________________________________

_________________________________________________

_________________________________________________

13. Please rank your satisfaction with the education you have been provided on physical activity / exercise throughout your cancer treatment (please circle):

14. Did you notice the wall stickers in the Clinic D waiting room encouraging physical activity?

• □Yes
• □No

15. If Yes to question #14, did this facilitate you to bring up exercise with your healthcare team?

• □Yes
• □No

Please answer the following questions about your physical activity level:

During a typical week, how many times (on average) do you participate in 15-minutes or more of strenuous exercise (heart beats rapidly). Examples include running, jogging, hockey, football, soccer, squash, basketball, cross country skiing, vigorous swimming, long distance bicycling.

Times

During a typical week, how many times (on average) do you participate in 15-minutes or more of moderate exercise (not exhausting exercise). Examples include fast walking, baseball, tennis, easy bicycling, volleyball, badminton, easy swimming, alpine skiing, dancing.

Times

During a typical week, how many times (on average) do you participate in 15-minutes or more of mild exercise (minimal effort). Examples include yoga, bowling, golf, easy walking.

Times

During a typical week, in your leisure time, how often do you engage in any regular activity long enough to work up a sweat (heart beats rapidly)?

• □Often
• □Sometimes
• □Never

Thank you for completing this survey!