An examination of the beliefs, attitudes and counselling practices of paediatric oncologists toward physical activity: A provincial survey

Abstract

BACKGROUND

With an increasing population of childhood cancer survivors and a growing recognition of the long-term effects of diagnosis and treatment, it is imperative that modifiable risk factors for long-term health and disease comorbidity be identified and addressed. Physical activity is one therapy that is gaining credibility in enhancing quality of life and reducing the burden of disease.

OBJECTIVES

To examine the beliefs, attitudes and counselling practices of a group of Alberta-based paediatric oncologists.

METHODS

All Alberta-based physicians with a known specialty in paediatric oncology were approached and asked to complete a onetime, mail-out survey.

RESULTS

All responding physicians regarded both personal exercise and physical activity for childhood cancer survivors as moderately to extremely important. Importantly, one-half of the respondents believed that there is no adverse risk associated with physical activity in this survivor group. While the bulk of physicians report prescribing physical activity, few believe that their patients actually follow these recommendations.

CONCLUSIONS

Responding oncologists acknowledge the importance of physical activity for all survivors; however, future research is needed to better understand how to best promote healthy active living within this group.

With the growing number of long-term paediatric survivors and with an increased recognition of the potential treatment-related sequelae, there is a need for ongoing supportive care to prevent negative outcomes and contributing health risk behaviours, and to promote positive outcomes and disease prevention practices. Moreover, the identification and recognition of modifiable risk factors, such as physical inactivity, may aid in shifting the survivor’s focus from the potentially uncontrollable aspects of their disease to initiating lifestyle behaviours that promote long-term well-being (1).

THE ROLE OF THE PAEDIATRICIAN

Physical activity (PA) is an important health issue and is widely recognized as an instrumental resource in enhancing quality of life (QoL) and reducing the burden of disease (2). Despite their natural tendencies, it is clear that today’s youth are becoming less physically active, with as many as 80% failing to meet guidelines for optimal growth and development (3). These issues may prove to be more salient to the growing population of paediatric cancer survivors because many of the health benefits associated with PA are negatively affected by their cancer treatment (4).

Although there is a lack of empirical data in children with cancer, four recent reports highlight the potential benefits of PA for the paediatric survivor (5–8). Specifically, late effects, such as reduced exercise tolerance, reduced bone mineral density, obesity and long-term implications, such as a heightened risk for cardiovascular disease and reduced QoL, can all benefit from PA (5–8).

Importantly, the advice of a physician carries a great deal of credibility, with as many as 75% of adolescents agreeing with the statement, “If my doctor told me to exercise I would do so” (9). Unfortunately, there are no studies that have examined the role of the paediatric oncologist in counselling their patients to be physically active. However, a recent report suggests that the mere promise of public health benefit justifies the development and evaluation of primary care PA interventions (10). Recent research in sedentary adults suggests that physician-based activity counselling can be effective (11–13), and is important in the adult cancer population in promoting exercise (14–16). The College of Family Physicians of Canada has partnered with Health Canada on a PA and health strategy initiative (‘Getting active about physical activity!’). Together, they have issued a call to action encouraging family physicians to incorporate PA advice and counselling into their daily practice. A similar initiative has been adopted by the Canadian Paediatric Society in which all paediatricians are encouraged to promote healthy active living at all well-child visits.

The purpose of the present study was to examine the beliefs, attitudes and counselling practices of paediatric oncologists, and their role in advocating and promoting PA. Specifically, we assessed the following: the percentage of physicians who report initiating a discussion about PA with the survivor during a follow-up consultation; the percentage of physicians who report being asked about appropriate PA behaviours by the paediatric survivor or parent; the perceived barriers to activity counselling; and the perceived importance and risk associated with PA in this group of survivors.

METHODS

Participants and procedures

Following approval from the local human institutional review board, all Alberta-based physicians with a known specialty in paediatric oncology (n=21) were asked to participate. The completion and return of the questionnaire package was understood as consent. A retrospective design was used in which physicians were asked to recall the frequency of PA discussions during follow-up care. Participants received a questionnaire package that included a detailed cover letter, an informed consent form, a survey, and a stamped self-addressed return envelope. Efforts to increase response rates included multiple reminders, stamped return envelopes, coloured paper, illustrations, assurances of confidentiality and a personalized cover letter (17).

Physician survey

The survey included an assessment of personal exercise beliefs, attitudes and habits. The survey was modelled on previous work by Abramson et al (18), who investigated the counselling practices of paediatricians, family practitioners, internists and geriatricians, and also on previous work by Jones and Courneya (16), who examined the role of the oncologist in promoting exercise in adult cancer survivors. Physicians were asked to report their actual exercise behaviour, their perceived barriers to personal exercise and their perceived importance of personal exercise. Additionally, they reported the perceived importance and risks of PA in adolescent survivors, in addition to their exercise counselling practices with this population. Counselling practices were assessed by a self-reported estimation of the percentage of survivors counselled during a routine follow-up visit regarding PA and the amount of time dedicated to these consultations. Demographic and medical data included practitioner age, sex and number of years in practice.

Physician self-reported PA behaviours were assessed using the leisure score index (LSI) of the Godin Leisure-Time Exercise Questionnaire (19,20). The LSI contains three questions and is designed to assess the frequency of mild, moderate and strenuous exercise/activity performed for at least 15 min over a typical week. A total LSI score was calculated by adding the frequency of exercise within the mild, moderate and strenuous categories. An independent evaluation of this tool has found it to be both a reliable and valid measure (21).

Statistical analysis

The collected questionnaires were analyzed with the statistical package provided by SPSS Version 12.0 (SPSS Inc, USA). Descriptive analyses are presented for the demographic profile of the respondents as well as the main outcome variables, including personal exercise attitudes, habits, and beliefs and exercise counselling practices.

RESULTS

The overall questionnaire response rate was 57.1% (12 of 21). Of the 12 surveys returned, eight were from male physicians, the mean age was 45.6 years, and 75% had been in practice for more than 11 years (Table 1). One respondent identified himself/herself as an ‘inpatient’ physician, working with extremely ill children, and, as such, did not provide any data on exercise counselling practices. Accordingly, exercise prescription and counselling behaviours are reported for the remaining 11 respondents. All physicians surveyed indicated that they were physically active on a regular basis and there was no significant difference between the frequency of self-reported activity for male physicians and female physicians (Table 2). The reasons cited for engaging in regular PA are presented in Table 3. The major barriers to personal exercise were lack of time (91.7%) and lack of motivation (33.3%).

TABLE 1.

Physician demographics (n=12)

Variable	n	%
Years in practice
6–10	3	25.0
11–15	4	33.3
Over 15	5	41.7
Sex
Male	8	66.7
Female	4	33.3
Age, years
40–45	5	41.7
46–50	5	41.7
Missing	2	16.7

TABLE 2.

Physician exercise behaviours (n=12)

	Average number of sessions per week
Variable	Men, mean (SD)	Women, mean (SD)	Group, mean (SD)
Mild activity	4.13 (3.48)	3.00 (3.56)	3.75 (3.39)
Moderate activity	2.75 (2.44)	0.75 (0.96)	2.08 (2.23)
Strenuous activity	2.50 (2.51)	3.50 (2.89)	2.83 (2.55)
Total activity	9.38 (5.93)	7.25 (4.57)	8.67 (5.40)

TABLE 3.

Physician physical activity beliefs and attitudes

Variable	n	%
Reasons for being physically active (n=12)
Cardiovascular fitness	9	75.0
General health/disease prevention	8	66.7
Musculoskeletal fitness	8	66.7
Weight control	5	41.7
Physical appearance	8	66.7
Psychological benefits	9	75.0
Social interaction	2	16.7
Other	4	33.3
Barriers limiting personal activity (n=12)
Lack of time	11	91.7
Lack of motivation	4	33.3
Reasons for counselling survivors to be physically active (n=11)
Cardiovascular fitness	9	75.0
General health/disease prevention	8	66.7
Musculoskeletal fitness	7	58.3
Weight control	7	58.3
Physical appearance	5	41.7
Psychological benefits	8	66.7
Social interaction	4	33.3
Barriers to counselling survivors (n=11)
Lack of time	5	45.5
Lack of motivation	1	9.1
Lack of knowledge/resources	6	54.5
Other (physician ignorance, lack of patient/parent receptivity)	2	18.2

Importantly, all responding physicians regarded PA for childhood cancer survivors as moderately to extremely important, and one-half (50%) believed there to be no adverse risk associated with PA in this group. While the bulk of physicians reported that they counselled patients about PA, few believed that their patients actually follow these recommendations. Only a small number of patients were reported to have initiated discussions regarding appropriate PA behaviours (Table 4).

TABLE 4.

Percentage of physician- and patient-initiated physical activity-related discussions (n=11)

Percentage	Patient-initiated	Physician-initiated
1–20	6	3
21–40	3	0
41–60	1	2
61–80	1	1
81–100	0	5

The reasons given for counselling patients about PA are listed in Table 3. The major barriers reported to PA counselling were lack of knowledge or resources (54.5%) and inadequate time (45.5%). Time spent counselling varied considerably; however, the majority (72.7%) indicated an allocation of 1 min to 5 min to exploring patient PA behaviours, the benefits of such activities, and activity prescription (Table 5).

TABLE 5.

Time spent counselling the patient about physical activity (n=11)

Time (min)	n	%
<1	1	9.1
1–2	3	27.3
3–5	4	36.4
6–10	1	9.1
>10	2	18.2

All respondents indicated that they provided verbal counselling for PA. Two of the physicians indicated that they also provided their patients with written materials. One physician indicated that they would refer the patient to a specialist if specific program details were sought or required. None of the remaining respondents indicated that they had made use of any type of referral mechanism (eg, exercise physiologist, physical therapist or certified fitness instructor/program).

Regrettably, although many physicians indicate that they spend time counselling their patients to be physically active, when asked to provide details on the four basic components of any PA program (ie, frequency, intensity, time and type), only one provided specific recommendations. The majority indicated that the patient should be active on a ‘regular’ or ‘daily’ basis and that the activity should include an ‘aerobic’ component, but further details were not provided. A summary of physician responses is provided in Table 6.

TABLE 6.

General exercise recommendations from physicians

Physician responses
Frequency
Refer to specialist if specific program details sought or required Too individualized to answer accurately Regular As patient/family suggests Regular Exercise regularly; daily if possible I take care of very ill, inpatient cancer kids and do not have a private practice or outpatient responsibilities Several times per week Daily Three to four times per week Increase Daily
Intensity
Refer to specialist if specific program details sought or required Too individualized to answer accurately No recommendation Moderate I take care of very ill, inpatient cancer kids and do not have a private practice or outpatient responsibilities At any level Generally light, increase as tolerated To induce heart rate increments according to age Increase
Time
Refer to specialist if specific program details sought or required Too individualized to answer accurately As patient/family suggests No recommendation 45 min to 90 min I take care of very ill, inpatient cancer kids and do not have a private practice or outpatient responsibilities No specific recommendations 20 min to 30 min Increase
Type
Refer to specialist if specific program details sought or required Too individualized to answer accurately Any As patient/family suggests Aerobic Variable. Mostly sports, jogging and swimming I take care of very ill, inpatient cancer kids and do not have a private practice or outpatient responsibilities Aerobic According to their interests Running, biking and swimming To do both

Physicians (n=12) were asked to indicate the frequency, intensity, duration and type of physical activity prescription provided to paediatric oncology survivors during routine follow-up visits

DISCUSSION

The present study provides the first report on the PA counselling attitudes and behaviours of a group of paediatric oncologists. Perhaps the most important finding of the present study was that all physicians regarded PA for childhood survivors as moderately to extremely important, with one-half reporting that there is no adverse risk associated with young survivors engaging in PA.

A second important finding of the present study is that physicians reported a lack of time, knowledge and resources as the primary barriers to PA counselling. Given the demanding nature and complexity of paediatric cancer care, lack of time was not an unexpected barrier. However, given that all respondents indicated that they were physically active on a regular basis and regarded PA as highly important for both themselves and their patients, ‘lack of knowledge’ is a particularly troubling barrier. Consequently, our results emphasize the importance of educating physicians regarding the potential benefits of PA, how to identify and access the appropriate resources, and how to best implement and facilitate behavioural change in their patients.

Activity prescription

Unfortunately, there is no direct evidence concerning the optimal exercise prescription for cancer survivors (22). Although general guidelines have been made available based on recent investigations with the adult population, no data are available for the paediatric population. This is exemplified in the physician responses to specific counselling practices, in which responses were varied and no clear recommendations were made. However, given the range of paediatric cancers, their biological behaviour and the varied treatment protocols, the appropriate activity prescription can and will vary considerably from patient to patient. Clearly, determining the optimal activity prescription for each cancer/treatment combination is an enormous challenge and awaits further research.

So how much and what kind of PA should be prescribed? Obviously, the decision concerning the optimal activity prescription will depend on the specific limitations imposed on each survivor. However, the work performed with adult cancer patients demonstrates that exercise is just as important for the psychological benefits as for the physical health benefits (17,18). Accordingly, any PA program should emphasize the following goals: optimize enjoyment and physical confidence, provide opportunities for enhancing a sense of control over their activity program, and incorporate social interaction (22).

However, because the majority of paediatric cancer survivors should be able to meet the current Canadian guidelines for health-enhancing PA for children and adolescents, survivors should be encouraged to build up to a minimum of 90 (total) min of total PA per day (60 min of moderate activity and 30 min of strenuous activity) (23). Considering the implications of cardiotoxic therapies, prevention of injuries and the effects of cancer treatment on motor skills, physical capacity and confidence, a gradual progression of activity should be encouraged. Activities should include a variety of weight-bearing activities as part of athletic pursuits, recreation, transportation, chores, work, planned exercise and school-based physical education. For optimal compliance, activities should be as unstructured and as ‘fun’ as possible. In addition, families and children should be counselled to reduce the amount of time dedicated to sedentary activities (see <www.paguide.com>) (24).

Ultimately, when considering optimal activity prescription, given the unique medical needs of each survivor, it is imperative that the physician acknowledges and assesses for any ongoing physical limitations when prescribing and tailoring activities. Physicians are also referred to the Canadian Paediatric Society for additional tools and resources to assist them in educating patients and families about the benefits of healthy active living (<www.cps.ca/english/HealthCentres/HAL/Index.htm>).

Limitations

Despite the important information gathered in this preliminary survey, there are limitations. Most obvious is the limited sample size, and thus only the descriptive analyses were obtained. Moreover, given the transparent nature of the study, it is likely that those physicians who are most interested in PA were also more willing to participate. Accordingly, the behaviours of physicians with less positive attitudes toward PA may not be known. Further, because the current study did not evaluate patient attitudes and behaviours, it was not possible to determine their understanding of physician advice, their perception of the importance of PA and their actual PA habits. Additional limitations include the retrospective study design and the reliance on self-report measures of PA. Future research employing prospective designs that include survivor reports from a nationally representative sample is needed. Additionally, because many children treated for cancer typically maintain their relationship with their primary care physician for acute care and health maintenance, and because many long-term survivors will no longer be under the direct care of the paediatric oncologist, it will be important in future studies to assess the primary physicians’ understanding of the long-term risks associated with a paediatric diagnosis, as well as any risks associated with PA, their approach to preventive health strategies, and their role in educating their patients on the importance of regular PA.

Clinical implications

The results of the current survey suggest that this sample of paediatric oncologists recognizes the importance of PA and frequently initiates discussions with their patients during follow-up consultations. Unfortunately, it does not appear that the oncologists believe that such discussions impact on patient activity habits or behaviours. It may be necessary to refer patients to exercise specialists who have expertise in exercise motivation and behaviour change. However, because survivors will continue to look to the medical profession for advice and credibility, it is imperative that we continue to educate physicians on the role of PA in the paediatric oncology population and make available the appropriate resources (eg, exercise specialist), thereby eliminating the ‘lack of knowledge’ barrier in physician activity counselling practices.