Abstract
Purpose:
Perioperative physical activity behavior change in older adults with cancer is complex. Identifying the barriers and facilitators to physical activity before and after surgery can help predict adherence and optimize outcomes. We aimed to determine the barriers and facilitators of adherence to a perioperative physical activity intervention in older adults with lung and gastrointestinal (GI ) cancers and their family caregivers (FCGs).
Methods:
A qualitative analysis of physical therapy/occupational therapy (PT/OT) baseline geriatric/functional assessment and intervention sessions notes were undertaken (N=34 dyads). Written text documents (N=6 independent PT/OT notes per dyad) were transcribed into a spreadsheet for coding and thematic analysis. Content analysis qualitative approach was used to identify themes and guide data interpretation.
Results:
Ten themes for barriers and five themes for facilitators emerged, reflecting barriers to and facilitators of perioperative physical activity adherence. Primary barriers to adherence included comorbid health conditions, physical symptoms, functional limitations, anxiety, other roles and responsibilities, unexpected life events, lack of time and motivation, not accustomed to physical activity, and environment/weather. Facilitators that enabled intervention adherence included physical activity as part of routine, coping strategies, setting goals for motivation, social/family support, and experiencing benefits from walking.
Conclusions:
Barriers and facilitators to a perioperative physical activity is multidimensional, and focused on social-ecological determinants of health behaviors, including intrapersonal, interpersonal, and environmental factors. Perioperative physical activity interventions for older adults with cancer and their FCGs should integrate strategies to promote self-efficacy, support realistic activity goals, enhance motivation, and optimize social support.
Keywords: physical activity, cancer, family caregivers, surgery, barriers, facilitators
Introduction
Cancer is a disease of aging, and older adults are disproportionately affected.1 Older adults face a number of barriers that affect mobility and functional capacity. These include multi-morbidity, frailty, and persistent physical and psychological symptoms that impairs an individual’s ability to engage in physical activity. Cancer treatments, including surgery, can abruptly decrease a patient’s physiologic reserve.2 Evidence suggests that older adults with cancer are at greater risk for postoperative functional decline and poor outcomes.3 Geriatric assessment domains, including functional activity, dependency with activities of daily living (ADL), and severe frailty were associated with major postoperative complications.4 Loss of independence, defined as decline in function or mobility, is associated with postoperative readmissions and post-discharge mortality in older adults.5,6
Physical activity is an evidence-based approach to enhance physical, cognitive, and emotional quality of life (QOL) for cancer patients.7 Mounting evidence points to the positive benefits of physical activity on functional health and overall survival. Despite these well-known benefits, older adults remain the least active age group, with less than a third meeting recommended physical activity levels.8–11 Physical activity behavior change is complicated, and adherence to physical activity is driven by intrapersonal, interpersonal, environmental, and structural factors.12 In lung cancer patients, symptoms, comorbidities, sedentary lifestyle, mood/fear, and the environment are multidimensional barriers to physical activity and exercise.13
Social support is recognized as a positive determinant of physical activity participation in cancer patients. Family caregivers (FCGs) are a major source of social support, and play a significant role in the direct care of cancer patients.14 FCGs may influence patient physical activity adoption and maintenance by serving as role models and motivators. Current evidence suggests that cancer caregiving is intense, episodic, and has a profound impact on the caregiver’s physical well-being and quality of life (QOL).15,16 However, FCGs may not participate in physical activity behaviors due to the demands of caregiving and caregiver burden.17,18
Maintaining physical activity before and after surgery is challenging for older adults with cancer and their family caregivers (FCGs). Few studies have investigated factors that promote and hinder perioperative physical activity adherence in older adults with cancer and their FCGs. Understanding the barriers and facilitators to physical activity is essential in designing feasible and effective interventions to improve dyadic functional capacity and QOL. The goal of this study was to explore barriers and facilitators of adherence to a perioperative physical activity intervention for older adults with lung and gastrointestinal (GI) cancers and their FCGs, in order to gain better insight into factors that may predict intervention engagement.
Methods
Intervention, Sample, and Setting
The parent intervention study was reviewed and approved by the Institutional Review Board (IRB). All participants provided written informed consent prior to enrolling in the study. Briefly, the perioperative physical activity intervention provided one-on-one coaching to optimize physical and psychological functioning before and after surgery. It was delivered by a trained physical therapist (PT) and occupational therapist (OT), and involved five videoconference and telephone sessions. The sessions were delivered before surgery and continued through hospitalization and up to two to four weeks post-discharge. Patients/FCGs were enrolled as dyads, using the following eligibility criteria: 1) diagnosis of lung or GI (colorectal, gastric, pancreas, liver) cancers; 2) scheduled to undergo surgery; 3) patient age ≥65 years; 4) family member/friend identified by the patient as the primary caregiver before and after surgery; 5) FCGs age ≥21 years; and 6) ability to read and understand English. Following baseline comprehensive assessment (geriatric assessment, six minute walking distance, short physical performance battery), a personalized walking and lower extremity exercise (sit to stand, step up and down-front, step up and down-sideways, standing wall push away) program was developed for patients. Classic behavioral change strategies were integrated, which included goal setting, identifying challenges/barriers to physical activity, problem solving to overcome the challenges/barriers, and skills building related to functional recovery. Throughout the study period, patients/FCGs wore wristband pedometers (Vivofit 3; Garmin Ltd) on the non-dominant hand for self-monitoring purposes. FCGs were trained to serve as “coaches,” and were encouraged to participate in the walking program with patients.
Procedures
All eligible participants who met the parent intervention study inclusion criteria were identified and recruited from one National Cancer Institute-designated comprehensive cancer center in Southern California over a seven month period. A total of 34 dyads (sixteen GI, eighteen lung) were enrolled. Median age for lung surgery patients was 74; for lung surgery FCGs, median age was 71. GI surgery patients and FCGs were younger, with median age of 68 and 67 respectively. Forty one percent of patients were female, 82% were of white race, and 94% were married. Fifty-nine percent of the caregivers were female, 82% were of white race, and approximately 53% were employed.
Baseline comprehensive assessments were completed during a routine clinic visit, while the intervention sessions were delivered via Zoom videoconferencing before surgery and during inpatient hospitalization following surgical procedures. The length of intervention sessions ranged from 30–70 minutes. Baseline comprehensive assessment encounters and intervention sessions were noted by PT/OT.
Data Analysis
We focused our analysis on PT/OT notes from the following encounters: 1) baseline comprehensive assessment, 2) intervention session #1 before surgery (Zoom videoconferencing), and 3) intervention session #2 during postoperative hospitalizatio n (inpatient encounter). PT and OT provided separate notes at each of the three encounters. For each of the 34 dyads, a total of six independent notes were available for analysis. Free-text data were transcribed into a spreadsheet for coding purposes. Data interpretation was guided by the direct qualitative content analysis approach, which allowed for the identification of initial key concepts by expanding on existing behavior change adherence theories and research.19 All written comments were read, individually coded, and categorized into themes by investigators experienced in qualitative analysis. One investigator (VS) read all notes and independently coded all data and categorized the content themes. Two investigators who did not participate in the initial review and selection process (SH, GV) conducted a final validation of themes and content. Data that were discordantly coded were discussed for refinement and consensus.
Results
A total of ten themes for potential barriers and five themes for facilitators to intervention adherence emerged (see Table 1). The responses indicated factors that inhibit intervention adherence, as well as strategies that facilitated participation in the prescribed walking and lower extremity exercise program. Representative patient and FCG comments from each theme are provided in Tables 2 and 3.
Table 1.
Barriers and Facilitators of Adherence from Physical Therapy/Occupational Therapy (PT/OT) Assessment and Session Notes
| Themes | |
|---|---|
| Barriers | 1. Comorbid conditions, procedures, and injuries |
| 2. Physical symptoms | |
| 3. Functional limitations/history of falls | |
| 4. Anxiety/feeling overwhelmed | |
| 5. Other roles and responsibilities | |
| 6. Other engagements/unexpected life events | |
| 7. Lack of time | |
| 8. Lack of motivation | |
| 9. Not accustomed to physical activity | |
| 10. Physical environment/weather | |
| Facilitators | 1. Physical activity as part of routine |
| 2. Coping strategies | |
| 3. Setting goals for motivation | |
| 4. Social/family support | |
| 5. Seeing benefits from walking |
Table 2.
Exemplars: Facilitators to Adherence
| Theme | Patient | Caregiver |
|---|---|---|
| Physical activity as part of routine | “He walks 5–7 × week for 60–80 minutes in the morning and 45 minutes in the afternoon. Also goes to the gym 2 × week for 90 minutes doing treadmill, weights and pilates. Patient likes to ski, walk, go to the gym, do his yard work.” “Active and goes to gym 2 × week and works out with a trainer with body weight resistance training and Pilates exercises.” “Patient is very active and walks 2–3 miles every day with her husband - about 45 minutes and also does tai-chi 1 × week for 60 mins, yoga 1 × week for 90 mins, senior fitness exercises 1 × week for 60 minutes.” “She is active throughout the week engaging in tennis weekly and yoga, aerobics, walking and weight lifting an additional 3–4 times per week.” “Spends his day doing yard work and general maintenance on his home and other properties.” “Normally, she enjoys walking around her block with her friends.” |
“Wife does Pilates twice a week and goes to the gym once a week.” “Husband is her primary caregiver and he hikes 2x a week in the mountains.” “Patient’s husband is her caregiver and he is also active and likes to golf for 3–4 hours a day.” |
| Coping strategies | “She states that she copes by praying and putting her problems in the hands of God.” “Faith is what grounds them through these experiences and that this actually turned out easier than they thought.” “Sits on the board for the local YMCA which involves meetings and events throughout the week.” “Socializing with family and friends.” “He also values keeping a clean home which includes mopping/vacuuming and washing dishes.” “Attempts to “control” an activity indoors, such as cleaning out the drawers.” “Her primary coping strategy is meditation.” “Patient normally manages her stress by performing labor intensive activities outdoors (e.g., picking up hay, mowing the lawn, etc.).” |
“She has been coping by relying on her faith, a prayer group.” “She is actively engaged in charity work and socializes daily.” “Cleans her home when she feels stressed.” “Caregiver states that she has been incorporating exercise consistently based on previous recommendation to utilize this as a coping strategy for stress.” |
| Setting goals for motivation | “Patient stated three goals for after surgery: Returning to the mountains, skiing and teaching skiing.” “Goal of increasing steps by 1,000 in the next two days.” “Reported cooking, returning to his job as a mechanic, painting, playing his musical instrument, and walking/jogging and important activities to continue or return to after surgery, rating each of 10/10 importance.” “His goal is to recover from surgery so he can get back to his routine of travelling and enjoying life.” “Patient stated that she is motivated to recover quickly as she has her children and grandchildren visiting for the holidays.” |
|
| Social/family support | “Pt states she has good support from friends who are contacting her throughout her hospital stay.” “His daughter and son are living with him on a temporary basis. He has multiple children and grandchildren, and described himself as being ‘lucky’ on having a good social support system.” “Patient reported that grandchild has purchased several books for him to read.” “Daughters prepare his meals and maintain the home to make it more convenient for him.” |
“Caregiver is extremely helpful in providing support and encouragement for her. Caregiver states that she will provide consistent encouragement for patient to walk daily.” “Husband very supportive and present; has been walking with the patient.” “Husband has been walking consistently and motivating her to join him.” “Patient’s wife expressed motivation to adhere to recommendations and stated that going through this process with her husband has changed the way she looks at her own health.” |
| Seeing benefits from walking | “Exercise helped improve symptoms of leg cramps throughout the night.” “Noted decreased anxiety as compared to the first session.” “They both stated that prior to surgery they increased their steps because they were preparing for guests on Easter. They both showed me the steps listed in the app and were excited to see the numbers increase over time.” “Reports that his back pain had diminished at home, which he and wife attributed to increased walking.” |
“Caregiver states that there are moments of increased anxiety however when she engages in activities this decreases.” |
Table 3.
Exemplars: Barriers to Adherence
| Theme | Patient | Caregiver |
|---|---|---|
| Comorbid conditions, procedures, and injuries | “Since his heart surgery in ‘08, there has been functional limitations and a decrease in engagement in meaningful activities.” “Patient states her activity at home is limited from COPD.” “She also stated that she does not do the exercises in the manual because it aggravates her arthritis.” “History of left ankle injury with instability since the past year.” “Patient states she is limited in walking second to allergies.” “Patient used to enjoy fishing and hunting however he has not engaged in this activities over the past year due to medication which does not allow for sun exposure.” |
“Has co-morbidities of COPD.” “Has been arthritis and trauma to her right knee from previous injury so is limited with her walking for exercise.” “Left ankle fracture and will be on walking restrictions for the next 6 weeks.” “Unsure if she will be able to walk with him due to allergies.” |
| Physical symptoms | “Patient states that his primary barrier to increasing physical activity is his back pain.” “History of right knee pain which is limiting her from being more active.” “Pt reported pain at the surgical site when attempting to stand straight while walking.” “Worsening neuropathy in bilateral feet.” “Patient has been mostly housebound in the past year and limited community ambulation due to shortness of breath.” “Fatigue prevent him from walking more.” “She stated she was also feeling nauseous which has discouraged her from being active.” “Patient has also been complaining of dizziness with ambulation.” “Limited and poor sleep due to frequent bathroom breaks (very important).” |
“Caregiver states that due to right knee pain there may be days she will be unable to walk with him.” “Hip pain with walking.” |
| Functional limitations/history of falls | “He reported the following functional deficits: SELF-CARE: fatigue after showers, difficulty with lower body dressing due to balance issues, limited endurance affecting functional mobility (very important), and no longer driving due to problems with hearing.” “Patient is independent with ADLs but needs extra time to complete, ambulates with SPC in the house for short distances.” “Multiple falls in the past 3 years. She fell in the past and fractured her pelvis and lower spine.” |
|
| Anxiety/Feeling Overwhelmed | “Patient stated that as he approaches his surgery date he feels more stressed and anxious.” “Patient expressed concerns regarding pathology results and is fearful of needing chemo.” “Anxiety triggered by thoughts about her recovery.” “Felt overwhelmed with tasks that they need to complete prior to surgery.” “Concerned that her other family members were leaving and that she would only have the support of her husband.” “She reports that she feels anxious about going home however she is glad to be leaving the hospital.” |
“Anxiety regarding [patient’s] surgery has increased and she is not coping well.” “Anxious about his recovery as well and what his quality of life will be after surgery.” “Spouse stated that the day of surgery was stressful.” “She is “maxed out” and extremely stressed about work and her husband’s current situation.” “Expressed concerns due to several family members and friends requesting to visit her husband in the hospital and this increases her stress.” |
| Other roles and responsibilities | “Patient’s husband does not drive and so she chaperones him for his errands. She provides general caregiver support for her husband who has neck/back injury.” “Patient states her barrier to increasing activity is her work responsibilities and fluctuating demands.” “He and his wife are heavily involved in the care of their 9 y/o grandson spending most of their time taking him to activities. They also care for elderly mother who lives in a local assisted living facility however she requires a lot of support.” |
“Caregiver stated that since she has been busy with family obligations she has not been walking often.” “Work responsibilities and the need to take time away from work to help her husband after surgery.” “Spouse is retired and spends her days managing the home and caring for several family member who have medical issues. Caring for several family member is overwhelming.” |
| Other engagements/unanticipated life events | “Upcoming holiday gatherings.” “Patient’s husband was in a car accident hence he has also not been able to walk for exercise and this has increased caregiving burden on the patient.” “Patient states that he received unexpected news from his endocrinologist that he will need an additional surgery.” |
“Caregiver stated that she has been occupied with MD appointments because she has an upcoming surgery.” |
| Lack of time | “They have been taking care of other appointments in the past two days but haven’t been able to formally engage in walking program or the exercises yet. They have been driving down from [out of town] and all the MD appointments.” | “Caregiver stated that her primary barrier to increased walking has been the busy schedule.” |
| Lack of motivation | “Patient identified motivation as being the primary barrier to incorporating walking program.” “Only barrier to incorporating walking and exercise is laziness. Primary barrier is decreased motivation.” “Does not like structured exercise and that the primary barrier to participating in walking and exercise is lack of interest and motivation.” “Reported that he does not enjoy walking.” |
|
| Not accustomed to physical activity | “Currently is not active, does not exercise.” “Active around the house but does not exercise.” |
“Spouse states that they are generally “lazy” and live a sedentary lifestyle. They do not engage in physical activity and do not socialize.” |
| Environment/weather | “He does not walk outside of the home due to living in the hills.” “Current weather pattern (rain).” “Does not want to go out when it’s hot and then it gets dark early.” “Cold weather aggravating joint pain.” “Limited in walking second to recent windy weather.” “Patient has not been walking outside due to cold weather.” |
Barriers to Intervention Adherence
Theme 1: Comorbid conditions, procedures, and injuries
Multiple comorbid conditions were frequently noted by both patients and FCGs as an intrapersonal barrier to intervention adherence. Several ailments and injuries were cited, with the majority of participants reporting cardiovascular, pulmonary, and arthritis related comorbid conditions as barriers. For some, other recent surgical procedures and lower extremity injuries limited participants’ ability to engage in physical activity. Among others, allergies and medication sensitivity prohibited participation in walking outdoors.
Theme 2: Physical symptoms
Physical symptoms secondary to comorbid conditions were frequently endorsed by participants as a key barrier to physical activity adherence. Chronic pain syndrome (back, hip, joint) prohibited patients and FCGs from fully participating in walking and lower extremity exercises. For some patients, treatment-related pain, such as chemotherapy-induced peripheral neuropathy and surgical site pain, made it difficult for patients to walk. Dyspnea secondary to pulmonary comorbidities were common, and severely limited some participant’s ability to ambulate. Other common activity- limiting symptoms included fatigue/general weakness, nausea, dizziness, and sleep disturbance.
Theme 3: Functional limitations/history of falls
Functional limitations secondary to comorbid conditions were common among study participants. For some, difficulty with activities of daily living (bathing, dressing) prohibited participation in any physical activity, including walking. Gait and balance issues limited mobility and ambulation for patients. Use of assistive devices, such as single point cane (SPC), allowed some patients to ambulate for short distances. History of multiple falls that resulted in serious fractures, further prohibited participants’ willingness to walk.
Theme 4: Anxiety/feeling overwhelmed
Emotional well-being, including anxiety, psychological distress, and stress, were common barriers to adherence for both patients and FCGs. Preoperative anxiety and fear regarding the upcoming surgery, other treatments, and results from surgery (pathology, etc.) made it challenging for participants to engage in the walking program. In addition to preoperative anxiety, stress-related to completing preoperative tasks and chores were overwhelming for patients and FCGs. Worries about postoperative recovery and quality of life were endorsed by both patients and FCGs as barriers to physical activity.
Theme 5: Other roles and responsibilities
Multiple roles and responsibilities for patients and FCGs posed a significant challenge for patient and FCG engagement in the physical activity intervention. In addition to their cancer diagnosis, many patients also served as the primary caregiver for their spouses with medical issues. Full-time employment, chores, other caregiving responsibilities, and their fluctuating demands were major barriers to adherence. For some FCGs, the demands of work and caregiving for several family members with medical issues was overwhelming; thus, they were unable to focus on physical activity.
Theme 6: Other engagements/unexpected life events
Patients and FCGs reported unexpected life events and additional engagements that limited their ability to stay physically active. The need to schedule and attend multiple MD appointments in the preoperative setting made it difficult to set aside time for walking. Unexpected life events, such as car accidents, additional medical issues, and unanticipated long distance travels limited participants’ ability to engage in the intervention.
Theme 7: Lack of time
As a result of multiple roles and responsibilities and unanticipated life events, lack of time was a significant barrier to physical activity. Patients and FCGs who travel from out of town for surgery had very limited time to engage in the walking program. For many participants, busy daily schedules and the need to make multiple trips between home, hospital, and MD visits was a primary barrier to walking.
Theme 8: Lack of motivation
An important intrapersonal barrier to intervention adherence included individual preferences, such as lack of motivation. This factor was endorsed by both patients and FCGs as a primary barrier to physical activity engagement. Decreased motivation after surgery, preference for sedentary lifestyle, disinterest, dislike of structured programs, and “laziness” were significant challenges to walking.
Theme 9: Not accustomed to physical activity
A lack of personal history of physical activity engagement was a common intrapersonal factor that resulted in disinterest and dislike of walking. For some patients and FCGs, preference for sedentary lifestyles, coupled with lack of socialization, posed a significant challenge to physical activity engagement. Others preferred leisurely activities over a more structured exercise. Because they were “active” leisurely, the need for structured walking programs were not necessary.
Theme 10: Physical environment/weather
As walking was the primary component of the physical activity intervention, environmental and weather were important factors in physical activity behavior. Weather and temperature patterns, such as rain and hot days, limited participant’s ability and willingness to walk. Additionally, access to places to walk with flat, even surfaces was important. Hills, uneven walking surface, and rainy weather were barriers to physical activity.
Facilitators to Intervention Adherence
Theme 1: Physical Activity as part of routine
Many participants reported physical activity as a part of their daily routine. Patients and FCGs engaged in many structured physical activity and exercise, including going to the gym, weight-lifting, hiking, yoga, and use of resistance bands. Participants also reported regular participation in sports, such as tennis and golfing. Among others, the merging of leisurely physical activity and social interactions (walking with friends) helped with overcoming barriers, and served as an effective motivator.
Theme 2: Coping strategies
The use of coping strategies to counter anxiety and stress served as an important facilitator of adherence to physical activity. Participants endorsed positive coping strategies, such as church/faith communities, prayers, social activities and interactions, distraction activities, and use of mind-body approaches (i.e. meditation) as helpful with managing anxiety and stress. This resulted in participant’s ability to focus on physical activity engagement. Distraction activities, such as cleaning, mopping/vacuuming, were helpful in attempts to “control” indoor activities. For others, knowing physical activity can reduce stress motivated them to stay active.
Theme 3: Setting goals for motivation
A number of participants reported setting goals to motivate and maintain daily participation in the physical activity intervention. Goals varied from returning to outdoors activities to incremental goals to increase number of daily steps, travelling, and the ability to keep up with children/grandchildren. The ability to perform activities that are important to participants’ quality of life was a strong motivator for physical activity engagement.
Theme 4: Social/family support
An important interpersonal factor that facilitated physical activity behavior was social support. Patient and FCG reciprocal encouragement to walk and participate in the intervention together served as a strong facilitator of physical activity. A number of participants discussed the importance of having a spouse, family member, or friend to “coax” then to engage in the walking program. Family members/friends were also indirect motivators for some, as keeping up with others served as an incentive for patients to maintain an active lifestyle before and after surgery.
Theme 5: Seeing benefits from walking
As patients and FCGs participated in the physical activity, many spoke about having learned that the intervention was beneficial for symptoms and anxiety. Participants spoke from experience, stating that the walking and lower extremity exercises helped them to relax, reduced stress and anxiety, and even helped with physical symptoms. For some, engaging in physical activity helped with multiple moments where anxiety levels were high.
Discussion
This study aimed to explore the barriers and facilitators of adherence to a perioperative physical activity intervention for older adults with lung and GI cancers and their FCGs. Our intervention was grounded in classic behavioral change theories, involved comprehensive preoperative assessment of functional status and geriatric domains, and the development of a personalized walking and lower extremity exercise program. The research presented in this paper was funded by City of Hope’s Center for Cancer and Aging. Dr. Arti Hurria was the founding director of the center. She provided extensive guidance and support to the study design, specifically with using geriatric assessment to prescribe a personalized walking and lower extremity exercise program for older adults undergoing cancer surgery.
Our results showed that a variety of intrapersonal, interpersonal, and environmental barriers and facilitators influenced intervention adherence. Behavioral change theories are predicated on several factors. First, an individual must make multiple, repeated choices on an hourly/daily basis to guide physical activity behaviors. Second, the decisions to engage in physical activity is based on behavioral, physical, psychological, environmental, and social factors.66 Attention to these social-ecological factors of health behaviors is critical to understanding the physical activity behavior change among older adults with cancer.20 Older adults with cancer come with varying degrees of frailty, levels of physical activity prior to surgery, symptoms, treatment history, and other sociodemographic and clinical factors, which can all contribute to their behavior change experience.21 Preferences, aversions, knowledge related to physical activity, as well as sociocultural factors can also influence the patient’s ability to engage in physical activity.22,23 Interventions should be personalized and account for potential barriers and facilitators of physical activity adherence based on these factors.
Our findings confirm that health conditions, including comorbid conditions, physical symptoms, and functional limitations, are important impediments for physical activity and intervention adherence.9–13,24,25. In addition, preoperative anxiety, concerns about postoperative recovery, and other stressful factors could result in lack of confidence in participating in physical activity among older adults with cancer. Interventions may have greater benefit if they integrate principles of behavior change, including self-efficacy as a modifiable and important predictor of adherence.25 Attention to not only physical functioning but also the psychological functioning of patients and FCGs in the perioperative setting may help facilitate self-efficacy in physical activity engagement.26
A key finding from our study highlights the influence of roles and responsibilities on physical activity engagement. For both patients and FCGs, additional caregiving roles, fluctuating demands, and multiple healthcare related appointments were noted as barriers to intervention adherence in our study. This results in overall lack of time for both patients and FCGs to engage in physical activity preoperatively. In addition, more than half of FCGs (62%) provide care to cancer patients age 65 and older.16 Older adults with cancer are at higher risk for physiological declines during and after treatments; this can result in greater needs for functional assistance.22,27 FCGs for older adults, therefore, are at greater risk for caregiving burden. However, a substantial number of FCGs set aside their own needs to care for a family member or friend with cancer. More than one-fifth of FCGs (23%) reported lack of adherence to national physical activity guidelines (moderate level).26,28 Physical activity interventions should include FCGs, due to their vital role in providing physical and emotional support for older adults with cancer.
Social support and goal setting were prominent themes that served as a facilitator and motivator for physical activity adherence in this study. Enjoyment of the social aspects of physical activity, and encouragement and companionship from others were factors that facilitated adherence to the physical activity intervention for both patients and FCGs.1,14,27 Guidance from PT/OT, setting realistic physical activity goals, and ability to self-monitor activity progress, can help foster self-efficacy and the belief in one’s ability to stay active, despite poor health conditions.29,30
Study limitations include a primarily Caucasian and well-educated participants, and may limit the generalizability of our study. Physical activity levels in racial/ethnic minorities, and underserved/under-resourced communities are estimated to be lower, and those with higher education levels have higher physical engagement. A further limitation is the relatively high level of self-reported physical activity engagement of our participants. Finally, we did not capture detailed information on the level of physical activity; therefore, we were unable to determine potential differences in barriers and facilitators by those who are already active and those who are sedentary.
Conclusions
Patient and FCG adherence to a perioperative physical activity intervention is influenced by multiple intrapersonal, interpersonal, and environmental barriers and facilitators. In older adults with cancer and their FCGs, overall health conditions, motivation, goal setting, and social support are important in the process of physical activity engagement. Interventions to enhance optimal postoperative functional recovery for older adults with cancer should include strategies to reduce barriers and optimize facilitators of physical activity.
Acknowledgement:
The lead author is grateful for Dr. Hurria’s mentorship, support, and guidance over the last six years. This paper is a tribute to Dr. Hurria’s contributions and legacy, particularly in advancing geriatric oncology nursing research and geriatric surgical oncology care.
Funding Disclosure: Research reported in this publication was supported by the City of Hope Center for Cancer and Aging. It was also supported by the National Cancer Institute of the National Institutes of Health under award number P30CA33572. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Center for Cancer and Aging or the National Institutes of Health.
Footnotes
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Conflict of Interest Disclosure: The authors have no conflicts of interest to disclose.
ClinicalTrials.gov identifier: NCT03267524
References
- 1.Williams GR, Pisu M, Rocque GB, et al. Unmet social support needs among older adults with cancer. Cancer February 1 2019;125(3):473–481. [DOI] [PubMed] [Google Scholar]
- 2.Johnston ME 2nd, Sussman JJ, Patel SH. Surgical Oncology and Geriatric Patients. Clinics in geriatric medicine February 2019;35(1):53–63. [DOI] [PubMed] [Google Scholar]
- 3.Shahrokni A, Alexander K. The Age of Talking About Age Alone is Over. Ann Surg Oncol January 2019;26(1):12–14. [DOI] [PubMed] [Google Scholar]
- 4.Feng MA, McMillan DT, Crowell K, Muss H, Nielsen ME, Smith AB. Geriatric assessment in surgical oncology: a systematic review. The Journal of surgical research January 2015;193(1):265–272. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Berian JR, Mohanty S, Ko CY, Rosenthal RA, Robinson TN. Association of Loss of Independence With Readmission and Death After Discharge in Older Patients After Surgical Procedures. JAMA surgery September 21 2016;151(9):e161689. [DOI] [PubMed] [Google Scholar]
- 6.Brinson Z, Tang VL, Finlayson E. Postoperative Functional Outcomes in Older Adults. Current surgery reports June 2016;4(6). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Wong JN, McAuley E, Trinh L. Physical activity programming and counseling preferences among cancer survivors: a systematic review. The international journal of behavioral nutrition and physical activity June 7 2018;15(1):48. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Carlson SA, Fulton JE, Schoenborn CA, Loustalot F. Trend and prevalence estimates based on the 2008 Physical Activity Guidelines for Americans. American journal of preventive medicine October 2010;39(4):305–313. [DOI] [PubMed] [Google Scholar]
- 9.Husebo AM, Dyrstad SM, Soreide JA, Bru E. Predicting exercise adherence in cancer patients and survivors: a systematic review and meta-analysis of motivational and behavioural factors. J Clin Nurs January 2013;22(1–2):4–21. [DOI] [PubMed] [Google Scholar]
- 10.Eng L, Pringle D, Su J, et al. Patterns, perceptions, and perceived barriers to physical activity in adult cancer survivors. Supportive care in cancer November 2018;26(11):3755–3763. [DOI] [PubMed] [Google Scholar]
- 11.Clifford BK, Mizrahi D, Sandler CX, et al. Barriers and facilitators of exercise experienced by cancer survivors: a mixed methods systematic review. Supportive care in cancer March 2018;26(3):685–700. [DOI] [PubMed] [Google Scholar]
- 12.Ormel HL, van der Schoot GGF, Sluiter WJ, Jalving M, Gietema JA, Walenkamp AME. Predictors of adherence to exercise interventions during and after cancer treatment: A systematic review. Psycho-oncology March 2018;27(3):713–724. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Granger CL, Connolly B, Denehy L, et al. Understanding factors influencing physical activity and exercise in lung cancer: a systematic review. Supportive care in cancer March 2017;25(3):983–999. [DOI] [PubMed] [Google Scholar]
- 14.Barber FD. Effects of social support on physical activity, self-efficacy, and quality of life in adult cancer survivors and their caregivers. Oncology nursing forum September 2013;40(5):481–489. [DOI] [PubMed] [Google Scholar]
- 15.Girgis A, Lambert S, Johnson C, Waller A, Currow D. Physical, psychosocial, relationship, and economic burden of caring for people with cancer: a review. Journal of oncology practice July 2013;9(4):197–202. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.National Alliance for Caregiving. Cancer Caregiving in the U.S 2016.
- 17.Kent EE, Rowland JH, Northouse L, et al. Caring for caregivers and patients: Research and clinical priorities for informal cancer caregiving. Cancer July 1 2016;122(13):1987–1995. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Biegel D, Sales E, Schulz R. Family Caregiving in Chronic Illness: Alzheimer’s Disease, Cancer, Heart DIisease, Mental Illness, and Stroke Thousand Oaks, CA: Sage Publications; 1991. [Google Scholar]
- 19.Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qualitative health research November 2005;15(9):1277–1288. [DOI] [PubMed] [Google Scholar]
- 20.McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health education quarterly. Winter 1988;15(4):351–377. [DOI] [PubMed] [Google Scholar]
- 21.Pisu M, Azuero A, Halilova KI, et al. Most impactful factors on the health-related quality of life of a geriatric population with cancer. Cancer December 18 2017:n/a-n/a. [DOI] [PubMed]
- 22.Pergolotti M, Deal AM, Williams GR, et al. Activities, function, and health-related quality of life (HRQOL) of older adults with cancer. J Geriatr Oncol July 2017;8(4):249–254. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Pergolotti M, Deal AM, Lavery J, Reeve BB, Muss HB. The prevalence of potentially modifiable functional deficits and the subsequent use of occupational and physical therapy by older adults with cancer. J Geriatr Oncol May 2015;6(3):194–201. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Guell C, Panter J, Griffin S, Ogilvie D. Towards co-designing active ageing strategies: A qualitative study to develop a meaningful physical activity typology for later life. Health expectations October 2018;21(5):919–926. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Essery R, Geraghty AW, Kirby S, Yardley L. Predictors of adherence to home-based physical therapies: a systematic review. Disabil Rehabil March 2017;39(6):519–534. [DOI] [PubMed] [Google Scholar]
- 26.Lambert SD, Duncan LR, Kapellas S, et al. A Descriptive Systematic Review of Physical Activity Interventions for Caregivers: Effects on Caregivers’ and Care Recipients’ Psychosocial Outcomes, Physical Activity Levels, and Physical Health. Annals of behavioral medicine December 2016;50(6):907–919. [DOI] [PubMed] [Google Scholar]
- 27.Gonzalez-Saenz de Tejada M, Bilbao A, Bare M, et al. Association of social support, functional status, and psychological variables with changes in health-related quality of life outcomes in patients with colorectal cancer. Psycho-oncology August 2016;25(8):891–897. [DOI] [PubMed] [Google Scholar]
- 28.Musich S, Wang SS, Kraemer S, Hawkins K, Wicker E. Caregivers for older adults: Prevalence, characteristics, and health care utilization and expenditures. Geriatric nursing Jan-Feb 2017;38(1):9–16. [DOI] [PubMed] [Google Scholar]
- 29.Pergolotti M, Williams GR, Campbell C, Munoz LA, Muss HB. Occupational Therapy for Adults With Cancer: Why It Matters. The oncologist March 2016;21(3):314–319. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Ormel HL, van der Schoot GGF, Westerink NL, Sluiter WJ, Gietema JA, Walenkamp AME. Self-monitoring physical activity with a smartphone application in cancer patients: a randomized feasibility study (SMART-trial). Supportive care in cancer November 2018;26(11):3915–3923. [DOI] [PMC free article] [PubMed] [Google Scholar]