Program Barriers and Facilitators in Virtual Cancer Exercise Implementation: A Qualitative Analysis

Abstract

Introduction/Purpose:

Due to the coronavirus disease 2019 (COVID-19) pandemic, many in-person cancer exercise and rehabilitation programs necessarily transitioned to virtual formats to meet the needs of individuals living with and beyond cancer. The purpose of this study was to qualitatively assess program-level facilitators and barriers to virtual exercise program implementation and to identify preferred strategies to overcome implementation barriers.

Methods:

US-based virtual cancer exercise and rehabilitation programs were recruited from professional networks via an emailed screening questionnaire. Eligible programs identified a point of contact for a 1:1 semi-structured interview to discuss program-level barriers and facilitators to implementing virtual exercise programs. Interview transcript analysis was conducted via inductive coding techniques using NVivo software. Barriers were categorized according to the Consolidated Framework for Implementation Research and a prioritized list of strategies to support implementation was created by mapping barriers to a list of Expert Recommendations for Implementing Change.

Results:

Of the 41 unique responses received, 24 program representatives completed semi-structured interviews. Interviewees represented individual programs, community-based programs, and hospital-based cancer exercise/rehabilitation programs. Analysis showed high correlation between facilitators and barriers by program type, with both program- and individual-level strategies used to implement exercise programs virtually. Strategies that ranked highest to support implementation include promoting program adaptability, building a coalition of stakeholders and identifying program champions, developing an implementation blueprint, altering organizational incentives and allowances, providing education across stakeholder groups, and accessing funding.

Conclusions:

Learning from the transition of cancer exercise and rehabilitation programs to virtual formats due to the COVID-19 pandemic, we identify program-level barriers and facilitators encountered in the implementation of virtual programs and highlight implementation strategies that are most relevant to overcome common barriers. We present a roadmap for programs to use these strategies for future work in virtual exercise and rehabilitation program implementation.

Introduction

The transition from in-person to telehealth interventions, prompted by the coronavirus disease 2019 (COVID-19) pandemic, was a necessary, rapid change to protect patients and healthcare professionals (1). This was especially true for individuals with cancer, as they are uniquely vulnerable to the virus due to immunosuppression induced by antineoplastic therapies (2,3). While active cancer treatment continued in-person during the pandemic, most outpatient ambulatory supportive care services were suggested to be delivered at a distance through telemedicine (4). While virtual supportive care management shows good fidelity in the framework of clinical research (5-8), the rapid transition to meet pragmatic clinical needs during the COVID-19 pandemic led to more ad hoc approaches to clinical implementation of telemedicine visits (9). Despite the accelerated timeline, many exercise and rehabilitation programs that serve individuals with cancer successfully transitioned to online formats to meet the needs of individuals living with and beyond cancer (10,11).

Exercise and rehabilitative interventions are commonly prescribed for symptom management and to improve function in individuals living with and beyond cancer and are effective in a virtual setting when trained staff experts, appropriate virtual platforms, and outreach and support mechanisms specific to the cancer population are used (12-15). Research trials using virtual exercise and rehabilitative interventions reveal that patients are receptive to the virtual format and found the experience to be positive (6,16). Importantly, evidence suggests that using virtual engagements effectively improved pain, fatigue, and cognitive symptoms among individuals with advanced cancer (17).

Although many programs transitioned successfully to virtual formats during the pandemic, little is known about the barriers that were encountered or the strategies that were used to optimize implementation of exercise in a virtual environment. Understanding these implementation strategies can provide insight to other programs seeking to overcome barriers in a clinical setting (13); therefore, the purpose of this study was to qualitatively assess the facilitators and barriers to implementing exercise and rehabilitation programs in a virtual environment, and to identify preferred program-level strategies to overcome implementation barriers with a goal of improving best-practices across United States (US)-based cancer exercise programs (18).

Methods

This protocol received ethical approval prior to study initiation (West Virginia University IRB Protocol # 2101224136). Recruitment email invitations were sent to the professional organization listservs of the American College of Sports Medicine cancer exercise specialists, the American Physical Therapy Association Academy of Oncologic Physical Therapy, the American Congress of Rehabilitation Medicine Cancer Rehabilitation Networking Group, and the American Academy of Physical Medicine and Rehabilitation Cancer Special Interest Group which collectively represent over 2,500 oncology exercise and rehabilitation professionals.

Respondents were screened for eligibility using a brief electronic survey through SurveyMonkey (Momentive, San Mateo, CA, USA). US-based cancer exercise or cancer rehabilitation programs that provided an interactive, virtual forum, either in group sessions or one-on-one, for individuals in any phase of cancer treatment were included as eligible programs. An “interactive virtual forum” was defined as providing synchronous engagement with individuals through an electronic format which could be video or telephone based. Research programs, with ≥75% of staff or operating costs supported by research funding, were excluded due to the risk that the controlled nature of research interventions, implementation approaches, and funding resources could bias results.

Eligible programs were asked to identify a representative who could provide a program-level perspective on the virtual program to participate in a one-on-one, semi-structured interview. All interviews were conducted by the same co-author (J.S.G.) using WebEx (San Jose, CA, USA). Participant consent was received prior to the interview. All interviews were recorded and transcribed.

The semi-structured interview guide (Supplemental Content 1) was developed by the author team with input from the Moving Through Cancer taskforce of the American College of Sports Medicine for face and content validity. The interview included three sections: 1. program demographics; 2. adaptations to assessment tools, exercise prescription elements, and exercise facilitation strategies in the virtual program; and 3. barriers and facilitators encountered in the implementation of the virtual program. Participants were asked to prioritize their top three barriers and facilitators. Demographics were coded in Excel (Microsoft, Redmond, WA, USA). The topic areas within sections 2 and 3 were used as the coding guide for the transcript analysis.

The coding guide was tested for concordance between authors using one transcript. The authors met twice to align on code definitions and scope of each topic, and to add or remove topics. The final coding list is identified in Table 1.

Table 1.

Topics for transcription coding

Topic	Definition	Examples
Assessment and evaluative tests and procedures	Any procedure or measurement tool that is used in evaluation of the participant, either at initial assessment or for a reassessment.	Patient questionnaires, clinical tests and measures such as the 6-minute walk test, 1RM, physiologic measures such as HR, BMI, and other measures that are used for assessing the individual at baseline or overtime.
Elements of the exercise prescription	Any exercise intervention provided to the participant including the prescription elements of frequency, intensity, time, type.	Prescribed sets/reps of exercises, elements of the exercise program such as deep breathing exercises, balance activities, weight lifting and other interventions prescribed through the program.
Facilitation strategies for participant participation	Focused at the individual level, any tool or tactic used to enhance the participants ability to engage with the virtual exercise program.	Sending text message reminders for appointments, teaching participants how to use the virtual platform capabilities, recommending equipment for the participant, coaching and supportive strategies.
Facilitators of the transition to virtual	Focused at the program level, any factor that enabled or supported the transition to a virtual format.	Staff training, marketing and outreach, changes to hours of operation.
Barriers to the transition to virtual	Focused at the program level, any factor that presented challenges for programs to overcome.	Technology challenges, socialization issues, participant willingness to engage.

NVivo Analysis

Coded transcripts were analyzed with NVivo software (QSR International, Burlington, MA, USA) for rank frequency of topics and terms, and association between topics. Frequency was reported for categorical data, means, and median for continuous data. Correlations between thematic topic areas were analyzed using Pearson correlation coefficient.

CFIR-ERIC mapping

The NVivo ranked program-level barriers were mapped to the Consolidated Framework for Implementation Research (CFIR). CFIR is a standardized taxonomy that categorizes implementation barriers around five domains: intervention characteristics, inner and outer setting of the organization, individual characteristics of those implementing the program, and process barriers (19). The CFIR categorization allows for analysis of barriers as they relate to the Expert Recommendations for Implementing Change (ERIC) which are consensus-based strategies recommended to overcome specific barriers to implementation in practice (20-22). Using a CFIR-ERIC online matching tool (https://cfirguide.org/choosing-strategies/), a list of preferred strategies was generated.

Results

Forty-one responses were received through recruitment outreach and reviewed for eligibility. Four programs were based outside of the US and excluded. Nine of the remaining 37 responses were classified as research programs and excluded. The remaining 28 non-research programs were contacted for enrollment. Twenty-four programs responded, consented, and completed a semi-structured interview. The remaining four programs were contacted three times but did not respond to interview requests and were considered lost to follow up. Table 2 provides the demographic information of the enrolled programs. Program names or brand names were redacted for privacy.

Table 2.

Descriptive information for virtual cancer exercise and rehabilitation programs

	n (%)
Virtual program developed in response to COVID-19 pandemic
Yes	19 (79.2)
No	5 (20.8)
Electronic Platform a
Zoom	11 (45.8)
EHR-based application	4 (16.7)
Facetime	4 (16.7)
Microsoft Teams	2 (8.3)
Blue jeans	1 (4.2)
Google meet	1 (4.2)
Jitsi	1 (4.2)
Skype	1 (4.2)
Program format
1:1 only	14 (58.3)
Both 1:1 and Group	7 (29.2)
Group only	3 (12.5)
Fee structures
No charge	8 (33.3)
Pay per session	5 (20.8) ($5.00-135.00 per session)
Billed to insurance	5 (20.8)
Pay per hour	4 (16.7) ($20.00-85.00 per hour)
Program membership	2 (8.3)
Number of instructors engaged in oncology exercise programs	Mean: 3.9 (±5.79) Median: 1.5 Range: 1-22
Professional background of oncology instructors
Personal trainer	8 (33.3)
Other exercise professional	6 (25.0)
Exercise physiologist	5 (20.8)
Rehabilitation professionals	5 (20.8)
Instructor certifications in oncology exercise
ASCM CET	6 (25.0)
CETI	1 (4.2)
CanRehab	1 (4.2)
Medical clearance required for participation
Yes	16 (66.7)
No	8 (33.3)
Geographic location of program by US region
North	7 (29.2)
Midwest	6 (25.0)
South	5 (20.8)
West	4 (16.7)
National program	1 (4.2)

^aPrograms reported more than one

Demographics

Of the programs evaluated, 79.2% reported starting a virtual exercise program as a result of the pandemic and associated shutdown of in-person engagement. The remaining programs (n=5) reported having some consultative virtual sessions prior to the pandemic but did not have formal virtual programs until the pandemic. Three categories of programs were identified. Nine programs (37.5%) were categorized as “individual,” comprised of a single exercise professional providing services to individuals living with or beyond cancer. These individuals were mostly personal trainers with varying professional backgrounds and experience, and all reported that their sessions were one-on-one with participants. Eight programs (33.3%) were categorized as “community-based,” administered through a fitness or wellness center. Seven programs (29.2%) were categorized as “hospital or health-system-based” and were implemented within, funded through, or otherwise organized as part of a healthcare delivery system.

All programs reported working across all cancer types. Two programs reported geriatric-specific programs and one identified a young-survivors-specific program. Two programs included caregivers into their virtual classes alongside the family member or friend who participated. Nine programs restricted participation to individuals from a specific healthcare system or cancer center while the remaining programs (n = 15) engaged participants from local, regional, and national geography.

Eight programs charged no fee for participation and instead subsidized the program through their hospital, cancer center, or a charitable foundation. Five programs that used rehabilitation professionals to provide services billed session charges to the participants insurance.

Description of exercise program components

There was significant heterogeneity reported in the assessment and evaluative tests and procedures and elements of the exercise prescription across programs. In general, most programs conducted a subjective intake that included medical history, assessment of individual preferences, experience with exercise, and goals. Intake assessments were completed either through email, ahead of participation, or during the first visit. All programs reported taking clinical measures of strength, endurance, and balance with substantial variety in the measurement tools they used. Although exercise interventions also varied substantially across programs, adherence to the FITT (frequency, intensity, time, type) principles in prescribing exercise was identified across all programs. Exercise interventions included various types of timed and repeated tasks and activities, body weight supported activities, and flexibility and balance exercises. Individual exercise facilitation strategies such as coaching, use of metaphors to encourage body mechanics and exercise form, and encouragement through email and text reminders were identified as the most common exercise facilitation strategies.

Barriers and Facilitators

Program-level barriers to implementation, as reported by participants, were categorized based on the CFIR domains and are provided in Table 3. Facilitators, as described by participants, were grouped into common themes by the authors. Themes include communication and engagement, program structure and delivery, technology, workforce and staffing, environmental factors, provider awareness and buy in, and costs and fees, and are outlined in Table 4. The difference in reported barriers across settings is shown in Figure 1.

Table 3.

Program context barriers, as described by participants.

CFIR-Based Program Barriers	Participant context
Characteristics of the Intervention Concerns regarding the quality and validity of exercise programs delivered in a virtual environment. Assessment and evaluation of maximal efforts and compensation is difficult to gauge. Limited interaction to reassess response to the program. Concerns about timely response to safety issues. Severity of symptoms is difficult to gauge. Exercise in the same place all the time with little variety in the program can become boring. Quality assurance in program delivery. Identifying and using on-line tools for measurement and assessments. Accountability concerns if the participants video is turned off.	“I was resistant to changing and didn’t think it could be done.” “Finding valid tools online for virtual engagement was difficult.” “We’ve had to adapt the assessment measures…so I’m not sure how valid they are.”
Characteristics of the Intervention Uncertainty that an exercise program can be adapted sufficiently or tailored to meet needs through a virtual format. Limited space in the participant’s home. Cannot fully see around the participant as they move. Structuring a program for different types of cancers in group formats means you may not be meeting all needs. Challenging to gauge symptoms during treatments. Difficult to instruct/cue individuals virtually. Not being able to provide tactile input to inform posture or positioning. Unable to put hands on and build confidence in participants. Virtual programs do not get participants out of their homes.	“Doing exercise virtually just isn’t the same as in-person.” “I can’t know if my patient is recruiting the right muscles for a task unless I’m there.” “Not having the social engagement of the classes has been a real loss…we’ll never get that back in virtual.”
Outer Setting External policies, regulations, mandates do not exist, or they undermine efforts to implement an exercise or rehabilitation program virtually. Lack of available bandwidth speeds to support video engagements. Regulatory limitations for licensed health care professionals to treat beyond state lines. Scaling for the future may not be cost effective due to regulatory and billing barriers. Lack of willingness of healthcare systems to bill for services.	“Licensed providers cannot treat patients across state lines.” “Exercise services are not paid for by insurers.”
Outer Setting Networks do not exist with external organizations to support the virtual program. Not having face to face, in-clinic time to meet and connect with participants made it hard to identify people during chemotherapy and radiation that could benefit from the program. Hard to sell or advertise virtual exercise.	“People can’t just walk by and see you there having a class and stop in…we used to have that happen a lot…but we can’t rely on people just finding us now as they are walking by the church.” “It was harder to get in front of the medical providers to let them know we still had a program.”
Inner Setting Networks do not exist for formal or informal internal communication regarding the virtual program. Communication required more repetition and different approaches to reach stakeholders who had, in the past, been supportive of the program. Providers were unaware that the programs had continued virtually. No clear communication pathways were established with referring providers or clinic staff. Technology platforms that do not communicate across settings. Missing the community feel and support of others.	“Getting messages to providers is harder because even though we are in the same (healthcare) system, we don’t use their EHR.” “We don’t have a way to market this program to our own providers.” “Its harder to get responses from doctors for medical clearance…mostly now we are just relying on participants to tell their doctors and keep them up to date.”
Inner Setting The virtual exercise program is not compatible with existing workflows and heightens risk for stakeholders. Provider hesitancy about a virtual program safety for complex patients. Exercise professionals and rehabilitation professionals managing technical problems and teaching participants how to use their technology took time and skills. Exercise professionals lacking the equipment for virtual engagement. Training providers to new referral processes and pathways.	“We had to set up a process for registering participants for classes, sending emails with video links, tracking who came on and off of the sessions.” “There are many assessments I just can’t do virtually.” “There are huge safety considerations especially if someone has their video off.” “We had to set up different channels for delivering information like home programs via email…or using apps to give exercises.”
Inner Setting No tangible or intangible benefits or incentives are in place to implement the virtual exercise program. COVID was a forcing function for programs to change, not the organization goals or mission. Outlining standards for a program took more time and effort that is not part of a therapist’s time or productivity standards.	“The organization makes money when people are coming into the clinics to see providers, so we will have to get back to that.” “COVID was the driver of moving everything virtual…when it’s gone I’m not sure what the higher ups will want to do.” “We haven’t developed productivity standards around virtual visits.”
Inner Setting Available resources are insufficient to support the innovation of a virtual exercise program. Participants (providers and patients) may not have the appropriate equipment (video camera, smartphones) for virtual engagements. Participants lack knowledge of how to use virtual platforms. Technology issues with hardware, computer crashes, batteries dying and lack of technical support. Internet and broadband connectivity and issues with dropping connections. Cost of set up, equipment, training, platform subscriptions, technical support, app fees.	“Patients don’t have adequate broadband…many don’t even have a smartphone or a computer.” “Our therapists needed to get the right equipment, like video cameras and software subscriptions. We had to get everyone ramped up fast.” “The scheduling is a challenge; everyone is managing their own schedules…tracking is a challenge.”
Inner Setting Stakeholders do not have access to information about the virtual exercise program nor how to incorporate it into work tasks. Making and sending home exercise programs through electronic means when participants are without the technology to receive them. Training providers to new referral processes and pathways. No clear communication pathways with referring providers or clinic staff. Technology platforms that do not communicate across settings. Difficulty standardizing interventions and tools across therapy centers.	“Getting referrals from the medical oncologists has become a big challenge, they don’t know we are still here providing exercise.” “no one is in the office at our center so we can’t get the faxes.” “You have to be there in the chemo suite and get in front of people to get them bought in.” “Our providers are having to solve IT-related issues and connectivity problems for participants.”
Individual Characteristics of those Involved with the Program Stakeholders are not skilled or enthused about using virtual exercise in a sustained way. Participants and exercise professional’s hesitancy to use internet. Digital divide between haves and have-nots, between rural and urban is magnified in virtual environment. Clinical decision making challenged by lack of real-time feedback. Screen fatigue. Staff reluctance to provide virtual coaching on interventions. Participants may be reluctant to have their home environment shared on video. Participants and exercise professionals may be reluctant to see themselves on video screens. Participation drop off over time.	“I don’t think it can all be done virtual, I don’t know how much will continue after COVID is over.” “Personally, I want to go back to in-person, I am not comfortable with all of this.”
Process A sequence of planning tasks or processes for developing the program have not been developed. Developing and using new referral processes and pathways. Identifying and using on-line tools for measurement and assessments. Assessment and evaluation tools are not standardized. Exercise professional’s lack of knowledge around use of virtual platforms. Clinic workflow to balance virtual and in-person.	“We closed on Friday and opened virtually on Monday. There was no plan.” “It has been ad hoc in putting it together, some has gone well, some has been more challenging.” “We are trying to get our heads around how to plan better.” “We’ve honed the process as we’ve gone along.”
Process A skilled implementation leader, with authority and responsibility to lead the implementation has not been identified. Lack of technology savvy among out staff. Exercise professionals and rehabilitation professionals managing technical problems and teaching participants how to use their technology.	“I am the only person in my facility, and they are pretty much letting me do what I need to.” “We have several professionals participating, they take on what they can and manage their own patients…we’ve started scheduling time for everyone to talk and discuss cases and problem solve, but nothing formalized.”
Process Individuals acting as champions to overcome barriers are not incorporated into the program planning. Hard to sell or advertise virtual exercise. Staff reluctance to provide virtual coaching on interventions. Quality assurance in program delivery.	“There isn’t a program plan, I just see my patients.” “As things settle down, we hope to have a structure in place for clinic champions or leaders.”

CFIR, Consolidated Framework for Implementation Research; COVID, coronavirus disease; EHR, electronic health record; IT, information technology.

Table 4.

Participant Self-reported Facilitators in Transitioning to a Virtual Format

Communication and engagement
Marketing and advertising a virtual program Social media engagement was received with greater receptivity. Brand loyalty and participant knowledge of the instructor/therapist helped to build on-line trust in the program. Building rapport with participants Virtual enabled instructors to show what needed to be done and demonstrate more. Talking and providing feedback was more targeted to the individual. Virtual forced more of a focus on developing rapport. Getting to know participants early, on an individual level. Communication strategies Establishing communication expectations early with participants. Scheduling greater frequency of touch points and check ins. Encouraged basic, evidence-based recommendations for exercise. Participant support and connectedness Participants enjoyed the cueing and modification for exercises. Enabled greater personalization and attention. Created a more patient-centered focus in engagements. Listening to participants online encourages greater attention and focus on their needs. Seeing participants enjoy learning.
Program structure and delivery
Intermittently still doing in-person sessions to compliment virtual. Consistency of schedule and program components. More participants can access programs using virtual forums. Greater flexibility for scheduling. Virtual program delivery eliminates travel concerns. Extremely well-lit office, large screen televisions. Using equipment that the participant already has in their home. Virtual encourages a participant to be more independent and successful on their own.
Technology
Virtual platforms and applications that allow message feeds and have tracking tools. Monitoring via applications promotes adherence and prevents drop-off. Incorporating exercise videos, phone calls, calendar reminders became the norm, not an exception or an extra annoyance. A good microphone and high quality screen. Enabling chat functions between participants on virtual platforms. Consistent use of platform helped participants and caregivers become more comfortable with the virtual forum for other engagements in personal and healthcare matters. Participants were given technology devices to enable work-from-home that also enabled exercise-from-home.
Workforce and staff
Familiarity with virtual applications and platforms. Development of policies and procedures to move to virtual care delivery. Staff buy in. Training and staff development on virtual care delivery practices. Forward thinking institutions that enabled virtual clinics and practices. Celebrating instructor or program successes. Providing high quality care. Sharing best practices on voice cueing, positioning. Sharing and problem-solving challenges. Staff that are reputable in their specialty field.
Environmental factors
Having an ongoing point of contact enables physical activity engagement and prevents boredom in lockdowns. More geographical reach enables more and more diverse participants in the program. People were craving contact and communication and this was an outlet. Patient demand for online continuation of their programs.
Provider awareness and buy in
Provider awareness of the virtual program and knowing exactly how to get individuals connected. Provider buy-in to the need for continuing exercise and rehabilitation virtually.
Cost and fees
Able to create sliding fee scales based on new format. Insurer buy in and payment for virtual telehealth.

Figure 1.

Barriers reported by setting

Correlations between topics

Pearson correlation coefficients showed large strength of association between the topics of facilitators and barriers (r = 0.62), exercise facilitation and barriers (r = 0.60), and facilitators and exercise facilitation (r = 0.54). Small strength of association was found between the topics of exercise prescription and barriers (r = 0.17) and exercise prescription and facilitators (r = 0.15). Complete analysis of all reported frequencies and all Pearson correlation coefficients across topics are included in Supplemental Content 2 and 3 (tables).

Implementation Strategies

The CFIR-ERIC tool recommended the following strategies, ranked by frequency, to overcome the barriers identified by our participants: creating an implementation blueprint and standardized process for program implementation, building coalitions and developing champions, promoting program adaptability, developing education and awareness efforts, and altering incentives and funding structures. Based on these prioritized strategies, we provide a roadmap with recommended approaches for individuals seeking to implement virtual exercise programs. The full output of cumulative percentages and rankings from the CFIR-ERIC tool can be found in Supplemental Content 4 (table).

Discussion

The COVID-19 pandemic incited rapid change in clinical care delivery norms and accelerated the uptake of telehealth for interventions, including exercise and rehabilitation, for individuals living with and beyond cancer (9,10). Our participants reported a sense of urgency to implement virtual programs to meet the continued needs of their patients. Many programs reported uncertainty about the future of their program once in-person sessions are safe to resume; however, most identified a high likelihood that some virtual programming would be sustained in the future. Overall our study participants felt they had succeeded in implementing their virtual program despite the adverse situation of the pandemic.

While exercise and rehabilitation needs remained relatively constant among the individuals served, virtual program components regarding assessment and evaluation and exercise facilitation strategies required adaptation from in-person formats. Our study participants described challenges in finding valid assessment tools for the virtual environment and assessing and monitoring an individual’s response to the exercise intervention. While adherence to the FITT principle for exercise prescription was high across all virtual programs, the way the exercise prescription components were administered and the strategies used to facilitate the exercise interventions changed remarkably. Challenges such as the inability to palpate body structures, lack of full body visibility, uncertainty about correct muscle activation with exercises, and monitoring exercise intensity were prevalent. Exercise professionals reported demonstrating exercises more frequently and providing more verbal cuing to individuals. Resistance exercise was reported as most challenging to administer virtually due to the lack of equipment for appropriate loading and the need to identify weighted items in the home (i.e., books, soup cans). Considerable time was spent coaching individuals on positioning their video cameras and adjusting in-home lighting or computer sound to enable the exercise provider to appropriately facilitate the intervention:

“I stuck closely to the evidence base for prescribing the exercises, but had to adapt how I explained the exercises…or look for things in their home that could be used as equipment…”

“I was textbook in the exercises I recommended…I just had to figure out how to get them use the right muscles…since I couldn’t feel with my hands to see what muscles they were really activating.”

Exercise professionals described exercise facilitation strategies that went beyond a typical in-person clinical engagement including using pre-exercise session meetings to review the electronic application for the exercise sessions and to identify any objects in the home that could be substituted as exercise equipment. Exercise professionals also used these pre-engagement sessions to assess the individual’s home environment and make safety recommendations, such as having a chair nearby to stabilize for balance and making sure that the individual could get down and up from the floor without assistance.

Transitioning to Virtual Platforms

Technology was identified as both a barrier and facilitator to program implementation by nearly every program. While necessary to facilitate a virtual engagement, the challenges that technology introduced were remarkable and required extensive workflow processes to be established, necessitated the professional workforce taking on different roles to support technology use, and introduced challenges in exercise program monitoring. Study participants were also acutely aware of the access issues that technology presented:

“This has really magnified the disparities of the haves and the have-nots…and that’s not even about broadband access. We have broadband, but many patients don’t have (cellular) plans or WIFI at home to give them adequate access to engage with us…few had the right hardware or video equipment…we can’t expect that people can afford to just get online and pick right up…”

While communication and engagement barriers were common, results revealed that virtual platforms also provided innovative communication avenues, such as messaging apps and calendar reminders, that enabled frequent contact with program participants. However, the predominant theme around communication was how significantly the virtual format changed the dynamic between the exercise professional and participant. Interviewees spoke frequently about challenges with relationship building, rapport, reading body language, and the lack of interpersonal connections. Overwhelmingly, exercise professionals felt that these interpersonal challenges would inhibit future adherence and participation in virtual exercise:

“It’s like, we are all ok with it and dealing with it now, because we’re in the middle of this pandemic, but in the future, I don’t think this is how we are going to get our patients (with cancer) to engage…they need more.”

“We are losing a great motivating factor for our patients…the motivation to get out of their house and go somewhere to exercise.”

“Losing the social engagement is so very critical and may be harmful to the relationships we have with our long-standing participants…we’ve lost some of them, but we’ve also gained some new ones.”

In examining the workforce and staffing challenges there is a common theme of resilience among the professionals we interviewed. Interview participants frequently reported that they succeeded because a small staff team had come together to make the program work without any formal guidance or structured approach to program development. While this ad hoc approach afforded substantial flexibility to transition into virtual environments, many participants felt that the flexibility they enjoyed due to the COVID-19 pandemic would wane in the future, specifically as cost, productivity, and resource issues were more closely examined: “Things will probably change significantly…once the bean counters get their heads around what we are doing.” All programs identified the need to examine practices and establish policies and procedures to sustain or grow their programs:

“Is it a good use of a therapists time to have to set up virtual links, monitor registration for sessions…no, hopefully we can find ways to develop efficient processes before they are forced upon us from higher up…”

A roadmap for virtual exercise program implementation

A robust body of evidence has developed to guide implementation of evidence-based programs into clinical practice. An implementation effort should be informed by an assessment of program-specific determinants to outline the necessary resources, processes, communication tools, educational materials, and milestones to achieve implementation (20,23). Using the results from the ERIC mapping analysis, we suggest the following strategies for virtual exercise program implementation:

Create an implementation blueprint and standardized processes for program implementation.

The blueprint, or implementation map, is ideally informed by a context assessment that identifies existing program resources and gaps and lays out the plan for implementation (24). While many theoretical frameworks exist to support the context assessment (25), an individualized approach is warranted and should include assessment of the internal and external setting that will influence the program, an understanding of stakeholder networks and their level of knowledge and support for the program, a clear assessment of existing and needed infrastructure and processes to implement the program, and a readiness assessment to evaluate barriers and facilitators for implementation. Documenting and standardizing processes around the implementation of the program will support future scale of the program. For example, clear documentation of the hardware requirements and necessary technical specifications needed for the virtual environment could be included to help standardize processes in implementation and to plan for time and resources for future program sustainability or growth.

Building coalitions and developing champions.

The implementation effort will require program champions, individuals who can lead the program and bring others along through training, advocacy, and awareness, and can create or shift the organizational culture in favor of the program implementation (26). This was reflected by our interviewees as a critical component to the success of their virtual program implementation and is a well-characterized strategy in successful implementation efforts (27). Our participants cited the importance of early adopters in leading and driving program implementation. Coalitions of stakeholders including administrators and executive boards, public partners, academic partnerships, clinical providers, and others were identified by our participants as contributors to their success. Coalitions can be used to develop local consensus for program support, recruit and train program leaders, and become a beneficial learning collaborative through the implementation process (28).

Promoting program adaptability.

A common theme throughout every aspect of our findings was that exercise program adaptations were necessary to implement an exercise program in a virtual environment. Therefore, in planning for implementation, program adaptations should be expected and encouraged to promote durable and sustainable programs (29). Our participants spoke of altered assessment tools and approaches, adaptations in their approach to motivating and engaging exercise program participants, and adapted monitoring strategies to gauge response to exercise. Program adaptability should seek to encourage flexibility and innovation while balancing the fidelity and integrity of the intervention (30). Adaptations should also consider the physical space and equipment needed to implement the program. In the case of our participants, adapting workstations, finding substitute equipment, and using the individuals’ home environments in lieu of the exercise facility became important adaptations for success.

Developing education and awareness efforts.

Education is essential and should target various stakeholder groups. Materials should be developed for the patient/participant to encourage their engagement in the program. Nearly as important are materials and forums to educate stakeholders such as referring health care professionals, administrators, and other exercise professionals. Assuring that these individuals understand the goal of the implementation effort and why the adaptations are needed will help to promote buy in and continued support of the program (31). Conducting educational forums is another strategy that brings stakeholders together to hear and learn from one another, in addition to learning from the program champions.

Altering incentives and funding structures.

Securing funding for the program staff and resources and assuring long-term sustainability was identified as a foremost challenge among our participants. Justifying staff time and work effort to continue exercise and rehabilitation programming in a virtual environment was reasonable during the COVID-19 pandemic because most of the US healthcare system was minimizing in-person care and society in general was on lockdown. However, our participants recognize the importance of securing long-term funding plans for their program to remain viable, either through ongoing administrative commitments, reimbursement for services from third-party payers, donations, or other forms of payment by participants. Many of our participants shared concerns about the sustainability of their programs beyond the pandemic as the expectations to return to “normal” programming and billing cycles would undoubtedly return. In order to successfully implement and sustain a virtual exercise program, it will be necessary to consider reliable and sustainable funding structures that may be different than past reimbursement structures (32). Payment incentives vary widely among third-party private or federal payers and alternative incentives may need to be sought to supplement the implementation plan with sustainable funding sources. Adjusting measures of productivity and exploring alternative metrics may be necessary to demonstrate program outcomes in the virtual environment.

Conclusion

Cancer exercise and rehabilitation programs can successfully be implemented in virtual environments. While COVID-19 was a forcing function to online virtual engagement, the use of virtual formats going forward could greatly benefit the oncology population by reducing travel time and costs, promoting access to services when individuals may not have the physical endurance to travel, and encouraging exercise behaviors in the home environment. Cancer exercise and rehabilitation specialists are not yet prevalent across the US, so the use of virtual formats could open opportunities for individuals living with and beyond cancer to engage with specialists beyond their geographic location. It is likely that virtual platforms will augment in-person exercise sessions in the future and serve as an additional pathway for patient engagement. To this end, it is critical for exercise and rehabilitation professionals who intend to create and implement virtual programs to use methodic approaches to assess their program context and to recognize the broad resources — financial, human, and technological — that are needed for program implementation. Adapting exercise interventions for a virtual environment, overcoming technology and infrastructure challenges, and building stakeholder coalitions through communication and awareness efforts are pragmatic strategies that can enable successful implementation of a virtual cancer exercise and rehabilitation program.

Supplementary Material

Supplemental Data File (.doc, .tif, pdf, etc.)_1

SC 1. Semi-structured interview guide (.docx)

Supplemental Data File (.doc, .tif, pdf, etc.)_2

SC 2. Frequency of coded references across all interview transcripts (.docx)

Supplemental Data File (.doc, .tif, pdf, etc.)_3

SC 3. Full analysis of Pearson’s correlation coefficient across all topics (.docx)

Supplemental Data File (.doc, .tif, pdf, etc.)_4

SC 4. ERIC Preferred Strategies to overcome common barriers- ranked by cumulative percent of agreement based on CFIR mapping of Program Context Barriers (.docx)