Updated: Oct 25
The positive relationship between physical activity and the reduced risk of preventable diseases such as coronary heart disease, cardiovascular disease, stroke, type II diabetes, osteoporosis and high blood pressure has been widely reported and has influenced the publications of public resources within national health care services world-wide (Hefferon et al., 2013; Irwin et al., 2013; Loh et al., 2013; NHS Foundation Trust, 2014). Physical activity has been shown throughout randomised controlled trials (RCT) to improve both physical and psychological outcomes amongst patients (Craike et al., 2013). It is therefore understandable that interventions, such as ‘Change 4 Life’, used by the Government and other national bodies, have the aim to positively influence the wellbeing and physical activity adherence in the whole population.
It is also widely reported that physical activity can reduce the risk of multiple cancers including colorectal, lung and uterine; and furthermore can prevent a specific cancer returning (Des Geutz et al., 2013; NHS Foundation Trust 2014). The World Health Organisation estimates that the risk of breast cancer in physically active women is between 20-40% lower than those who are sedentary. A cancer survivor can be defined as someone who has been diagnosed with cancer, from the time of diagnosis through the rest of his or her life (American Cancer Society, 2012). The link between breast cancer survivors and physical activity has been researched in depth, however, there is a smaller body of evidence exclusively utilising behavioural change theory to increase adherence to physical activity programs particularly in less common cancers.
The number of cancer survivors worldwide is due to triple from 25 million in 2008 to 75 million in 2030 and in the UK alone there will be 3 million cancer survivors by 2022; therefore interventions to promote physical and psychological health are of paramount importance (James et al., 2011; Thomas et al., 2014). Due to different genders, socio-economic backgrounds and site of cancer variability between individuals as well as the developments in cancer treatment, the literature can only broadly estimate future epidemiology of cancer within a population.
Fong et al. (2012) reported that 65% of studies, included in a meta-analysis of RCT for physical activity in cancer survivors, had a population group who had suffered from breast cancer; with fewer studies researching colorectal (9%), endometrial (3%) and other cancers (27%). In addition, a Cochrane Review by Cramp and Byron-Daniel (2012) found that twenty-eight of the thirty-eight papers that met their inclusion criteria focussed on breast cancer survivors. There is a specific bias in the research towards breast cancer survivors who may present with different barriers, facilitators and self-efficacy than other cancer survivors. Psychological benefits of physical activity are less commonly reported across the literature however within female cancer survivor’s, physical appearance, enjoyment and social interaction are common measurements (Craike et al., 2013). The intervention strategies used to influence specific populations often fail to be underpinned by key behavioural change theories while utilising behavioural change techniques (BCT) as outlined in the CALO-RE taxonomy in order to create a universally applicable intervention (Michie et al., 2013). The effectiveness of interventions in promoting sustained physical activity behaviour change within public health and specifically with female cancer survivors requires analysis to inform recommendations for practice and identify indications for further research.
Barriers and facilitators
Commonly the barriers cited for female cancer survivors are fatigue, lack of an exercise partner, fear, not being sporty, comorbities, weight gain, employment and family roles (Clark et al., 2007; Hefferson et al., 2013). The perceived benefits of physical activity are increased sense of control, improved body image, a distraction, physical functioning and quality of life (Clark et al., 2007). Many barriers and facilitators for cancer survivors appear to be shared throughout the literature with the wider population, with some specific barriers such as low immune system, cancer site pain and treatment related fatigue. There has been no single questionnaire universally adopted by the academic research community. The Exercise Benefits/Barriers Scale used by both Ansari and Lovell (2009) and Lovell et al (2010) is unstandardised, however it can be matched to other barrier and self-efficacy measures such as the exercise and self-esteem model (EXSEM) in order for researchers to create comparison between populations (McAuley et al., 2005).
Behavioural Change Theory
Self-efficacy is a key construct in Behavioural Cognitive Theory (Bandura, 1977), the Transtheoretical Model (Prochaska and DiClemente, 1982) and the Theory of Planned Behaviour (Ajzen, 1991) and can determine adherence to physical activity, as it is a direct predictor of behaviour (Robbins et al., 2004). Self-efficacy is widely accepted as one’s perception of their ability to complete a given behaviour and is related to past performance, social influences, internal factors, perceived barriers and positive outcomes with four pillars of information that were described in the original self-efficacy model; past performance, vicarious experience, verbal persuasion and physiological arousal (Clark et al., 2007; Loh and Quek 2011). Behaviour change taxonomy standardised by CALO-RE taxonomy can be used to categorise BCT within interventions and in clinical practice. In a prominent paper by Olander et al (2013) studying the use of BCT in an obese population, action planning, teach to use/prompt, prompt practice and provide instruction were highlighted in accordance with the taxonomy as causing significant changes in self-efficacy and physical activity; while in the wider population goal setting was the most commonly employed technique (Ashford et al., 2010). Unfortunately, the same BCT investigations have not been made for female cancer survivors. Within the literature BCT have been used as part of the intervention strategies, although they have not been clearly documented in relation to the taxonomy previously described, further clouding the application of BCT within interventions. It is also not yet clear as to whether the findings within the obese population can be transferred to other populations to increase both short-term and long-term adherence to physical activity.
A research study by Pinto (2005) on self-efficacy and exercise related interventions for cancer survivors was the only paper to be included in a Cochrane Review of thirty-eight papers for reporting outcome measurements of self-efficacy and physical activity; although the included papers had taken several other outcome measures including fatigue, quality of life, anxiety and depression via numerous reported scales (Cramp and Byron-Daniel, 2012). On the other hand, in a wider literature search, various articles consistently report measuring self-efficacy, with the most common form of assessment using Likert scales specific to the population being studied. It may be assumed that this could cause a lack of reproducibility due to an absence of protocol for the assessment of such measures in the clinical setting, but may allow the clinician or researcher to ensure that outcome self-efficacy measures are directly related to the populations group involved. In addition multiple papers utilise methodology whereby self-efficacy and physical activity measures are self-reported and therefore are subjective which may lead to over-estimation of intervention effects (Clark et al., 2007). The Cancer Behaviour Inventory (CBI) has been regularly used to assess a cancer patient’s self-efficacy to coping with treatment and may be an additional tool available to the clinician to estimate a patient’s adherence to an intervention but this research has not yet been conducted.
Supervised and unsupervised physical activity and exercise programs are regularly used to have positive influences on both physical and psychological aspects in both the wider public and female cancer survivors (Craike et al., 2013; Des Guetz et al., 2013; James et al., 2011; Luszczynska et al., 2010). Typical interventions for the wider population are lifestyle changes such as increased walking, gardening and recreational physical activity changes including aerobics and gym sessions which incorporate face-to-face and telephone counselling, discussion groups and email feedback; with interventions ranging from 2-5 minutes to two years (Ashford et al., 2010; Carpenter et al., 1999). On the other hand, a review paper by Fong et al (2013) highlighted that physical activity interventions in cancer survivor patients varied between three to sixty weeks, with a mean intervention period of thirteen weeks. There has been no difference in adherence to physical activity found over the short-term (8 weeks) or long-term (18 months) interventions or with the use of intermittent or continuous interventions, however this was in comparison to a control group and didn’t directly compare the different forms of intervention (Linke et al., 2011). It is worth noting that such studies may be subject to publication bias as statistically significant results are favourable when being published in peer-reviewed journals. This creates a clear difficulty for the clinician as the interventions differ vastly and therefore make it difficult to conclude the most effective intervention duration and type considering that positive influences on self-efficacy have been reported throughout the studies. The range of the subject numbers and ages for physical activity interventions is wide within cancer survivor studies, recruiting between 14 and 641 (mean 93) participants, aged 39 to 74 years (mean 55), without differentiating between males and females (Cramp and Byron-Daniel, 2012; Fong et al., 2012). The wide groupings shown within studies for cancer survivors may not represent a homogenous sample and this should be carefully considered when assessing the literature; despite this, it would be unwise to discount information that may still apply to cancer survivors from various age and gender brackets. The majority of studies clearly outlined the inclusion criteria allowing for comparison, although some are distinctly different in the population selection and the intervention approach. A study by James et al (2011) investigated independent variables of physical activity, patient education and nutritional advice in 150 cancer patients, resulting in positive physical activity outcomes. They also identified limitations that the intervention was tailored to individuals therefore reducing the reproducibility, and there was self-reported body composition and dietary behaviour, creating potential errors. These limitations are reflected in many studies conducting questionnaire based assessment and face-to-face interviews (Loh et al., 2013).
Self-efficacy is identified in every paper reviewed as being of great importance for physical activity intervention and the increasing adherence to the program, but rarely are specific references made to behavioural change techniques as described earlier.
Quality of life and decreased symptoms in cancer patients are measured outcomes in many studies, however such self-reported questionnaires may be subject to threats such as halo effects depending upon where and when the patient has completed their questionnaire. After accepting the limitations of self-efficacy measurements, its repeated use in the majority of studies within the clinical and wider population is a tribute to its reliability as well as it demonstrating an increase in self-efficacy and physical activity self-efficacy across all the studies.
There is an evident and distinct lack of long-term follow up of patients who have undertaken a physical activity intervention with many studies only maintaining follow-up up to 12 months post-interventions (Aghdam et al., 2013). Without adequate follow-up within the research design it is difficult to successfully prescribe physical activity and exercise based upon long-term results and therefore it is challenging to critically analyse the most effective BCT to encourage long-term adherence.
The use of behavioural change theory
Self-efficacy is the most cited aspect of behavioural change theory for both the wider population as well as female cancer survivors, the reason for which may be hypothesised as its ease of measure, low-cost of implementation through patient questionnaires and the large body of evidence for its positive relationship with physical activity. It is also reported to be a key construct in the majority of behavioural change theories including Behavioural Cognitive Theory (Bandura, 1977), the Transtheoretical Model (Prochaska and DiClemente, 1982) and the Theory of Planned Behaviour (Ajzen, 1991). However there are limitations to its use reported in the literature including it being taken at one moment in time, individual over-estimation of measures, familiarisation with the questionnaire and a lack of prior categorisation into socio-economic groups, which may influence outcomes. Although self-efficacy is an important determinant of change in behaviour there still remains a gap within the knowledge regarding how to change this psychological construct (Ashford et al., 2010).
Recommendations for practice
After reviewing the literature it is recommended that clinician should fully understand the use of BCT taxonomy in order to accurately and reliability implement interventions. Self-efficacy measures within individual institutions should be standardised with a view to creating a universally accepted self-efficacy measure that can be used throughout clinical and academic practice.
Indications for further research
Comparing physical activity interventions is difficult due to the number of studies that inadequately report the intervention components, a common finding in many previous reviews of the effects of interventions. The current implications for further research indicate that more RCT are required across a wider range of cancers, with clear outcome measures of physical activity assessment and intensity with further assessment of the efficacy of physical activity on other health outcomes in both the wider public and cancer survivors. It is also evident that more research is needed into specific populations of cancer survivors, other than breast cancer, were BCT can be applied through exercise prescription to enhance adherence to long-term physical activity.
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