An investigation of what influences exercise adherence in people with advanced cancer, and how to encourage lasting exercise behaviour after completion of supervised programmes

Abstract

Evidence is accumulating to indicate exercise, for people with advanced cancer, can result in a range of benefits largely relating to the physical, psychological and social problems caused by the disease and treatment. However, most research has been in specialist settings with professional supervision, a context not possible to replicate for all who would benefit nor for an indefinite period of time. Studies which have investigated supervised exercise followed by a period of unsupervised exercise have found that typically participants do not continue to exercise once the supervised period ends. This study aimed to answer the question: What is the experience of people with advanced cancer participating in supervised exercise programmes delivered in health care facilities, and how can exercise adherence be encouraged and facilitated as people transition to an unsupervised home-based approach? A series of investigations, named here as ‘Elements’, were developed to explore and answer the research question. The study design was guided by the ‘Person-Based Approach’, a method of intervention design and development, proposed to encourage intervention acceptability and feasibility. The elements included: Element 1, a mixed method review exploring adherence in advanced cancer; Element 2, a qualitative review exploring how living with advance cancer may impact exercise adherence; Element 3, an empirical investigation of how participants with advanced cancer experience partaking in therapeutic exercise interventions; Element 4, the creation of a conceptual model to show what influences exercise adherence in advanced cancer. Findings from each element generated an increasing understanding of exercise adherence. Element 1 suggests how components of an intervention might influence adherence. Element 2 proposes how factors identified in daily life of people with advanced cancer may impact upon exercise behaviour. Element 3 identifies the meta-theme of ‘moments of conscious decision’, and the related themes of ‘drivers of participation’ and ‘mitigation and accommodation of impediments’. Further sub themes explain and expand upon those two themes, and demonstrate the differences between the supervised and unsupervised periods. Element 4 demonstrates and explains how ‘pre-existing factors’, the ‘demands of the home exercise protocol’, ‘home exercise determinants’, and ‘theoretical mechanisms’ interact to influence a person’s decision to exercise, and their performance of exercise. Recommendations are discussed in the form of guiding principles as per the person-based approach. These recommendations propose key objectives any intervention should aim to achieve to maximise adherence and key features an intervention should include to achieve those objectives. This study has shown how in order to perform unsupervised home exercise, participants need the ‘motivation’ and ‘self-efficacy’ to perform the exercise or the ‘agency’ to respond positively to occasions when motivation and self-efficacy are inadequate. Attempts to maximise adherence during the supervised period may not have a positive influence upon adherence in the subsequent unsupervised period and may in fact undermine or prevent the development of factors necessary to adhere to an unsupervised home intervention. A stepped approach involving combinations of continuing support and sufficient preparation to exercise without that support, may enhance ‘motivation’, ‘self-efficacy’ and ‘agency’ and lead to enhanced exercise behaviour after completion of supervised programmes.

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Identifiers

ORCID for Daniel Aze: orcid.org/0000-0002-9934-5863

ORCID for Alison Richardson: orcid.org/0000-0003-3127-5755

ORCID for Richard Wagland: orcid.org/0000-0003-1825-7587

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