Implementing a behavioral physical activity program in children and adolescent survivors of childhood cancer: a pilot randomized controlled trial.

Purpose We aimed to document the acceptability (enrollment rate) and feasibility (phone call delivery rate) of implementing a behavioral PA intervention over 12 weeks, in addition to documenting its effects on patient-reported outcomes and physical functioning. This study also describes the costs of carrying out a behavioral PA intervention. A total of 40 participants were randomized in a 1:1 ratio. The tailored behavioral PA intervention was developed based on the most recent PA guidelines in pediatric oncology and on the COM-B framework to enact PA behavior changes. The prescription (frequency, intensity, time and type (FITT)) was adjusted each week during the weekly support calls. The control group did not receive the intervention. 26 males and 14 females (13.6 years old on average and 2.9 years post-cancer treatment on average) participated in our study. The acceptability rate was 90.9% and the feasibility rate was > 85%. We found that 85% improved PA frequency, 80% improved PA intensity, 100% improved PA time, and 50.0% achieved the recommended PA guidelines. No adverse events were reported over the duration of the intervention. Physical function improved with longer 6-minute walk distances in the intervention group (465.8 ± 74.5 m) than in the control group (398.7 ± 92.9 m) (p = 0.016). PROs scores for all participants were within the limits of the normal range. The estimated cost per participant of carrying out this intervention was USD $126.57. Our 12-week behavioral PA intervention, based on the COM-B framework, was found to be acceptable, feasible and safe in childhood cancer survivors. This study is an important step in the right direction to make exercise standard practice in pediatric oncology.

AYA-UNITE: Lessons Learned on Intervention Development Promoting Social and Physical Health of Adolescent/Young Adult Cancer Survivors.

Adolescent/young adult cancer survivors (AYACS) struggle with poor psychosocial health related to social disruptions due to cancer diagnosis, impacting long-term goal achievement and overall health. In particular, social health promotion is overlooked in AYACS' care. AYA-UNITE, a sociobehavioral exercise intervention pilot for AYACS 15-21 years of age at cancer diagnosis, was designed to foster AYACS' social and physical health. AYA-UNITE was a 12-week group-based virtual exercise program incorporating strength training and aerobic activity. In this brief report, we account AYA-UNITE's conceptual design, lessons learned through AYA-UNITE intervention development, and opportunities for improvement in implementing effective AYACS psychosocial interventions (NCT03778658).

Addressing metastatic individuals everyday: Rationale and design of the nurse AMIE for Amazon Echo Show trial among metastatic breast cancer patients.

Background: Metastatic Breast Cancer (MBC) patients often feel their symptom-related needs are unmet, despite visiting their doctors up to once a week. Novel approaches are needed to address symptoms without requiring additional appointments. Technology based symptom management approaches to address symptoms have not been well tested. Methods: Nurse AMIE (Addressing Metastatic Individuals Everyday) is a technology based supportive care platform that provides guideline-concordant symptom management interventions in response to patient reported symptoms. We have previously successfully implemented a tablet version of Nurse AMIE. However, some eligible patients chose not to participate because they were overwhelmed by the technology. To address this barrier, we translated the Nurse AMIE platform to the Amazon Echo Show, which allowed for voice-based interactions. Forty-two MBC patients were randomized 1:1 to receive the Nurse AMIE for Echo Show immediately for six months, or to receive the same intervention for three months, after a three month delay. The primary outcome was change in physical distress over three months, and secondary outcomes included feasibility, acceptability, patient reported outcomes and usability. Conclusions: Results from the Nurse AMIE for Echo Show trial will identify the feasibility, acceptability, and preliminary effects of the Nurse AMIE for Echo Show on patient reported outcomes. Untested novel technologies, particularly voice-based artificial intelligence devices may an effective and scalable vehicle through which we can deliver supportive care interventions. Clinicaltrialsgov identifier: NCT04673019.

Light-intensity and moderate-to-vigorous intensity physical activity among older adult breast cancer survivors with obesity: A narrative review.

BACKGROUND: With an aging population, rising incidence of breast cancer, improved survival rates, and obesity epidemic, there will be a growing population of older adult breast cancer survivors with obesity. This complex population, often with multimorbidity, is at risk for several poor health outcomes, including recurrence, cardiovascular disease, dementia, and diabetes, and a number of deleterious symptoms, including a worsened inflammatory profile, breast cancer- related lymphedema, mobility disability, cognitive impairment, anxiety, and depressive symptoms. A wealth of meta-analytic and randomized controlled trial evidence show that adherence to World Health Organization and 2018 United States Physical Activity guidelines-based levels of moderate-to-vigorous physical activity (MVPA) reduces risk of all-cause mortality, and improves symptoms. However, few survivors engage in recommended levels of MVPA, and symptoms related to their multimorbidity may preclude engaging in sufficient levels of MVPA. Additional research of MVPA in this population is warranted; however, understudied light-intensity physical activity (LIPA) may be a more pragmatic target than MVPA among this complex population facing extensive challenges meeting MVPA recommendations. Large benefits are likely to occur from increasing these survivors' total activity, and LIPA prescriptions may be a more pragmatic approach than MVPA to aid this transition. METHODS: We present a broad, narrative review of the evidence for MVPA and LIPA in this population on an array of health outcomes across the translational science spectrum (clinical, implementation, and public health), and identify a number of directions for future research focused on understanding the potential diverse health effects of LIPA. CONCLUSION: Additional LIPA research is warranted, as LIPA prescriptions may be a pragmatic strategy to effectively promote physical activity to this complex population.

Cost evaluation of an exercise oncology intervention: The exercise in all chemotherapy trial.

BACKGROUND: There is strong evidence supporting the efficacy of exercise oncology programs to improve physical and psychosocial outcomes during active treatment. However, there is a paucity of evidence on the effect of exercise on healthcare utilization and cost analyzes of exercise oncology programs. AIMS: Our objective was to assess the effects of a pragmatic exercise oncology program (ENACT) during active chemotherapy treatment on healthcare utilization and associated costs. METHODS: We conducted post-hoc analyzes on 160 ENACT participants and 75 comparison participants matched on cancer site, stage, age range, and gender. We obtained complete healthcare utilization histories for each patient (specific to emergency department [ED] visits and hospital admissions) coinciding with their participation in ENACT. A sub-analysis was conducted for advanced stage breast, gastrointestinal, and pancreatic cancer patients. RESULTS: Healthcare costs for patients who participated in the ENACT exercise oncology intervention were numerically lower than healthcare costs for the comparison group, even after accounting for the cost of the intervention. However, the differences were not statistically significant. CONCLUSION: Our findings suggest that an exercise oncology program during active chemotherapy treatment are at least cost neutral for all cancer patients, including advanced stage cancers. Additional research is warranted to evaluate the potential for exercise oncology programs to reduce healthcare utilization, particularly in advanced cancer patients.

The exercise in all chemotherapy trial.

BACKGROUND: Multiple international organizations have called for exercise to become standard practice in the setting of oncology care. The feasibility of integrating exercise within systemic chemotherapy has not been investigated. METHODS: Patients slated to receive infusion therapy between April 2017 and October 2018 were screened for possible inclusion. The study goal was to establish the acceptability and feasibility of embedding an exercise professional into the chemotherapy infusion suite as a method of making exercise a standard part of cancer care. The exercise prescriptions provided to patients were individualized according to results of brief baseline functional testing. RESULTS: In all, 544 patients were screened, and their respective treating oncologists deemed 83% of them to be medically eligible to participate. After further eligibility screening, 226 patients were approached. Nearly 71% of these patients (n = 160) accepted the invitation to participate in the Exercise in All Chemotherapy trial. Feasibility was established because 71%, 55%, 69%, and 63% of the aerobic, resistance, balance, and flexibility exercises prescribed to patients were completed. Qualitative data also supported the acceptability and feasibility of the intervention from the perspective of patients and clinicians. The per-patient cost of the intervention was $190.68 to $382.40. CONCLUSIONS: Embedding an exercise professional into the chemotherapy infusion suite is an acceptable and feasible approach to making exercise standard practice. Moreover, the cost of the intervention is lower than the cost of other common community programs. Future studies should test whether colocating an exercise professional with infusion therapy could reach more patients in comparison with not colocating. LAY SUMMARY: Few studies have tested the implementation of exercise for patients with cancer by embedding an exercise professional directly into the chemotherapy infusion suite. The Exercise in All Chemotherapy trial shows that this approach is both acceptable and feasible from the perspective of clinicians and patients.

Implementing Strength after Breast Cancer (SABC) in outpatient rehabilitation clinics: mapping clinician survey data onto key implementation outcomes.

BACKGROUND: While 3.5 million breast cancer survivors in the USA are indicative of promising disease-free survival, many experience adverse effects in recovering from treatment. Evidence-based exercise programs may be a low-cost, easily disseminable solution to the challenge of recovering from adverse treatment affects. Therefore, after establishing efficacy in a large randomized controlled trial, we developed the Strength after Breast Cancer (SABC) program and the accompanying online course for clinicians interested in physical therapy to learn to deliver this rehabilitative exercise program to individuals with breast cancer. We surveyed clinicians who took the course to assess implementation of the program in outpatient rehabilitation clinics. METHODS: Ninety-six clinicians completed the survey between June and December, 2017 (24% response). Guided by Proctor's implementation outcomes framework, the respondents were asked if they had implemented (adoption) and are still implementing the program (sustainability), and which programmatic components they implemented (fidelity). Respondents were asked how many patients completed the program (reach), how patients got into the program (reach), the program's delivery format (appropriateness), and whether clinics were reimbursed by third-party payers (cost). Finally, respondents were asked what barriers they faced in delivery of SABC (feasibility) and whether others in the clinic completed the course (penetration). RESULTS: Seventy-six percent of respondents implemented SABC and among those, 93% (68/73) were still delivering it. All programmatic components were implemented by over two thirds of respondents (67-95%). On average, the program was delivered to 13 patients per clinic by the time respondents took the survey. Most patient referrals were from oncology clinics (50%). The majority of clinicians delivered SABC one-on-one (96%) and 72% of clinics were compensated via third-party payers. Major barriers were lack of referrals from oncologists (40%) and clinic's competing demands (33%). We found no differences (Fisher's exact test p > .05) in reported barriers between those who implemented the program and those who did not. CONCLUSION: Our findings suggest that the online training was sufficient to successfully implement the SABC program in outpatient rehabilitation clinics with high levels of adoption, fidelity, reach, and capacity for sustainability. Information on patient acceptability, cost-effectiveness, and how to overcome implementation barriers are still needed.

Physical Activity Mode and Mental Distress in Adulthood.

INTRODUCTION: Nearly one fifth of American adults suffer from mental health issues, yet many treatments have side effects and stigma attached. Physical activity can be an effective treatment for mental health disorders, but most promotion efforts fail. One understudied aspect of physical activity is the specific mode, including if it engages others, and how this may relate to mental health. This study examined the potential relationship between different modes of physical activity and the frequency of mental distress. METHODS: Data from the 2000 Behavioral Risk Factor Surveillance System were analyzed in 2015 to determine the relationship between participation in different modes of physical activity and frequent mental distress. RESULTS: Data were obtained on physical activity and frequent mental distress from 183,341 adults (aged 18-99 years, 51.9% female, 57.4% overweight/obese, 9.5% frequent mental distress). Prevalence of mental distress for those reporting activities was contrasted against walking alone. People who participated in tennis had 46% lower odds (95% CI=0.35, 0.84) of frequent mental distress. Approaching significance, non-team play sports were associated with 18% lower odds (95% CI=0.66, 1.01) of frequent mental distress, compared with walking alone. CONCLUSIONS: Activity modes are associated with mental health outcomes above and beyond the frequency and duration of activity. Given the social and play nature of the activities, this may reflect the relational aspect, enjoyment, or a combination of both. These results suggest that adding social or affective components to physical activity may enhance engagement and retention in activity promotion efforts and their benefits on mental health.

Intention-behavior gap is wider for walking and moderate physical activity than for vigorous physical activity in university students.

OBJECTIVES: The theory of planned behavior proposes that physical activity is the result of intentions; however little is known about whether the relation between intentions and behavior differs between vigorous, moderate physical activity, and walking. For university students, vigorous physical activity is oftentimes enacted as a goal-directed behavior; whereas walking is oftentimes a means to achieving a goal other than physical activity (e.g., transportation). DESIGN: The study was a one-week prospective study. METHODS: Undergraduate students (N=164) reported intentions for walking, moderate physical activity, and vigorous physical activity and self-reported these behaviors one week later. RESULTS: Hierarchical linear modeling revealed that intentions were more strongly related to vigorous physical activity than to moderate physical activity or walking. CONCLUSIONS: Intention-enhancing interventions may effectively promote vigorous physical activity, but other motivational processes may be more appropriate to target in interventions of walking and moderate physical activity.

A Daily Process Analysis of Physical Activity, Sedentary Behavior, and Perceived Cognitive Abilities.

OBJECTIVES: This study evaluated the role of both physical activity and sedentary behavior in daily perceptions of cognitive abilities and whether these relations exist within-person, between-person, or both. DESIGN: Non-experimental, intensive longitudinal research using ecological momentary assessments. METHOD: College students wore accelerometers and provided end-of-day reports on physical activity, sedentary behavior, and perceived cognitive abilities for 14 days. RESULTS: Across self-reports and objective measures of behavior, daily deviations in physical activity were positively associated with perceived cognitive abilities. Daily deviations in self-reported, but not objectively-assessed, sedentary behavior also were negatively associated with perceived cognitive abilities. Contrary to previous research, overall levels of physical activity and sedentary behaviors were not associated with perceived cognitive abilities. CONCLUSIONS: These findings indicate that physical activity has a within- rather than between-person association with perceived cognitive abilities although between-person associations effects may require longer monitoring periods to manifest. Further research is needed to establish the direction of causality and resolve whether the nature (rather than quantity) of sedentary activities influences cognition.

Habits predict physical activity on days when intentions are weak.

Physical activity is regulated by controlled processes, such as intentions, and automatic processes, such as habits. Intentions relate to physical activity more strongly for people with weak habits than for people with strong habits, but people's intentions vary day by day. Physical activity may be regulated by habits unless daily physical activity intentions are strong. University students (N = 128) self-reported their physical activity habit strength and subsequently self-reported daily physical activity intentions and wore an accelerometer for 14 days. On days when people had intentions that were weaker than typical for them, habit strength was positively related to physical activity, but on days when people had typical or stronger intentions than was typical for them, habit strength was unrelated to daily physical activity. Efforts to promote physical activity may need to account for habits and the dynamics of intentions.

Daily satisfaction with life is regulated by both physical activity and sedentary behavior.

Recent research revealed that on days when college students engage in more physical activity than is typical for them, they also experience greater satisfaction with life (SWL). That work relied on self-reported physical activity and did not differentiate between low levels of physical activity and sedentary behavior. This study was designed to (1) determine if the association between self-reported physical activity and SWL would exist when physical activity was monitored objectively and (2) examine the between- and within-person associations among physical activity, sedentary behavior, and SWL. During a 14-day ecological momentary assessment study, college students (N = 128) wore an accelerometer to objectively measure physical activity and sedentary behavior, and they self-reported their physical activity, sedentary behavior, and SWL at the end of each day. Physical activity and sedentary behavior had additive, within-person associations with SWL across self-reported and objective-measures of behavior. Strategies to promote daily well-being should encourage college students to incorporate greater amounts of physical activity as well as limit their sedentary behavior.

Social cognitive determinants of dietary behavior change in university employes.

Many adults have poor dietary habits and few studies have focused on mechanisms underlying these behaviors. This study examined psychosocial determinants of dietary behavior change in university employes across a 5-month period. Participants completed measures of fruit and vegetable consumption (FVC) and low fat food consumption (LFC) and social cognitive constructs. Multiple regression analyses accounted for a unique proportion of variation in dietary change. Outcome expectations significantly predicted FVC and LFC. Self-efficacy significantly predicted LFC. Goals were not associated with dietary behaviors. Further research into implementation strategies may provide insight into how goals work to bring about change.

A daily process analysis of intentions and physical activity in college students.

Social-cognitive theories, such as the theory of planned behavior, posit intentions as proximal influences on physical activity (PA). This paper extends those theories by examining within-person variation in intentions and moderate-to-vigorous physical activity (MVPA) as a function of the unfolding constraints in people's daily lives (e.g., perceived time availability, fatigue, soreness, weather, overeating). College students (N = 63) completed a 14-day diary study over the Internet that rated daily motivation, contextual constraints, and MVPA. Key findings from multilevel analyses were that (1) between-person differences represented 46% and 33% of the variability in daily MVPA intentions and behavior, respectively; (2) attitudes, injunctive norms, self-efficacy, perceptions of limited time availability, and weekend status predicted daily changes in intention strength; and (3) daily changes in intentions, perceptions of limited time availability, and weekend status predicted day-to-day changes in MVPA. Embedding future motivation and PA research in the context of people's daily lives will advance understanding of individual PA change processes.

Sedentary behavior as a daily process regulated by habits and intentions.

OBJECTIVE: Sedentary behavior is a health risk but little is known about the motivational processes that regulate daily sedentary behavior. This study was designed to test a dual-process model of daily sedentary behavior, with an emphasis on the role of intentions and habits in regulating daily sedentary behavior. METHOD: College students (N = 128) self-reported on their habit strength for sitting and completed a 14-day ecological momentary assessment study that combined daily diaries for reporting motivation and behavior with ambulatory monitoring of sedentary behavior using accelerometers. RESULTS: Less than half of the variance in daily sedentary behavior was attributable to between-person differences. People with stronger sedentary habits reported more sedentary behavior on average. People whose intentions for limiting sedentary behavior were stronger, on average, exhibited less self-reported sedentary behavior (and marginally less monitored sedentary behavior). Daily deviations in those intentions were negatively associated with changes in daily sedentary behavior (i.e., stronger than usual intentions to limit sedentary behavior were associated with reduced sedentary behavior). Sedentary behavior also varied within people as a function of concurrent physical activity, the day of week, and the day in the sequence of the monitoring period. CONCLUSIONS: Sedentary behavior was regulated by both automatic and controlled motivational processes. Interventions should target both of these motivational processes to facilitate and maintain behavior change. Links between sedentary behavior and daily deviations in intentions also indicate the need for ongoing efforts to support controlled motivational processes on a daily basis.

A daily analysis of physical activity and satisfaction with life in emerging adults.

OBJECTIVE: Subjective well-being has well-established positive health consequences. During emerging adulthood, from ages 18 to 25 years, people's global evaluations of their well-being (i.e., satisfaction with life [SWL]) appear to worsen more than any other time in the adult life span, indicating that this population would benefit from strategies to enhance SWL. In these studies, we investigated top-down (i.e., time-invariant, trait-like) and bottom-up (i.e., time-varying, state-like) influences of physical activity (PA) on daily SWL. METHODS: Two daily diary studies lasting 8 days (N = 190) and 14 days (N = 63) were conducted with samples of emerging adults enrolled in college to evaluate relations between daily PA and SWL while controlling for established and plausible top-down and bottom-up influences on SWL. RESULTS: In both studies, multilevel models indicated that people reported greater SWL on days when they were more active (a within-person, bottom-up effect). Top-down effects of PA were not significant in either study. These findings were robust when we controlled for competing top-down influences (e.g., sex, personality traits, self-esteem, body mass index, mental health symptoms, fatigue) and bottom-up influences (e.g., daily self-esteem, daily mental health symptoms, daily fatigue). CONCLUSIONS: We concluded that SWL was impacted by people's daily PA rather than their trait level of PA over time. These findings extend evidence that PA is a health behavior with important consequences for daily well-being and should be considered when developing national policies to enhance SWL.

The stability of automatic evaluations of physical activity and their relations with physical activity.

Accumulating research indicates that physical activity is motivated by automatic evaluations of physical activity. Little is known about the stability of automatic evaluations or how their dynamics impact physical activity. We tested the measurement invariance and stability of university students' (N = 164) automatic evaluations of physical activity. In addition, multiple regression and structural equation models with latent interaction variables were used to investigate how changes in automatic evaluations related to change in self-reported physical activity and differences in the level of directly measured physical activity. It was revealed that automatic evaluations had strict measurement invariance and that automatic evaluations have both stable and unstable components. People whose unfavorable automatic evaluations became more favorable over the week showed a larger increase in self-reported physical activity from the previous week than did people whose automatic evaluations remained unfavorable. These results indicated that the dynamics of automatic evaluations and physical activity can be intertwined.

The dynamic nature of physical activity intentions: a within-person perspective on intention-behavior coupling.

The intention-behavior gap has proven to be a vexing problem for theorists and practitioners interested in physical activity. Intention stability is one factor which moderates this gap. This study articulated and tested contrasting views of intention stability as (a) a dynamic characteristic of people that influences assessment error (and therefore the predictive power of intentions) and (b) the product of a dynamic process that unfolds within people over time. Using an ecological momentary assessment design, young adults (N = 30) rated weekly physical activity intentions for 10 weeks and wore pedometers for the first 4 weeks of the study. Substantial within-person variability existed in intentions over both 4- and 10-week intervals, and this variability was not a function of time exclusively. Multilevel modeling revealed that overall intention strength (across weeks) and weekly deviations in intention strength interacted to predict weekday (but not weekend) physical activity. These findings indicate that the person and context interact to selectively couple or decouple intentions from daily physical activity.

Implicit attitudes and explicit motivation prospectively predict physical activity.

BACKGROUND: Contemporary approaches to physical activity motivation and promotion focus on explicit motivational processes which regulate intentional physical activity. Less is known about the role of implicit processes, which may be instrumental in regulating habitual aspects of unintentional (i.e., incidental) physical activity (PA). PURPOSE: To test the proposition that the routine nature of unintentional PA makes it amenable to control by implicit processes. METHODS: Participants (N = 201) completed measures of explicit motivation (i.e., efficacy beliefs, outcome expectations, behavioral intentions, perceived behavioral control) and implicit attitudes toward physical activity, and then wore a pedometer for 1 week. RESULTS: Implicit attitudes positively predicted PA after controlling for well-established predictors of intentional physical activity. CONCLUSIONS: PA motivation involves both explicit and implicit processes, and PA promotion efforts may be enhanced by attending to relevant implicit motivation processes.

Trajectory of declines in physical activity in community-dwelling older women: social cognitive influences.

Studies examining physical activity behavior suggest that activity levels decline with age. Such declines are particularly problematic among older adults in light of the research suggesting a protective effect of physical activity on numerous physical health outcomes associated with independent living. Despite a growing recognition of the importance of a physically active lifestyle, little is known about the role of demographic and psychosocial variables on this trajectory of change. In this study, the roles played by outcome expectations, self-efficacy, and functional limitations on changes in physical activity levels over a 2-year period in older women were assessed using latent growth curve modeling. Data were obtained from 249 community-dwelling older women (M age = 68.12, n = 81 Black, and n = 168 White). Demographic, health status, and psychosocial data were collected via self-report upon entry into the study. Self-reported physical activity was assessed at baseline and again at 12 and 24 months. As expected, physical activity declined over the 2-year period. Self-efficacy demonstrated an indirect association with the trajectory of decline in physical activity through functional limitations. Importantly, the pattern of relationships appears independent of demographic factors and chronic health conditions.