Title: Development of a conceptual model and intervention to promote sustained, long-term physical activity after cancer.
Funder: Department of Health and Social Care

Abstract: Background: Physical inactivity costs the NHS in excess of 1billion a year and studies suggest cancer survivors are less active than those without a history of the disease, making them an important population for targeted interventions to increase activity levels. There is also good evidence that physical activity can improve many of the distressing problems often experienced after cancer including declines in physical function, cancer-related fatigue and poor quality of life. Furthermore, in some cancer types observational evidence suggests physical activity may reduce deaths from all causes, cancer, and cancer recurrence. However, the majority of cancer survivors are insufficiently active. Consequently, a recent report from the Independent Cancer Taskforce, proposing a strategy for improving cancer outcomes in the NHS, recommends all cancer patients be given advice to improve lifestyle behaviours, including physical activity. Many interventions have described short-term increases in physical activity but very little is known about how to achieve sustained long-term behaviour change, a requirement if the benefits described above are to be maintained. Aims: 1: to better understand the factors and mechanisms that promote and inhibit participation in sustained physical activity, 2: to develop a conceptual model for maintenance of physical activity after colorectal cancer, 3: to design an intervention to support long-term physical activity in colorectal cancer survivors. Work package (WP) 1: Part 1: Overview of reviews of physical activity behaviour change interventions in cancer survivors. Deliverable: a synthesis of available evidence of the impact of interventions on long-term behaviour change in cancer survivors, identifying intervention components most likely to elicit sustained change. Part 2: A systematic meta-synthesis of qualitative studies describing the implementation (incorporation into habitual everyday life) of physical activity behaviour change in cancer survivors. Deliverable: identification of factors that promote and inhibit implementation of sustained behaviour change.WP 2: A qualitative study to explore the determinants and strategies for sustained physical activity in colorectal cancer survivors. Semi-structured interviews will be conducted with colorectal cancer survivors and their partners/carers who have previously taken part in an intervention to increase physical activity behaviour. A framework approach to analysis will be used. Deliverable: characterisation of facilitators and barriers to maintenance of physical activity after colorectal cancer. WP 3: Development of a conceptual model of sustained physical activity in colorectal cancer survivors. Results from WP1 & 2, existing theories of behaviour change, Social Networking Theory and Burden of Treatment Theory will inform the identification of salient factors and capabilities that promote or inhibit engagement in sustained physical activity. Explanations of the mechanisms by which they impact on behaviour will be proposed. Face validity will be improved through small group reviews and deviant case analysis. Deliverable: a conceptual model. WP 4: Development of an intervention for colorectal cancer survivors, based on the conceived conceptual model, in collaboration with patients, carers, clinicians, academics and stakeholders. Behaviour change strategies to operationalise the factors identified in the conceptual model in WP3 with be identified. The intervention will be reviewed by patients and carers for its utility and acceptability and refinements made. Further funding will be sought to trial the intervention. Deliverable: an intervention to support sustained long-term physical activity. Impact: A novel conceptual model of sustained physical activity behaviour change and the development of a promising intervention for colorectal cancer survivors, which importantly, will be transferrable to other cancers and chronic disease populations, has the potential for considerable cost benefits. Participants who habitually increase their activity levels will benefit from numerous improvements in cancer sequale and a reduced risk of comorbid disease.

Lay abstract: Background: Physical inactivity costs the NHS in excess of 1billion a year and studies suggest cancer survivors are less active than those without a history of the disease, making them an important population for targeted interventions to increase activity levels. There is good evidence that physical activity can improve many of the distressing problems often experienced after cancer, such as fatigue, depressed mood, declining mobility and loss of function. Furthermore, in some cancer types studies suggest physical activity may reduce the risk of a cancer returning and death from cancer. Cancer survivors (and the health care system) have much to gain from being physically active. A recent report from the Independent Cancer Taskforce (who developed a strategy for improving the lives of people diagnosed with cancer), recommended all cancer patients be given advice to improve lifestyle behaviours, including physical activity. Intervention studies to support cancer survivors to increase their activity have been successful in the short-term (e.g. 3 months). However, these improvements tend to diminish over time and we know little about how to encourage long-term behaviour change. Without sustained, long-term physical activity the benefits described above will not to be maintained.Aims: 1) To better understand factors that promote and inhibit participation in sustained physical activity after cancer: 2) To develop a model to describe the processes involved in adopting and maintaining participation in regular physical activity after colorectal cancer: 3) To design an intervention to support long-term physical activity participation in cancer survivors. Methods: The aims of this fellowship will be achieved through the activities of four related work packages (WP). WP1: The evidence from reviews of studies describing long-term change after physical activity interventions in cancer survivors will be summarised in an overview of reviews to establish which intervention components achieve sustained increases in physical activity. A systematic review of exploratory studies describing how physical activity interventions are incorporated into participants' lives will then be conducted. This will identify factors that promote and inhibit engagement in physical activity as part of everyday life. WP2: An interview study will explore the determinants and strategies for sustaining physical activity in bowel cancer survivors (N~30). Survivors who have previously taken part in an intervention study to increase physical activity will be identified (via National Cancer Research Institute clinical studies groups). They and their partner/carer will be invited to attend an interview. The facilitators to maintenance of habitual physical activity will be explored among those who participate in regular physical activity. The barriers described by those who have tried, but failed to increase their activity levels in the long-term will also be explored. WP3: Results from WP1 & 2, existing behaviour change theories, Social Network Theory and Burden of Treatment Theory will inform the identification of factors that promote or inhibit engagement in sustained physical activity. Explanations of the mechanisms by which they impact on behaviour will be proposed. The model will then be reviewed by two groups of cancer survivors and carers to discuss its relevance to them.WP 4: Using the model developed in WP3 and in collaboration with patients, carers, clinicians, academics and stakeholders, an intervention to support long-term physical activity in colorectal cancer survivors will be designed. The intervention will be reviewed by patients and carers for its utility and acceptability and refinements made as required. Further funding will be sought to trial the intervention. Patient and public involvement: Patients have been involved in the conception of the application and their continued involvement will be integral throughout the fellowship, particularly in the development of the intervention as part of the Study Advisory Team. They will also help with the development of study materials, and dissemination to patient groups and wider public audiences. Impact: Physical inactivity has a significant impact on NHS costs and resources. A novel model of sustained physical activity behaviour change and the development of an intervention, which importantly, could be translated to suit people with other types of cancer and chronic diseases, has the potential for considerable cost benefits. Participants who habitually increase their activity levels will benefit from numerous improvements in physical and emotional health and a reduced risk of comorbid disease.Dissemination: Academic papers will be published in peer reviewed journals and the work presented at carefully chosen national and international conferences to ensure dissemination to appropriate academic and clinical audiences. Outputs will be shared with relevant stakeholders, including charities such as Macmillan Cancer Support, and clinical commissioning groups.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: CANCER AND NEOPLASMS;CARDIOVASCULAR;METABOLIC AND ENDOCRINE;ORAL AND GASTROINTESTINAL;STROKE