Design of the steps to health study of physical activity in survivors of endometrial cancer: Testing a social cognitive theory model

doi:10.1016/j.psychsport.2010.07.010

Psychology of Sport and Exercise

Volume 12, Issue 1, January 2011, Pages 27-35

https://doi.org/10.1016/j.psychsport.2010.07.010 Get rights and content

Abstract

Objectives

Physical activity has been shown to benefit cancer survivors' physical functioning, emotional well-being, and symptoms. Physical activity may be of particular benefit to survivors of endometrial cancer because they are more likely to be obese and sedentary than the general population, as these are risk factors for the disease, and thus experience a number of related co-morbid health problems. However, there is little research systematically studying mechanisms of physical activity adherence in cancer survivor populations. This paper describes the design of the Steps to Health study, which applies a Social Cognitive Theory-based model of endometrial cancer survivors' adoption and maintenance of exercise in the context of an intervention to increase walking or other moderate intensity cardiovascular activity.

Method

In Steps to Health we will test the influence of self-efficacy and outcome expectations on adherence to exercise recommendations, as well as studying the determinants of self-efficacy. Endometrial cancer survivors who are at least 6 months post-treatment are provided with an intervention involving print materials and telephone counseling, and complete assessments of fitness, activity, self-efficacy and outcome expectations, and determinants of self-efficacy every 2 months for a 6-month period. In addition to testing an innovative model, the Steps to Health study employs multiple assessment methods, including ecological momentary assessment, implicit tests of cognitive variables, and ambulatory monitoring of physical activity.

Conclusion

The study results can be used to develop more effective interventions for increasing physical activity in sedentary cancer survivors by taking into account the full complement of sources of self-efficacy information and outcome expectations.

Research highlights

► Exercise improves cancer survivors' quality of life and physical functioning. ► Process of exercise adoption and maintenance has received little study. ► Social Cognitive Theory can be applied to understand survivors' exercise behavior. ► Self-efficacy is a key determinant of exercise behavior. ► We need to understand how cancer survivors form self-efficacy expectations.

Section snippets

Social cognitive theory

To study the mechanisms of physical activity adoption and maintenance in endometrial cancer survivors we are applying a model based on Bandura’s Social Cognitive Theory (Bandura, 1977, Bandura, 1986, Bandura, 1997). Previous studies have applied Social Cognitive Theory to evaluate and increase physical activity in other populations, but this theory has not been systematically applied to study the mechanisms of exercise adoption and maintenance in cancer survivors. Furthermore, most studies have

Analysis of data

We propose a sample size of 200, based on the number of participants needed to detect Pearson’s correlation coefficients of ρ = .20 or higher with 80% power, using a significance level of α = .05. For the multiple regression analyses, we are using hierarchical modeling. In these analyses, demographic and medical characteristics are first entered into the models for a given outcome measure, followed by the social cognitive measures of interest. If approximately 4–8 demographic and medical

Moving the field forward

The Steps to Health study will elucidate how cancer survivors form self-efficacy expectations about physical activity, including how cardiorespiratory fitness and somatic sensations during exercise influence self-efficacy. In addition we will identify the types of self-efficacy that are most influential at different points in the exercise adoption and maintenance processes. It also will help us understand the influence of outcome expectations and the expectancy violation effect in a cancer

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Cited by (26)

Endometrial cancer survivors' sleep patterns before and after a physical activity intervention: A retrospective cohort analysis
2018, Gynecologic Oncology
Citation Excerpt :
As described previously, Steps to Health participants completed a baseline assessment of their sleep, physical activity, quality of life and stress. They then received individualized exercise prescriptions based on their baseline functioning [21]. The research team supported the participants' adherence to the American College of Sports Medicine guidelines, requiring 30 min of moderate exercise 5 or more days a week or at least 20 min of vigorous exercise 3 or more days a week, via telephone-based counseling sessions, printed materials, and pedometers.
To identify the baseline sleep patterns of endometrial cancer survivors and examine the impact of a physical activity intervention on their sleep quality via retrospective secondary analysis.
Early-stage endometrial cancer survivors participated in a 6-month single-arm exercise intervention using printed materials, telephone-based counseling, and pedometers to encourage adherence to exercise guidelines. Participants completed questionnaires evaluating their sleep (PSQI), physical activity (CHAMPS), quality of life (SF-36), and stress (PSS) at baseline and study completion.
Ninety-five survivors had PSQI data at both time points. Mean age was 57.1 years (range, 25–76). Mean body mass index was 34.3 kg/m². The majority were non-Hispanic white (75%) and had stage I disease (80%). At baseline, most survivors (61%) had poor sleep quality (PSQI > 5), with 24% reporting fairly or very bad sleep. The majority (63%) slept <7 h/night. At least once during the preceding month, 83% had an episode of daytime dysfunction. A pairwise comparison showed that obese survivors had more sleep disturbances than normal weight survivors (p = 0.029). No other clinicodemographic factors were associated with sleep. In unadjusted analyses, sleep quality significantly improved in women who increased weekly total or moderate/vigorous physical activity (p = 0.004 and p < 0.050, respectively). This association persisted after adjusting for the potential covariates of age, time since diagnosis, obesity status, disease stage, and treatment (p = 0.026).
Our data demonstrated that poor sleep is common and detrimental to endometrial cancer survivors. Increasing exercise may improve this dysfunction and should be investigated as part of a prospective study.
Optimizing endometrial cancer follow-up and survivorship care for rural and other underserved women: Patient and provider perspectives
2017, Gynecologic Oncology
Citation Excerpt :
The quality of care of EC survivors could be improved by shifting from a purely disease focused approach to a wellness-centered approach that emphasized all the patient care needs including referrals to health coaches to help EC survivors change and maintain positive heath behaviors. Evidence-based remote interventions for rural dwellers may be particularly effective in improving lifestyle behaviors and co-morbidities [24,25]. Another important finding in our study concerns the use of survivorship care plans (SCPs).
This study describes patient and provider attitudes on transitioning cancer surveillance visits and treatment of comorbid conditions to the primary care setting in a rural patient population as a strategy for minimizing financial and travel related barriers for patients while simultaneously enhancing quality and availability of health care options.
Focus group discussions and telephone interviews were conducted with endometrial cancer (EC) survivors and primary care providers (PCPs) to provide insights into post-treatment follow-up practices and the acceptability of transitioning follow-up to primary care setting utilizing a cancer survivorship care plan model.
EC survivors expressed high levels of satisfaction with their oncology care and suggested that transitioning to PCPs for follow-up care would be convenient yet challenging. Challenges cited include: 1) patient perceptions of deficits in PCP's understandings of cancer surveillance; 2) inability to identify a personal PCP; and 3) lack of communication between oncologists and PCPs. PCP participants similarly identified the need for extensive EC training and effective communication strategies with oncologists as necessary factors for accepting responsibility for EC follow-up care. Both groups offered strategies to create a more team based approach to EC survivorship care.
Increasing the role of the PCP in the ongoing care of EC survivors was generally considered acceptable by both patients and providers in both rural and urban women. Successful coordination of care between cancer survivors, oncologists and PCPs will be a critical step in improving the cancer care delivery of our rural patient and provider population.
Sexual health of endometrial cancer survivors before and after a physical activity intervention: A retrospective cohort analysis
2016, Gynecologic Oncology
Sexual dysfunction is common in endometrial cancer survivors (ECS). Our group previously tested a six-month exercise intervention in ECS. We performed a secondary analysis to determine intervention's impact on sexual health.
We studied 100 post-treatment Stage I-IIIa sedentary ECS who participated in a non-controlled, single-arm, home-based exercise intervention utilizing telephone counseling, printed material, and pedometers. Quality-of-life and physical activity measures were collected at baseline and six months. Sexual function (SF) and sexual interest (SI) scores were extracted from the QLACS questionnaire.
Baseline SF and SI were lower in survivors with less than a four-year college degree (P < 0.001). Baseline SI was higher in survivors who were married or living with a significant other (P = 0.012). No significant differences in SF or SI were observed based on obesity status, race, time since diagnosis, or treatment type. Post-intervention, mean SF score improved (P = 0.002), 51% of participants had improved SI, and 43% had improved SF. When controlled for age and time since diagnosis, a one-hour increase in weekly physical activity was associated with a 6.5% increased likelihood of improved SI (P = 0.04). Increased physical activity was not associated with improved SF.
Although causation cannot be determined in this study, the correlation between receipt of an exercise intervention and improved sexual health for ECS is a novel finding. This finding suggests a role for physical activity as a strategy to improve the sexual health of ECS, which our group is examining in a larger prospective study.
Traditional and Rasch psychometric analyses of the Quality of Life in Adult Cancer Survivors (QLACS) questionnaire in shorter-term cancer survivors 15months post-diagnosis
2014, Journal of Psychosomatic Research
Citation Excerpt :
These findings indicate that, although QLACS was developed for patients over 5 years post-diagnosis, in terms of traditional psychometrics, the questionnaire performs similarly well among shorter-term survivors. This is an important and encouraging result given that researchers are already using QLACS with shorter-term survivors (e.g. [15–18]), and because it suggests that longitudinal studies could validly use QLACS across the survivorship continuum. Although two-thirds (8/12) of the domains were free of floor effects, extremely consistent with the development studies [11,19], notably more than 15% of participants obtained the minimum score for the finance, appearance, social and family-distress domains.
The aim of this paper is to provide new insights into the psychometrics of the Quality of Life in Adult Cancer Survivors (QLACS) questionnaire, originally developed for longer-term survivors 5 + years post-diagnosis. Specifically, to examine the classic psychometric properties of QLACS in a sample of shorter-term survivors, and to undertake Rasch analysis to explore the extent to which the Generic and Cancer-Specific summary scales (and separately-analysed Benefits of cancer domain) are unidimensional, with linear measurement properties and no differential item functioning (DIF).
Patients with potentially curable breast, colorectal or prostate cancer completed QLACS 15 months post-diagnosis (N = 407). Score distributions, floor and ceiling effects, internal reliability, and feasibility (completion time and missing data) were examined. Rasch analysis included examination of item fit, DIF and unidimensionality.
The QLACS domains and summary scales had very similar score distributions and classic psychometric properties (no ceiling effects, majority no floor effects, acceptable reliability) to those found in development work with longer-term survivors. Median completion time was 10 min and total missing data 2.3%. The Generic summary scale contained several misfitting items and exhibited multidimensionality. The Cancer-Specific summary scale and Benefits domain showed fit to the Rasch model and demonstrated unidimensionality and no DIF, with just one or no item modifications respectively.
QLACS demonstrates similarly good classic psychometric properties among shorter-term as among longer-term survivors, and has good feasibility. The Cancer-Specific summary scale and Benefits domain showed an impressive degree of fit to the Rasch model, although the validity of computing the Generic summary score was not supported.
Response to an exercise intervention after endometrial cancer: Differences between obese and non-obese survivors
2014, Gynecologic Oncology
Citation Excerpt :
This paper is a secondary analysis of data from the Steps to Health study, a 6-month longitudinal study to assess predictors of exercise behavior in endometrial cancer survivors who received a home-based exercise intervention. Specific details on study methodology have been published previously [18,19]. Participants were 100 women diagnosed with Stage I, II, or IIIa endometrial cancer who were at least 6 months post-treatment with no evidence of disease.
The objective of this paper is to describe baseline differences between obese and non-obese endometrial cancer survivor in anthropometrics, exercise behavior, fitness, heart rate and blood pressure, and quality of life, and to analyze whether the effect of a home-based exercise intervention on these outcomes differed for obese and non-obese participants.
One hundred post-treatment Stage I–IIIa endometrial cancer survivors participated in a single arm 6 month study in which they received a home-based exercise intervention. Cardiorespiratory fitness, anthropometrics, and exercise behavior were measured every two months, and quality of life (QOL) and psychological distress were measured at baseline and 6 months.
Adjusting for potential confounders, at baseline obese survivors had poorer cardiorespiratory fitness (p = .002), higher systolic blood pressure (p = .018), and lower physical functioning (p < .001) and ratings of general health (p = .002), and more pain (p = .037) and somatization (.002). Significant improvements were seen in exercise behavior, resting heart rate, systolic blood pressure, and multiple QOL domains over the course of the intervention. Obese survivors had less improvement in exercise behavior and cardiorespiratory fitness than non-obese survivors, but there were no differences with regard to improvements in QOL and stress.
Home based exercise interventions are beneficial to endometrial cancer survivors, including those whose BMI is in the obese range. While obese survivors have lower levels of physical activity and fitness, they experienced similar activity, fitness, quality of life and mental health benefits. Exercise should be encouraged in endometrial cancer survivors, including those who are obese.
Understanding the mechanism of physical activity behavior change: Challenges and a call for action
2011, Psychology of Sport and Exercise

View all citing articles on Scopus

^☆: Supported in part by NIH Grant R01 CA109919, Karen Basen-Engquist, Ph.D., Principal Investigator, a cancer prevention fellowship from the National Cancer Institute grant R25 CA57730, Robert M. Chamberlain, Ph.D., Principal Investigator, and P30 CA16672, John Mendelsohn, MD, Principal Investigator.

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Design of the steps to health study of physical activity in survivors of endometrial cancer: Testing a social cognitive theory model☆

Abstract

Objectives

Method

Conclusion

Research highlights

Section snippets

Social cognitive theory

Analysis of data

Moving the field forward

American Journal of Obstetrics and Gynecology

Patient Education and Counseling

American Journal of Preventive Medicine

Psychiatry Research

Gynecologic Oncology

Lancet

International Journal of Radiation Oncology, Biology, Physics

The American Journal of Cardiology

Maturitas

Journal of Behavior Therapy and Experimental Psychiatry

Preventive Medicine

Gynecologic Oncology

American Journal of Clinical Nutrition

Preventive Medicine

Postoperative external irradiation and prognostic parameters in stage I endometrial carcinoma: clinical and histopathologic study of 540 patients

Obstetrics & Gynecology

Randomized controlled trial of weight training and lymphedema in breast cancer survivors

Journal of Clinical Oncology

Guidelines for exercise testing and prescription

Assessing quality of life in adult cancer survivors (QLACS)

Quality of Life Research

Self-efficacy: toward a unifying theory of behavioral change

Psychological Review

Social foundations of thought and action: A social-cognitive theory

Self-efficacy: The exercise of control

The moderator–mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations

Journal of Personality and Social Psychology

Motivational interviewing to increase physical activity in long-term cancer survivors: a randomized controlled trial

Nursing Research

Living with the worry of cancer: health perceptions and behaviors of elderly people with self, vicarious, or no history of cancer

Psycho-Oncology

Total, direct, and indirect effects in structural equation models

Structural equations with latent variables

Health-related quality of life occurrence of intestinal side effects after pelvic radiotherapy. Evaluation of long-term effects of diagnosis and treatment

Acta Oncologica

Fatigue in cancer patients compared with fatigue in the general United States population

Cancer

Beyond attentional strategies: a cognitive–perceptual model of somatic interpretation

Psychological Bulletin

Exercise self-efficacy and its correlates among socioeconomically disadvantaged older adults

Health Education and Behavior

A global measure of perceived stress

Journal of Health and Social Behavior

Exercise interventions during cancer treatment: biopsychosocial outcomes

Exercise and Sport Science Reviews

Exercise in cancer survivors: an overview of research

Medicine and Science in Sports and Exercise

Determinants of exercise during colorectal cancer treatment: an application of the theory of planned behavior

Oncology Nursing Forum

Physical exercise and quality of life following cancer diagnosis: a literature review

Annals of Behavioral Medicine

Utility of the theory of planned behavior for understanding exercise during breast cancer treatment

Psycho-Oncology

Social cognitive determinants of hospital-based exercise in cancer patients following high-dose chemotherapy and bone marrow transplantation

International Journal of Behavioral Medicine

Effects of aerobic and resistance exercise in breast cancer patients receiving adjuvant chemotherapy: a multicenter randomized controlled trial

Journal of Clinical Oncology

Physical activity and endometrial cancer risk: a review of the current evidence, biologic mechanisms and the quality of physical activity assessment methods

Cancer Causes and Control

Randomized trial of exercise therapy in women treated for breast cancer

Journal of Clinical Oncology

Brief symptom inventory 18: Administration, scoring, and procedures Manual

Therapy and the 1990s: osteoporosis

British Journal of Rheumatology

Effects of physical activity on the fatigue and psychologic status of cancer patients during chemotherapy

Cancer

Clinical gynecologic oncology

Effects of nurse counseling on walking for exercise in elderly primary care patients

Journals of Gerontology Series A: Biological Sciences and Medical Sciences

Social support and efficacy cognitions in exercise adherence: a latent growth curve analysis