Exploring digital support for physical activity and diet in breast cancer, a mixed methods service evaluation

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Methods: A mixed methods approach was used with a survey available online and in print, and two online focus groups. Participants were recruited through an online patient voices platform, in clinic, and through social media. Descriptive statistical analysis was used for survey responses, with thematic analysis for free text comments. Focus groups were recorded, transcribed, and analysed using thematic analysis. Results: There were 97 survey respondents, mainly white British background, all female, 58% within the 50-59 age bracket, all on treatment or within two years of treatment completion for breast cancer. Whilst 70% wanted information on PA, only 29% of those received it. For diet this was 76% and 26% respectively. Most participants (66%) were very or extremely interested in digital support for PA and diet. Priorities for digital content were strengthening exercise, management of side effects and underlying research evidence. Two focus groups were held, with 13 attendees in total. The main themes from the focus groups were desire for personalised support, perceived importance of PA and diet, facilitators and barriers to access, and describing good digital support which included a hybrid approach with face to face and mechanisms for accountability. Conclusion : Participants were open to support on PA and diet being delivered digitally, but with emphasis on a hybrid model with face-to-face, and with some synchronous elements such as feedback or checking in. Breast Cancer diet physical activity digital Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Breast cancer is the most common cancer in the UK [ 1 ] .Whilst 76% of people with breast cancer survive 10 years or more, those surviving the disease often live with long term consequences of treatment [ 1 ]. To support the mitigation of such side effects and improve long term health, people living with and beyond their breast cancer diagnosis are recommended to follow the World Cancer Research Fund (WCRF) lifestyle guidance, which includes physical activity (PA) and diet recommendations [ 2 ]. The evidence for supporting this guidance is clear. Systematic reviews and meta- analyses found that physical activity for people with breast cancer can have a positive impact on quality of life (QoL), cardiorespiratory fitness and physical function, and weight management [ 3 ]. Adherence to the dietary recommendations can improve health related quality of life (QoL) and is associated with lower scores in nausea and vomiting, loss of appetite, constipation, and diarrhoea [ 4 ]. Following physical activity and diet advice can help to maintain a healthy Body Mass Index (BMI) which has been shown to impact on better physical function and lower fatigue, pain and breathless scores [ 4 ]. As well as symptom management, diet as part of weight management and influencing body composition may improve long term outcomes. A recent systematic review and meta-analysis found strong probable evidence that higher postdiagnosis body fatness in women diagnosed with breast cancer increases the risk of breast cancer specific mortality and development of a second primary breast cancer, as well as a higher risk of all-cause mortality [ 5 ]. In addition, data from observational studies suggest that those who are most physically active following treatment, experience a potential risk reduction of recurrence of 38% compared to those most inactive [ 6 ] Despite this evidence base, patient surveys continue to show that people with cancer aren’t routinely receiving the support they need [ 7 ]. Whilst many Healthcare professionals (HCPs) recognise the importance of physical activity, diet, and weight management, they often do not refer to services that can provide health behaviour change support due to lack of resources, time and perceived resistance of patients to make health behaviour change [ 8 ] Digital health interventions may be an approach to provide trusted information for PA and dietary changes. NICE (2020) describes digital health interventions as interventions which “are delivered through: hardware and electronic devices, such as smartwatches; software, such as computer programs or apps; and websites” [ 9 ]. Such technologies can deliver PA and diet support interventions, independently from healthcare professionals known as asynchronous interventions, or can be used synchronously alongside health care professional’s support. [ 9 ], [ 10 ] Digital technologies aimed at behaviour change in people with cancer may improve PA and Body Mass Index (BMI), with mixed evidence for diet [ 11 ]. The evidence for digital health interventions indicates small to moderate improvements in behaviour change for PA and diet with further research needed to determine which methods of digital delivery are the most effective [ 10 ]. Programmes which address both exercise and diet as part of lifestyle behaviour change are recommended [ 12 ]. However in practice, this is not routinely delivered, and if it is delivered often not with both components in place. At the tertiary cancer centre where this service evaluation was completed, there is access to physiotherapy and dietitians, and a growing resource of digital support, yet there hadn’t been an evaluation of whether this was being routinely offered and accessed. This is particularly relevant in the post-covid period, where interest in and usage of digital health interventions significantly increased. The purpose of this service evaluation was therefore to seek opinion from patients being treated for breast cancer on the following: Their experience of current PA and diet information and support after diagnosis The barriers and facilitators to changing diet and PA The potential role of digital health interventions in providing further support What “good” digital support might look like to inform a future feasibility study. Methods This service evaluation was carried out at a Tertiary Cancer Centre. Ethical approval was provided by the Royal Marsden Hospital Service Evaluation Committee (SE1124). The survey was conducted in accordance with the principles outlines in the Declaration of Helsinki. A prospective survey was designed, adapted from the Health and Lifestyle After Cancer Survey, that was used to gather data from 5835 people living with and beyond breast, prostate and colorectal cancer[13]. This was approved by patient and public representatives as part of the service evaluation approval process. This survey was available in paper versions in clinic, and on the Patient Public Involvement Engagement (PPIE) digital platform Cancer Patients’ Voices (Cancer Patients' Voice (cancerbrc.org)). Whilst most respondents were from the treating centre, the nature of the platform online meant that people outside of the centre could respond. A copy of the survey is in appendix 1. The survey was initially launched in October 2021 and closed in February 2022. It was shared on Social Media and patient information sheets were available in clinic with paper surveys. Participants were included if they had been treated for breast cancer in the last two years, had sufficient mental capacity to take part and sufficient English to answer the survey or take part in the focus groups. Participants who completed the survey, shared their email address if they wished to take part in focus groups, and these were stored on a secure NHS server. Two focus groups were then carried out via video platform Microsoft Teams to further explore the barriers, facilitators and type of digital support needed. The focus groups were led by physiotherapist (SCD), co-facilitated by lead researcher for therapies (CS) and guided by a semi-structured topic guide. The topic guide summary is shown in Figure 1. It included experience of access to PA, and diet, the barriers and facilitators to access, and what would be helpful or not helpful with digital support. Written consent was gained for recording purposes. Analysis The closed questions and multiple-choice questions on survey were analysed with descriptive statistics using the survey analysis within Cancer Patients’ Voices. Descriptive statistics were used to summarize characteristics of the study population, and the percentage responses to the survey questions. The focus groups were transcribed and thematic analysis undertaken using the six steps of reflexive thematic analysis outlined by Braun and Clarke [14]. The two focus groups transcripts were coded by lead researcher, with themes verified by co-facilitator. Comments and free text from the survey were coded by lead researcher, verified by co-facilitator and analysed alongside focus groups themes. As part of the developing and reviewing the themes stage, focus group participants were sent the themes for comment and approval. Results Ninety-seven questionnaires were completed, 88 online, and 9 via paper survey. The method of recruitment meant that it wasn’t possible to determine how many people saw the initial survey invite. The demographics of participants is shown is Table 1 . Table 1 Demographics N = 97 Percentage Age 30–39 5 5 40–49 18 19 50–59 56 58 60–69 11 11 70–79 7 7 Ethnicity White 88 91 Black African 1 1 Asian/ Asian British 2 2 Mixed 1 1 Arab 1 1 Missing 4 4 Time since diagnosis Still on treatment 54 56 Less than three months 6 6 Between three and 12 months 15 15 Over 12 months 22 23 Treatment type Chemotherapy 60 62 Radiotherapy 61 63 Surgery 85 88 Hormone Therapy 55 57 Immunotherapy 11 11 Other 11 11 Disability Yes 13 13 No 80 82 Missing 4 4 Physical activity and Diet information and support at the time of diagnosis. Of the 97 respondents, 68 participants (70%) reported they would have liked information on PA at diagnosis, with 22 (23%) not wanting information and seven (7%) who could not recall. Of those 68 who would have liked information, only 20 (29%,) reported receiving information on physical activity, 43 (63%) did not receive information and five (5%) didn’t know or couldn’t recall. Regarding diet, 74 participants (76%) wanted information on diet, 22 (23%) did not want information, and one didn’t know or couldn’t recall. Of those 74, only 19 (26%) received information, 50 (68%) didn’t and 5 (5%) could not remember. Timing of information Shown in Fig. 2 , pre-treatment was the most popular point for information. Participants could give multiple answers for when they wanted to receive this information. Modes of delivery for information and support in physical activity and diet Participants were asked about their level of interest in different modes of non-digital and digital information delivery. Those expressing no interest (1), some interest (2–5), and very or extremely interested (4–5) in different types of digital and non-digital modes of delivery are shown in Figs. 3 and 4 . Overall Interest in digital support. 64 (66%) were very or extremely interested in digital support. Participants were given a tick list of types of content, and were able to tick more than one option. Strength, research evidence and side effects were the most popular content items (see Fig. 5 ) Free text comments Free text comments were analysed and presented with the thematic analysis from the focus groups, see Table 2 . Focus groups There were 13 people who took part in focus groups. The first group had four attendees and the second group had nine. The main themes were personalised information, perceived importance, facilitators and barriers, and what good digital support might look like. Each theme had subthemes, all shown in Table 2 . Table 2 Themes and subthemes of Focus Groups and Open Comments Theme 1 Physical Activity and Diet support must be personalised • Timing of information “I just feel that that lack of education to start with was a major for me” (P6) • Different needs for different people at different stages. “During chemotherapy, all I could do really was long walks. Well, not even long walks, but walking, that was the only real activity that I did and again coming towards the end of chemotherapy. And then when I had surgery and then radiotherapy, I remember thinking as soon as I'm done with this sort of active treatment, I really want to up my physical activity” (P3) • Side effects- and these being individual “I love vegetables, but I what I don't have at the moment. It's the strength to stand peeling out... I have a lot of problems with my spine and energy and just holding my body up right”. (P11) • Breast cancer specific “… I waited weeks and weeks to speak to a dietitian and I had loads of questions about oestrogen. How can I reduce it through? Like what I’m eating? Should I stop dairy? What about soya? You know all these questions came up and then when I got to speak to the dietitian it was again a blanket of I'll just have a healthy, balanced diet. Just everything in moderation… I was slightly disappointed with the dietitians advice, because again, it wasn't tailored” (P4) “It would help if there were diet tips for people taking tamoxifen” (open comments) Theme 2 : Perceived importance of diet and physical activity • Pre-diagnosis and Post-diagnosis importance “But I felt very fit and active and do quite a lot of exercises before diagnosis” (P7) “So I didn't have any exercise or nutrition support and till a few months after surgery and I think for me it would have been helpful from… in an ideal world and without limits on resources, of course it would be really helpful from the moment of diagnosis” (P12) “I was really conscious about being physically active and when I got my diagnosis it was something that was really at the front of my mind because I was thinking I have to go through six months of chemotherapy and I know that people would be telling me it's such a gruelling thing to go through. I had to have my mind clear and the first one of the first things was how do I keep myself active and physical” (P3) “I was doing regular exercise and eating healthily prior to my diagnosis, and struggled to find information/support about getting back to my previous level of physical activity, even when I asked about this specifically. Was instead given leaflets covering diet and exercise (walking) at a very basic level, which were not helpful to me” (Open comments) Theme 3: Facilitators to physical activity and diet on treatment • Individualised support “For me personally, it would be nice if somebody said right listen, There's a menu for the week. Go out buy salmon and broccoli go and buy this. Have this Monday Tuesday, Wednesday, Thursday, Friday, Saturday.” (P4) “Would welcome something which can be tailored to the individual. I was doing regular exercise and eating healthily prior to my diagnosis, and struggled to find information/support about getting back to my previous level of physical activity, even when I asked about this specifically. Was instead given leaflets covering diet and exercise (walking) at a very basic level, which were not helpful to me.” (Open comments) • Check in opportunities Encouragement and motivational support would be helpful - ongoing i.e. some way of checking in to help sustain progress as it can be easy to begin an activity but sustaining without support can be difficult (open Comments) • Feedback- e.g., diary keeping “I would count the number of steps I was doing every day to try and get my steps up. Some of these little reminders of little handy tips could easily be digitized” (P1) • Social opportunity “…the social aspect of going to these groups and exercising together in this to swap support group exercise session really really motivates me” (P10) • Support at different time points in treatment “Well, how do I look after myself going forward post treatment and what do I need to do? And actually now I've got a bit more energy and bit more time” (P7) • “Fear” “the motivator for eating well and exercising well is actually the sheer terror of it coming back” (P5) • Joined up care “I'm in my second diagnosis… I'm under dietitian gastrology … physios all joining up for me because it wasn't there in the past and that's being more important because you know, hearing all you have a ladies that was my experience.” (P4) Theme 4: Barriers to physical activity and diet on treatment • System level: Chance of access/ availability of services “ I found the thing that I find irritating is that I found all these things out. Incidentally, nobody kind of told me about them. It just happened that I saw the poster just happened that I went to that and then somebody told me about this other group and they're all brilliant.” (P 10 referring to 5k your way and access to exercise support) “ … what's my next appointment and what do I need to do. So I think that reality check, and I certainly wasn't offered a conversation with the dietitian. It was there's a leaflet in your pack.” (P8) P9 “No health professional (doctor or nurse) has ever talked to me about the importance of diet and exercise in the 4 years I have been receiving treatment” (Open Comments) • Services not individualised. “But what I've found is that they seem to blanket everybody with the same thing”. (P4) • Individual level barriers- knowledge, motivation . “I find I've really got to motivate myself to go into the kitchen and cook something” (p4) “… then I've been quite committed to being active… but I just feel that that lack of education to start with was a major for me.” (P5) Theme 5: What would good digital support look like • Personalised “Need to make quality information personal to some degree otherwise it's just another website with a lot of information and it's up to the observer to determine what is right for them - one thing we learn through cancer diagnosis is everyone is different.” (Open comments) • Must be hybrid “I would be happy with some digital, but I do think it's that mix of personal and digital.” (P8) “It needs to have the human touch so that you feel connected - more than just a patient / figure” (Open comments) • Visually appealing Make it lifestyle led/modern. Some cancer info quite old school. We’re still a consumer! (open comments) • Videos rather than just written “I could know that I that that video is there and so if I need to refer back to that video and maybe watch it 2/3 times for it for the information to go in because the whole thing with cancer is your information overload” (P3) • Accountability, check in and feedback needed (synchronous support) “So having sort of every like so six weeks or phone call with the dietitian, who will give you, you know, instructions in between or something so you know there's always gonna be someone there” (P2). • Opportunity for question and answer with HCP “Say that I could come in if there was, for example, maybe a weekly Q&A. So if you had a Q&A on your session on your website, your brochure is so simple that I had been” (P4) • Longer term advice and support- for example the booklets only cover up to 12 weeks. “[Leaflets] seem to stop at 12 weeks .... Don't worry about it now you should be fine, but a lot of us are saying, well, we still you know I feel like I'm probably at maybe 70% of where I'd like to be” (P4) • Group support but with individualisation “It makes it more social and enjoyable as well… I don't know some dance class or something, but cater to the level of each of our needs .” (P4) Discussion This mixed methods service evaluation aimed to explore the views of people with breast cancer on the support they received for physical activity and dietary advice, the perceived barriers and facilitators to this, and their views on the role digital health interventions may play in supporting people to make positive behaviour changes. The survey findings show that there is a strong interest in digital health interventions, but qualitative findings emphasised that digital support must be delivered in a tailored and personalised way in combination with face-to-face support. The findings will be discussed in relation to the original aims outlined. Experience of current PA and diet information and support after diagnosis Whilst most participants wanted information on physical activity and diet at the point of diagnosis, this need was often unmet with less than a third receiving such information. And for those who did manage to access support, there were criticisms that the access was due to chance rather than direction from the treatment team, and disappointment for some in not having more tailored support. The lack of information, support and signposting given by HCPs has been recognised as a barrier to implementing exercise in the oncology setting, and the element of chance in accessing support has been previously highlighted in an experience-based co-design project at the same centre [ 15 ]. The perceived lack of information from health care professionals is reflected in a survey of HCPs in the USA; whilst teams recognise the importance of physical activity, diet, and weight management they often do not refer to services who can provide lifestyle change support[ 8 ]. Participants in this survey wanted information on physical activity and diet at diagnosis before treatment starts. This is consistent with the current drive towards “prehabilitation” whereby interventions aimed at preparing and optimising people for treatment through diet, exercise and psychological support are embedded at the start of the pathway [ 16 ]. The breast cancer pathway can have many treatment interventions, such as surgery, chemotherapy, hormone therapy and radiotherapy. The focus group participants explained how support was needed in different ways at different parts of the pathway, as each intervention has its own physiological impact and side effects, so adaptable and personalised support is needed throughout. This is concurrent with the “multi-phasic approach” to prehabilitation, described by Santa-Mina and colleagues, where the potential impacts of each treatment are considered and the patient is optimised ahead of this, whilst also rehabilitating from side effects in previous treatments [ 17 ]. Barriers and Facilitators Barriers and facilitators were explored in the focus groups, and sub-themed into “system level” and “individual level” barriers. At an individual level, barriers such as motivation, time and impact of physical side effects such as fatigue are consistent with other research findings [ 18 ], [ 19 ]. The system level barriers were a lack of access and education (translating into individual barrier of knowledge). There were observations that the system was set up to address specific consequences of treatment, such as post-operative shoulder issues, but not wider health and wellbeing needs or longer-term health. The facilitators identified in this study (Table 2 ) are consistent with some of the findings from an acceptability study with intervention of diet and weight loss exercise, which found that the facilitators to the programme were education, routine, motivation, goal-setting, meal-provisioning [ 20 ]. Although not the most popular mode of intervention in the survey, almost 70% showed some interest in remotely delivered groups or multiple groups. Beckenstein et al (2021) found that social support was an important element to support diet and weight loss[ 20 ]. In the survey, 40% of the respondents ticked option of community support as content for digital support, and open comments also reflected an interest with suggestions of online groups for health and wellbeing, buddying and walking groups as potential facilitators to physical activity. The potential role of digital health interventions in providing further support In this survey, 98% had some interest in digital support, with 66% being very or extremely interested. Despite this interest, the most popular result for mode of delivery in the survey was a one-off face to face consultation with a healthcare professional. This was confirmed in the open comments and focus groups where consensus was that a hybrid model would be more helpful than a standalone digital intervention. A systematic review in 2020 highlighted that the best approach, whether synchoronous, asynchronous or a combination of both, is unclear [ 10 ]. The participants in this evaluation valued feedback, checking in, reporting behaviours such as step counts and a hybrid approach with HCPs. This would be described as a synchronous approach, and these techniques are in line with the Behaviour Change Ontology where behaviour change techniques such as goal setting, feedback, and nudges can support behaviour change[ 21 ]. Whilst the participants in this project welcomed the idea of videos over paper leaflets, they disliked the asynchronous approach of just being given videos in absence of any feedback or connection with a HCP. What “good” digital support might look like Participants in the focus groups, and open comments in survey, agreed that any intervention aimed at PA or diet needs to feel personalised and individualised. This is consistent with research recommendations in exercise oncology, where exercise specifically (as a planned, structured and personalised intervention) needs to be prescribed in order to accommodate the side effects, individual needs and for overall safety and benefit [ 22 ]. This was also the case for those who experienced oestrogen responsive cancers, in both the focus groups and in open comments, this group wanted specific advice regarding oestrogen and diet. In terms of content for the digital intervention the highest scoring elements were muscle strengthening, research evidence and side effects. This was reiterated in the focus groups, with patients wanting longer term support beyond 12 weeks post-surgery and into strength training, for approaches to be tailored to their stage of treatment and side effects. They were keen for the research evidence to underpin digital content, particularly about diet. When asked what type of intervention would be most helpful, internet information, an application (app) and multiple video consultations were most popular. Interestingly DVD/video did not score highly, but the focus groups expressed preferences for video content over written information. The inclusion of “DVD” with video may have been misleading in the survey. The preferences for videos came from being able to watch again (participants used examples of social media short videos). Group interventions were discussed, as the focus group members reported being mindful of what could realistically be delivered on a one-to-one basis and how a remotely delivered drop-in session or telephone follow up with physiotherapist or dietitian were suggested. It was emphasised however that it needed to still feel individualised. This has been achieved in other remote online groups [ 23 ]. Whilst applications (apps) were one of the interventions identified as a preferred mode of delivery on the survey, the focus groups highlighted that the issues with apps were the attractiveness and engagement of them. They did not feature highly in the discussion. Limitations: Although the survey was made available in paper form, the vast majority used the online method. Despite efforts to have the paper version available in a variety of clinics, few were returned. There is likely to be some selection bias as potentially those most interested in PA and diet, or digital support would have responded. Those replying and attending focus groups, by the very nature of the questions, are more likely to be engaged in digital support and interested in PA and diet. The participants were largely from white ethnic background. Attempts were made to target different ethnicities and age groups through specific messaging on social media and to clinicians, and initially emails for participants in focus group was tailored to the 10% from non-white backgrounds, and a range of age groups. This had to be extended due to low number of replies. This will be addressed in future feasibility work with a more diverse patient and public steering group. Future Research Further research is needed to co-design hybrid digital approaches for diet and physical activity interventions for people with breast cancer, with a focus implementation and scalable approaches reducing burden on NHS staff whilst enabling this to be embedded in standard care. Conclusion Participants in this service evaluation open to digital support for physical activity and diet if combined with some interaction with healthcare professionals. Digital interventions for physical activity and diet need to include research evidence, support to adapt to side effects and specific guidance on strengthening. Future research is needed to determine the optimal mode of delivery. Declarations Funding Siobhan Cowan-Dickie received funding from Royal Marsden Cancer Charity to complete a pre-doctoral fellowship and undertook this service evaluation under that fellowship. Competing Interests The authors have no relevant financial or non-financial interests to disclose. Author contributions All authors contributed to the study conception and design. Study proposal, data collection and analysis were performed by, Siobhan Cowan-Dickie and Clare Shaw. The first draft of the manuscript was written by Siobhan Cowan-Dickie and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Ethics approval Ethical approval was provided by the Royal Marsden Hospital Service Evaluation Committee (SE1124). The survey was conducted in accordance with the principles outlines in the Declaration of Helsinki Consent to participate Informed consent was gained from all participants as outlined in the manuscript. Consent to publish Informed consent was gained for publication of anonymised data, including quotes taken from semi-structured interviews. References Cancer Research UK, “Cancer Statistics for the UK.” World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR), Diet, Nutrition, Physical Activity and Cancer: a Global Perspective . 2018. A. Joaquim et al. , “Impact of physical exercise programs in breast cancer survivors on health-related quality of life, physical fitness, and body composition: Evidence from systematic reviews and meta-analyses,” Dec. 09, 2022, Frontiers Media S.A. doi: 10.3389/fonc.2022.955505. Y. Y. Lei et al. , “Adherence to the world cancer research fund/ American institute for cancer research guideline is associated with better health-related quality of life among Chinese patients with breast cancer,” JNCCN Journal of the National Comprehensive Cancer Network , vol. 16, no. 3, pp. 275–285, Mar. 2018, doi: 10.6004/jnccn.2017.7202. D. S. M. Chan et al. , “Postdiagnosis body fatness, weight change and breast cancer prognosis: Global Cancer Update Program (CUP global) systematic literature review and meta-analysis,” Int J Cancer , vol. 152, no. 4, pp. 572–599, Feb. 2023, doi: 10.1002/ijc.34322. C. M. Friedenreich, H. K. Neilson, M. S. Farris, and K. S. Courneya, “Physical Activity and Cancer Outcomes: A Precision Medicine Approach,” Clinical Cancer Research , vol. 22, no. 19, pp. 4766 LP – 4775, Oct. 2016, doi: 10.1158/1078-0432.CCR-16-0067. J. A. Ligibel et al. , “Attention to diet, exercise, and weight in oncology care: Results of an American Society of Clinical Oncology national patient survey,” Cancer , Apr. 2022, doi: 10.1002/cncr.34231. J. A. Ligibel et al. , “Oncologists’ Attitudes and Practice of Addressing Diet, Physical Activity, and Weight Management With Patients With Cancer: Findings of an ASCO Survey of the Oncology Workforce,” J Oncol Pract , vol. 15, no. 6, pp. e520–e528, 2019, doi: 10.1200/JOP.19.00124. NICE, “Behaviour change : digital and mobile health interventions,” no. October, 2020. K. Furness, M. N. Sarkies, C. E. Huggins, D. Croagh, and T. P. Haines, “Impact of the Method of Delivering Electronic Health Behavior Change Interventions in Survivors of Cancer on Engagement, Health Behaviors, and Health Outcomes: Systematic Review and Meta-Analysis,” J Med Internet Res , vol. 22, no. 6, p. e16112, Jun. 2020, doi: 10.2196/16112. A. L. Roberts, A. Fisher, L. Smith, M. Heinrich, and H. W. W. Potts, “Digital health behaviour change interventions targeting physical activity and diet in cancer survivors: a systematic review and meta-analysis,” Dec. 01, 2017, Springer New York LLC . doi: 10.1007/s11764-017-0632-1. T. Jia, Y. Liu, Y. Fan, L. Wang, and E. Jiang, “Association of Healthy Diet and Physical Activity With Breast Cancer: Lifestyle Interventions and Oncology Education,” Mar. 23, 2022, Frontiers Media S.A. doi: 10.3389/fpubh.2022.797794. F. Kennedy et al. , “Fatigue, quality of life and associations with adherence to the World Cancer Research Fund guidelines for health behaviours in 5835 adults living with and beyond breast, prostate and colorectal cancer in England: A cross-sectional study,” Cancer Med , vol. 12, no. 11, pp. 12705–12716, Jun. 2023, doi: 10.1002/cam4.5899. V. Braun and V. Clarke, “Using thematic analysis in psychology,” Qual Res Psychol , vol. 3, no. 2, pp. 77–101, 2006, doi: 10.1191/1478088706qp063oa. S. Cowan-Dickie et al. , “‘Not another leaflet please’: Improving the delivery of physical activity information and interventions for people with breast cancer,” The Journal of Health Design; Vol 5, No 2 (2020): Treating people, not patients , 2020, [Online]. Available: https://www.journalofhealthdesign.com/JHD/article/view?path= Macmillan Cancer Support, “Principles and guidance for prehabilitation within the management and support of people with cancer,” 2019. D. Santa Mina et al. , “Multiphasic Prehabilitation Across the Cancer Continuum: A Narrative Review and Conceptual Framework,” Jan. 11, 2021, Frontiers Media S.A. doi: 10.3389/fonc.2020.598425. J. A. Ligibel, K. Basen-Engquist, and J. W. Bea, “Weight Management and Physical Activity for Breast Cancer Prevention and Control,” American Society of Clinical Oncology Educational Book , no. 39, pp. e22–e33, 2019, doi: 10.1200/edbk_237423. D. Cho and C. L. Park, “Barriers to physical activity and healthy diet among breast cancer survivors: A multilevel perspective,” Eur J Cancer Care (Engl) , vol. 27, no. 1, pp. 1–8, 2018, doi: 10.1111/ecc.12772. H. Beckenstein, M. Slim, H. Kim, H. Plourde, R. Kilgour, and T. R. Cohen, “Acceptability of a structured diet and exercise weight loss intervention in breast cancer survivors living with an overweight condition or obesity: A qualitative analysis,” Cancer Rep , vol. 4, no. 3, pp. 1–8, 2021, doi: 10.1002/cnr2.1337. M. M. Marques et al. , “The Behaviour Change Technique Ontology: Transforming the Behaviour Change Technique Taxonomy v1,” Wellcome Open Res , vol. 8, 2023, doi: 10.12688/wellcomeopenres.19363.1. D. S. Mina et al. , “Connecting people with cancer to physical activity and exercise programs: A pathway to create accessibility and engagement,” Current Oncology , vol. 25, no. 2, pp. 149–162, Apr. 2018, doi: 10.3747/co.25.3977. V. Hailey, A. Rojas-Garcia, and A. P. Kassianos, “A systematic review of behaviour change techniques used in interventions to increase physical activity among breast cancer survivors,” Mar. 01, 2022, Springer Japan . doi: 10.1007/s12282-021-01323-z. Additional Declarations No competing interests reported. Supplementary Files Appendix1.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5306355","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":370348351,"identity":"3840edf0-21db-4c2a-b5da-60c68d5c8211","order_by":0,"name":"Siobhan Cowan-Dickie","email":"","orcid":"","institution":"Royal Marsden NHS Foundation Trust","correspondingAuthor":false,"prefix":"","firstName":"Siobhan","middleName":"","lastName":"Cowan-Dickie","suffix":""},{"id":370348352,"identity":"ffc2d033-1b5c-4853-bc12-b7ebe150c6ac","order_by":1,"name":"Abi Fisher","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDElEQVRIie2RvWrDMBRGrxFYy4WsDm7TV5AJuA017bOIQrt27BgQJIshq6Ev0QfooKChW7Ia3KEQMB06JJuhHnqldOiieO2gMwj0c7jfhwACgf9IEs0BxBVwBTFtCwB+vBADSgJonHIPwAaV3xW1U8ywMnpW6rN7JIXz9uPwupUrBdG+AzP1DnlfL2alDcbwMqvaRlYG2LgEk3uD1XIhkJRbhnGKupEvFCylhIXPuCAl690U3qa93liFfZ9SRC3VDp0CeQpaWyW2U7zBMurCzkSC1CUfl/puWpnItnvw1p80y93hqy8mOHprk07fnK+WytTd03U29/aH2H4N/jlwn+t/T7D9yetAIBAI/ABAyE27qjkfrgAAAABJRU5ErkJggg==","orcid":"","institution":"University College London","correspondingAuthor":true,"prefix":"","firstName":"Abi","middleName":"","lastName":"Fisher","suffix":""},{"id":370348354,"identity":"5b7fe06c-fb5f-48c5-be74-192f2fb4f387","order_by":2,"name":"Clare Shaw","email":"","orcid":"","institution":"Royal Marsden NHS Foundation Trust","correspondingAuthor":false,"prefix":"","firstName":"Clare","middleName":"","lastName":"Shaw","suffix":""}],"badges":[],"createdAt":"2024-10-21 17:38:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5306355/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5306355/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":69079976,"identity":"ce5fa09a-d711-42eb-8f59-bed6c5385574","added_by":"auto","created_at":"2024-11-15 11:45:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":86916,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTopic Guide\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5306355/v1/338de0377ea447cba89f3544.png"},{"id":69079980,"identity":"37fbc3d2-e93d-47a0-acab-3873a7edd347","added_by":"auto","created_at":"2024-11-15 11:45:54","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":20620,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe best time (s) to offer information about diet and physical activity*\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e* Participants were allowed to choose multiple responses, so the percentage adds up to more than 100% overall.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5306355/v1/f71a9cce0a4633c2fa2bf06e.png"},{"id":69079979,"identity":"a6fa4118-7644-4497-b3ff-7a7304610b90","added_by":"auto","created_at":"2024-11-15 11:45:54","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":34960,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eInterest in non-digital modes of information delivery about diet and physical activity\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5306355/v1/52072d018279394dd9833e6e.png"},{"id":69079981,"identity":"3aa29a86-0263-4bc0-9e63-750b80185b45","added_by":"auto","created_at":"2024-11-15 11:45:55","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":79610,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eInterest in digital/telehealth modes of information delivery about diet and physical activity.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5306355/v1/d5acfbe849defddc66107ef1.png"},{"id":69080743,"identity":"1ec5c252-0901-4ede-b188-d12e94152dc0","added_by":"auto","created_at":"2024-11-15 11:53:53","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":23984,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePreferences for digital content\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-5306355/v1/e49f5cc7f9f640e0d1fd1f6e.png"},{"id":82404583,"identity":"70822ca3-4861-414f-bdb4-d86d7dae9cd8","added_by":"auto","created_at":"2025-05-10 02:16:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1179331,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5306355/v1/49599b33-a4df-4fb2-bb94-9647c4ad343d.pdf"},{"id":69079977,"identity":"260afd37-58ed-4d23-a37d-513afff72ec5","added_by":"auto","created_at":"2024-11-15 11:45:54","extension":"docx","order_by":9,"title":"","display":"","copyAsset":false,"role":"supplement","size":28473,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-5306355/v1/e1ebb675c1cebd2fad661fb2.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring digital support for physical activity and diet in breast cancer, a mixed methods service evaluation","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBreast cancer is the most common cancer in the UK [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] .Whilst 76% of people with breast cancer survive 10 years or more, those surviving the disease often live with long term consequences of treatment [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. To support the mitigation of such side effects and improve long term health, people living with and beyond their breast cancer diagnosis are recommended to follow the World Cancer Research Fund (WCRF) lifestyle guidance, which includes physical activity (PA) and diet recommendations [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe evidence for supporting this guidance is clear. Systematic reviews and meta- analyses found that physical activity for people with breast cancer can have a positive impact on quality of life (QoL), cardiorespiratory fitness and physical function, and weight management [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Adherence to the dietary recommendations can improve health related quality of life (QoL) and is associated with lower scores in nausea and vomiting, loss of appetite, constipation, and diarrhoea [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Following physical activity and diet advice can help to maintain a healthy Body Mass Index (BMI) which has been shown to impact on better physical function and lower fatigue, pain and breathless scores [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. As well as symptom management, diet as part of weight management and influencing body composition may improve long term outcomes. A recent systematic review and meta-analysis found strong probable evidence that higher postdiagnosis body fatness in women diagnosed with breast cancer increases the risk of breast cancer specific mortality and development of a second primary breast cancer, as well as a higher risk of all-cause mortality [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In addition, data from observational studies suggest that those who are most physically active following treatment, experience a potential risk reduction of recurrence of 38% compared to those most inactive [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eDespite this evidence base, patient surveys continue to show that people with cancer aren\u0026rsquo;t routinely receiving the support they need [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Whilst many Healthcare professionals (HCPs) recognise the importance of physical activity, diet, and weight management, they often do not refer to services that can provide health behaviour change support due to lack of resources, time and perceived resistance of patients to make health behaviour change [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eDigital health interventions may be an approach to provide trusted information for PA and dietary changes. NICE (2020) describes digital health interventions as interventions which \u0026ldquo;are delivered through: hardware and electronic devices, such as smartwatches; software, such as computer programs or apps; and websites\u0026rdquo; [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Such technologies can deliver PA and diet support interventions, independently from healthcare professionals known as asynchronous interventions, or can be used synchronously alongside health care professional\u0026rsquo;s support. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eDigital technologies aimed at behaviour change in people with cancer may improve PA and Body Mass Index (BMI), with mixed evidence for diet [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The evidence for digital health interventions indicates small to moderate improvements in behaviour change for PA and diet with further research needed to determine which methods of digital delivery are the most effective [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eProgrammes which address both exercise and diet as part of lifestyle behaviour change are recommended [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However in practice, this is not routinely delivered, and if it is delivered often not with both components in place. At the tertiary cancer centre where this service evaluation was completed, there is access to physiotherapy and dietitians, and a growing resource of digital support, yet there hadn\u0026rsquo;t been an evaluation of whether this was being routinely offered and accessed. This is particularly relevant in the post-covid period, where interest in and usage of digital health interventions significantly increased. The purpose of this service evaluation was therefore to seek opinion from patients being treated for breast cancer on the following:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTheir experience of current PA and diet information and support after diagnosis\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe barriers and facilitators to changing diet and PA\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe potential role of digital health interventions in providing further support\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat \u0026ldquo;good\u0026rdquo; digital support might look like to inform a future feasibility study.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis service evaluation was carried out at a Tertiary Cancer Centre. Ethical approval was provided by the Royal Marsden Hospital Service Evaluation Committee (SE1124). The survey was conducted in accordance with the principles outlines in the Declaration of Helsinki. A prospective survey was designed, adapted from the Health and Lifestyle After Cancer Survey, that was used to gather data from 5835 people living with and beyond breast, prostate and colorectal cancer[13]. This was approved by patient and public representatives as part of the service evaluation approval process. This survey was available in paper versions in clinic, and on the Patient Public Involvement Engagement (PPIE) digital platform Cancer Patients\u0026rsquo; Voices (Cancer Patients\u0026apos; Voice (cancerbrc.org)). Whilst most respondents were from the treating centre, the nature of the platform online meant that people outside of the centre could respond. A copy of the survey is in appendix 1.\u003c/p\u003e\n\u003cp\u003eThe survey was initially launched in October 2021 and closed in February 2022. It was shared on Social Media and patient information sheets were available in clinic with paper surveys. Participants were included if they had been treated for breast cancer in the last two years, had sufficient mental capacity to take part and sufficient English to answer the survey or take part in the focus groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants who completed the survey, shared their email address if they wished to take part in focus groups, and these were stored on a secure NHS server.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTwo focus groups were then carried out via video platform Microsoft Teams to further explore the barriers, facilitators and type of digital support needed. The focus groups were led by physiotherapist (SCD), co-facilitated by lead researcher for therapies (CS) and guided by a semi-structured topic guide. \u0026nbsp;The topic guide summary is shown in Figure 1. It included experience of access to PA, and diet, the barriers and facilitators to access, and what would be helpful or not helpful with digital support. Written consent was gained for recording purposes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe closed questions and multiple-choice questions on survey were analysed with descriptive statistics using the survey analysis within Cancer Patients\u0026rsquo; Voices. Descriptive statistics were used to summarize characteristics of the study population, and the percentage responses to the survey questions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe focus groups were transcribed and thematic analysis undertaken using the six steps of reflexive thematic analysis outlined by Braun and Clarke [14].\u0026nbsp;The two focus groups transcripts were coded by lead researcher, with themes verified by co-facilitator. Comments and free text from the survey were coded by lead researcher, verified by co-facilitator and analysed alongside focus groups themes. As part of the developing and reviewing the themes stage, focus group participants were sent the themes for comment and approval.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eNinety-seven questionnaires were completed, 88 online, and 9 via paper survey. The method of recruitment meant that it wasn\u0026rsquo;t possible to determine how many people saw the initial survey invite.\u003c/p\u003e\n\u003cp\u003eThe demographics of participants is shown is Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDemographics\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;97\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u0026ndash;39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40\u0026ndash;49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50\u0026ndash;59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60\u0026ndash;69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e70\u0026ndash;79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWhite\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBlack African\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsian/ Asian British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eArab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime since diagnosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStill on treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLess than three months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBetween three and 12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOver 12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChemotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRadiotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSurgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHormone Therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eImmunotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisability\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003ePhysical activity and Diet information and support at the time of diagnosis.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 97 respondents, 68 participants (70%) reported they would have liked information on PA at diagnosis, with 22 (23%) not wanting information and seven (7%) who could not recall. Of those 68 who would have liked information, only 20 (29%,) reported receiving information on physical activity, 43 (63%) did not receive information and five (5%) didn\u0026rsquo;t know or couldn\u0026rsquo;t recall.\u003c/p\u003e\n\u003cp\u003eRegarding diet, 74 participants (76%) wanted information on diet, 22 (23%) did not want information, and one didn\u0026rsquo;t know or couldn\u0026rsquo;t recall. Of those 74, only 19 (26%) received information, 50 (68%) didn\u0026rsquo;t and 5 (5%) could not remember.\u003c/p\u003e\n\u003ch3\u003eTiming of information\u003c/h3\u003e\n\u003cp\u003eShown in Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e, pre-treatment was the most popular point for information. Participants could give multiple answers for when they wanted to receive this information.\u003c/p\u003e\n\u003ch3\u003eModes of delivery for information and support in physical activity and diet\u003c/h3\u003e\n\u003cp\u003eParticipants were asked about their level of interest in different modes of non-digital and digital information delivery. Those expressing no interest (1), some interest (2\u0026ndash;5), and very or extremely interested (4\u0026ndash;5) in different types of digital and non-digital modes of delivery are shown in Figs. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOverall Interest in digital support.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e64 (66%) were very or extremely interested in digital support. Participants were given a tick list of types of content, and were able to tick more than one option. Strength, research evidence and side effects were the most popular content items (see Fig. \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\n\u003ch3\u003eFree text comments\u003c/h3\u003e\n\u003cp\u003eFree text comments were analysed and presented with the thematic analysis from the focus groups, see Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eFocus groups\u003c/h2\u003e\n \u003cp\u003eThere were 13 people who took part in focus groups. The first group had four attendees and the second group had nine. The main themes were personalised information, perceived importance, facilitators and barriers, and what good digital support might look like. Each theme had subthemes, all shown in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eThemes and subthemes of Focus Groups and Open Comments\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eTheme 1\u003c/span\u003e Physical Activity and Diet support must be personalised\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eTiming of information\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I just feel that that lack of education to start with was a major for me\u0026rdquo; (P6)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eDifferent needs for different people at different stages.\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;During chemotherapy, all I could do really was long walks. Well, not even long walks, but walking, that was the only real activity that I did and again coming towards the end of chemotherapy. And then when I had surgery and then radiotherapy, I remember thinking as soon as I\u0026apos;m done with this sort of active treatment, I really want to up my physical activity\u0026rdquo; (P3)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSide effects- and these being individual\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I love vegetables, but I what I don\u0026apos;t have at the moment. It\u0026apos;s the strength to stand peeling out... I have a lot of problems with my spine and energy and just holding my body up right\u0026rdquo;. (P11)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eBreast cancer specific\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip; I waited weeks and weeks to speak to a dietitian and I had loads of questions about oestrogen. How can I reduce it through? Like what I\u0026rsquo;m eating? Should I stop dairy? What about soya? You know all these questions came up and then when I got to speak to the dietitian it was again a blanket of I\u0026apos;ll just have a healthy, balanced diet. Just everything in moderation\u0026hellip; I was slightly disappointed with the dietitians advice, because again, it wasn\u0026apos;t tailored\u0026rdquo; (P4)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It would help if there were diet tips for people taking tamoxifen\u0026rdquo; (open comments)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eTheme 2\u003c/span\u003e: \u003cstrong\u003ePerceived importance of diet and physical activity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ePre-diagnosis and Post-diagnosis importance\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;But I felt very fit and active and do quite a lot of exercises before diagnosis\u0026rdquo; (P7)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;So I didn\u0026apos;t have any exercise or nutrition support and till a few months after surgery and I think for me it would have been helpful from\u0026hellip; in an ideal world and without limits on resources, of course it would be really helpful from the moment of diagnosis\u0026rdquo; (P12)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I was really conscious about being physically active and when I got my diagnosis it was something that was really at the front of my mind because I was thinking I have to go through six months of chemotherapy and I know that people would be telling me it\u0026apos;s such a gruelling thing to go through. I had to have my mind clear and the first one of the first things was how do I keep myself active and physical\u0026rdquo; (P3)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I was doing regular exercise and eating healthily prior to my diagnosis, and struggled to find information/support about getting back to my previous level of physical activity, even when I asked about this specifically. Was instead given leaflets covering diet and exercise (walking) at a very basic level, which were not helpful to me\u0026rdquo; (Open comments)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme 3: Facilitators to physical activity and diet on treatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eIndividualised support\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;For me personally, it would be nice if somebody said right listen, There\u0026apos;s a menu for the week. Go out buy salmon and broccoli go and buy this. Have this Monday Tuesday, Wednesday, Thursday, Friday, Saturday.\u0026rdquo; (P4)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Would welcome something which can be tailored to the individual. I was doing regular exercise and eating healthily prior to my diagnosis, and struggled to find information/support about getting back to my previous level of physical activity, even when I asked about this specifically. Was instead given leaflets covering diet and exercise (walking) at a very basic level, which were not helpful to me.\u0026rdquo; (Open comments)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCheck in opportunities\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eEncouragement and motivational support would be helpful - ongoing i.e. some way of checking in to help sustain progress as it can be easy to begin an activity but sustaining without support can be difficult (open Comments)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eFeedback- e.g., diary keeping\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I would count the number of steps I was doing every day to try and get my steps up. Some of these little reminders of little handy tips could easily be digitized\u0026rdquo; (P1)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSocial opportunity\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;the social aspect of going to these groups and exercising together in this to swap support group exercise session really really motivates me\u0026rdquo; (P10)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSupport at different time points in treatment\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Well, how do I look after myself going forward post treatment and what do I need to do? And actually now I\u0026apos;ve got a bit more energy and bit more time\u0026rdquo; (P7)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ldquo;Fear\u0026rdquo;\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;the motivator for eating well and exercising well is actually the sheer terror of it coming back\u0026rdquo; (P5)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eJoined up care\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026apos;m in my second diagnosis\u0026hellip; I\u0026apos;m under dietitian gastrology \u0026hellip; physios all joining up for me because it wasn\u0026apos;t there in the past and that\u0026apos;s being more important because you know, hearing all you have a ladies that was my experience.\u0026rdquo; (P4)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme 4: Barriers to physical activity and diet on treatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSystem level: Chance of access/ availability of services\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ldquo;\u003c/span\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eI\u003c/span\u003e \u003cem\u003efound the thing that I find irritating is that I found all these things out. Incidentally, nobody kind of told me about them. It just happened that I saw the poster just happened that I went to that and then somebody told me about this other group and they\u0026apos;re all brilliant.\u0026rdquo; (P 10 referring to 5k your way and access to exercise support)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;\u003cem\u003e\u0026hellip; what\u0026apos;s my next appointment and what do I need to do. So I think that reality check, and I certainly wasn\u0026apos;t offered a conversation with the dietitian. It was there\u0026apos;s a leaflet in your pack.\u0026rdquo; (P8)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eP9\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;No health professional (doctor or nurse) has ever talked to me about the importance of diet and exercise in the 4 years I have been receiving treatment\u0026rdquo; (Open Comments)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eServices not individualised.\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;But what I\u0026apos;ve found is that they seem to blanket everybody with the same thing\u0026rdquo;. (P4)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eIndividual level barriers- knowledge, motivation\u003c/span\u003e.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I find I\u0026apos;ve really got to motivate myself to go into the kitchen and cook something\u0026rdquo; (p4)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip; then I\u0026apos;ve been quite committed to being active\u0026hellip; but I just feel that that lack of education to start with was a major for me.\u0026rdquo; (P5)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme 5: What would good digital support look like\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ePersonalised\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Need to make quality information personal to some degree otherwise it\u0026apos;s just another website with a lot of information and it\u0026apos;s up to the observer to determine what is right for them - one thing we learn through cancer diagnosis is everyone is different.\u0026rdquo; (Open comments)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eMust be hybrid\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I would be happy with some digital, but I do think it\u0026apos;s that mix of personal and digital.\u0026rdquo; (P8)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It needs to have the human touch so that you feel connected - more than just a patient / figure\u0026rdquo; (Open comments)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eVisually appealing\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eMake it lifestyle led/modern. Some cancer info quite old school. We\u0026rsquo;re still a consumer! (open comments)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eVideos rather than just written\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I could know that I that that video is there and so if I need to refer back to that video and maybe watch it 2/3 times for it for the information to go in because the whole thing with cancer is your information overload\u0026rdquo; (P3)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eAccountability, check in and feedback needed (synchronous support)\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;So having sort of every like so six weeks or phone call with the dietitian, who will give you, you know, instructions in between or something so you know there\u0026apos;s always gonna be someone there\u0026rdquo; (P2).\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eOpportunity for question and answer with HCP\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Say that I could come in if there was, for example, maybe a weekly Q\u0026amp;A. So if you had a Q\u0026amp;A on your session on your website, your brochure is so simple that I had been\u0026rdquo; (P4)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eLonger term advice and support- for example the booklets only cover up to 12 weeks.\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;[Leaflets] seem to stop at 12 weeks .... Don\u0026apos;t worry about it now you should be fine, but a lot of us are saying, well, we still you know I feel like I\u0026apos;m probably at maybe 70% of where I\u0026apos;d like to be\u0026rdquo; (P4)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eGroup support but with individualisation\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It makes it more social and enjoyable as well\u0026hellip; I don\u0026apos;t know some dance class or something, but cater to the level of each of our needs\u003c/em\u003e.\u0026rdquo; \u003cem\u003e(P4)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis mixed methods service evaluation aimed to explore the views of people with breast cancer on the support they received for physical activity and dietary advice, the perceived barriers and facilitators to this, and their views on the role digital health interventions may play in supporting people to make positive behaviour changes. The survey findings show that there is a strong interest in digital health interventions, but qualitative findings emphasised that digital support must be delivered in a tailored and personalised way in combination with face-to-face support.\u003c/p\u003e \u003cp\u003eThe findings will be discussed in relation to the original aims outlined.\u003c/p\u003e\n\u003ch3\u003eExperience of current PA and diet information and support after diagnosis\u003c/h3\u003e\n\u003cp\u003eWhilst most participants wanted information on physical activity and diet at the point of diagnosis, this need was often unmet with less than a third receiving such information. And for those who did manage to access support, there were criticisms that the access was due to chance rather than direction from the treatment team, and disappointment for some in not having more tailored support.\u003c/p\u003e \u003cp\u003eThe lack of information, support and signposting given by HCPs has been recognised as a barrier to implementing exercise in the oncology setting, and the element of chance in accessing support has been previously highlighted in an experience-based co-design project at the same centre [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The perceived lack of information from health care professionals is reflected in a survey of HCPs in the USA; whilst teams recognise the importance of physical activity, diet, and weight management they often do not refer to services who can provide lifestyle change support[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eParticipants in this survey wanted information on physical activity and diet at diagnosis before treatment starts. This is consistent with the current drive towards \u0026ldquo;prehabilitation\u0026rdquo; whereby interventions aimed at preparing and optimising people for treatment through diet, exercise and psychological support are embedded at the start of the pathway [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe breast cancer pathway can have many treatment interventions, such as surgery, chemotherapy, hormone therapy and radiotherapy. The focus group participants explained how support was needed in different ways at different parts of the pathway, as each intervention has its own physiological impact and side effects, so adaptable and personalised support is needed throughout. This is concurrent with the \u0026ldquo;multi-phasic approach\u0026rdquo; to prehabilitation, described by Santa-Mina and colleagues, where the potential impacts of each treatment are considered and the patient is optimised ahead of this, whilst also rehabilitating from side effects in previous treatments [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eBarriers and Facilitators\u003c/h2\u003e \u003cp\u003eBarriers and facilitators were explored in the focus groups, and sub-themed into \u0026ldquo;system level\u0026rdquo; and \u0026ldquo;individual level\u0026rdquo; barriers. At an individual level, barriers such as motivation, time and impact of physical side effects such as fatigue are consistent with other research findings [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The system level barriers were a lack of access and education (translating into individual barrier of knowledge). There were observations that the system was set up to address specific consequences of treatment, such as post-operative shoulder issues, but not wider health and wellbeing needs or longer-term health.\u003c/p\u003e \u003cp\u003eThe facilitators identified in this study (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) are consistent with some of the findings from an acceptability study with intervention of diet and weight loss exercise, which found that the facilitators to the programme were education, routine, motivation, goal-setting, meal-provisioning [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Although not the most popular mode of intervention in the survey, almost 70% showed some interest in remotely delivered groups or multiple groups. Beckenstein et al (2021) found that social support was an important element to support diet and weight loss[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In the survey, 40% of the respondents ticked option of community support as content for digital support, and open comments also reflected an interest with suggestions of online groups for health and wellbeing, buddying and walking groups as potential facilitators to physical activity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eThe potential role of digital health interventions in providing further support\u003c/h2\u003e \u003cp\u003eIn this survey, 98% had some interest in digital support, with 66% being very or extremely interested. Despite this interest, the most popular result for mode of delivery in the survey was a one-off face to face consultation with a healthcare professional. This was confirmed in the open comments and focus groups where consensus was that a hybrid model would be more helpful than a standalone digital intervention.\u003c/p\u003e \u003cp\u003eA systematic review in 2020 highlighted that the best approach, whether synchoronous, asynchronous or a combination of both, is unclear [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The participants in this evaluation valued feedback, checking in, reporting behaviours such as step counts and a hybrid approach with HCPs. This would be described as a synchronous approach, and these techniques are in line with the Behaviour Change Ontology where behaviour change techniques such as goal setting, feedback, and nudges can support behaviour change[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Whilst the participants in this project welcomed the idea of videos over paper leaflets, they disliked the asynchronous approach of just being given videos in absence of any feedback or connection with a HCP.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eWhat \u0026ldquo;good\u0026rdquo; digital support might look like\u003c/h2\u003e \u003cp\u003eParticipants in the focus groups, and open comments in survey, agreed that any intervention aimed at PA or diet needs to feel personalised and individualised. This is consistent with research recommendations in exercise oncology, where exercise specifically (as a planned, structured and personalised intervention) needs to be prescribed in order to accommodate the side effects, individual needs and for overall safety and benefit [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This was also the case for those who experienced oestrogen responsive cancers, in both the focus groups and in open comments, this group wanted specific advice regarding oestrogen and diet.\u003c/p\u003e \u003cp\u003eIn terms of content for the digital intervention the highest scoring elements were muscle strengthening, research evidence and side effects. This was reiterated in the focus groups, with patients wanting longer term support beyond 12 weeks post-surgery and into strength training, for approaches to be tailored to their stage of treatment and side effects. They were keen for the research evidence to underpin digital content, particularly about diet.\u003c/p\u003e \u003cp\u003eWhen asked what type of intervention would be most helpful, internet information, an application (app) and multiple video consultations were most popular. Interestingly DVD/video did not score highly, but the focus groups expressed preferences for video content over written information. The inclusion of \u0026ldquo;DVD\u0026rdquo; with video may have been misleading in the survey. The preferences for videos came from being able to watch again (participants used examples of social media short videos).\u003c/p\u003e \u003cp\u003eGroup interventions were discussed, as the focus group members reported being mindful of what could realistically be delivered on a one-to-one basis and how a remotely delivered drop-in session or telephone follow up with physiotherapist or dietitian were suggested. It was emphasised however that it needed to still feel individualised. This has been achieved in other remote online groups [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhilst applications (apps) were one of the interventions identified as a preferred mode of delivery on the survey, the focus groups highlighted that the issues with apps were the attractiveness and engagement of them. They did not feature highly in the discussion.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLimitations:\u003c/h2\u003e \u003cp\u003eAlthough the survey was made available in paper form, the vast majority used the online method. Despite efforts to have the paper version available in a variety of clinics, few were returned. There is likely to be some selection bias as potentially those most interested in PA and diet, or digital support would have responded. Those replying and attending focus groups, by the very nature of the questions, are more likely to be engaged in digital support and interested in PA and diet.\u003c/p\u003e \u003cp\u003eThe participants were largely from white ethnic background. Attempts were made to target different ethnicities and age groups through specific messaging on social media and to clinicians, and initially emails for participants in focus group was tailored to the 10% from non-white backgrounds, and a range of age groups. This had to be extended due to low number of replies. This will be addressed in future feasibility work with a more diverse patient and public steering group.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eFuture Research\u003c/h2\u003e \u003cp\u003eFurther research is needed to co-design hybrid digital approaches for diet and physical activity interventions for people with breast cancer, with a focus implementation and scalable approaches reducing burden on NHS staff whilst enabling this to be embedded in standard care.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eParticipants in this service evaluation open to digital support for physical activity and diet if combined with some interaction with healthcare professionals. Digital interventions for physical activity and diet need to include research evidence, support to adapt to side effects and specific guidance on strengthening. Future research is needed to determine the optimal mode of delivery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSiobhan Cowan-Dickie received funding from Royal Marsden Cancer Charity to complete a pre-doctoral fellowship and undertook this service evaluation under that fellowship.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Study proposal, data collection and analysis were performed by, Siobhan Cowan-Dickie and Clare Shaw. The first draft of the manuscript was written by Siobhan Cowan-Dickie and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was provided by the Royal Marsden Hospital Service Evaluation Committee (SE1124). The survey was conducted in accordance with the principles outlines in the Declaration of Helsinki\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was gained from all participants as outlined in the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was gained for publication of anonymised data, including quotes taken from semi-structured interviews.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCancer Research UK, \u0026ldquo;Cancer Statistics for the UK.\u0026rdquo;\u003c/li\u003e\n\u003cli\u003eWorld Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR), \u003cem\u003eDiet, Nutrition, Physical Activity and Cancer: a Global Perspective\u003c/em\u003e. 2018.\u003c/li\u003e\n\u003cli\u003eA. Joaquim \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Impact of physical exercise programs in breast cancer survivors on health-related quality of life, physical fitness, and body composition: Evidence from systematic reviews and meta-analyses,\u0026rdquo; Dec. 09, 2022, \u003cem\u003eFrontiers Media S.A.\u003c/em\u003e doi: 10.3389/fonc.2022.955505.\u003c/li\u003e\n\u003cli\u003eY. Y. Lei \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Adherence to the world cancer research fund/ American institute for cancer research guideline is associated with better health-related quality of life among Chinese patients with breast cancer,\u0026rdquo; \u003cem\u003eJNCCN Journal of the National Comprehensive Cancer Network\u003c/em\u003e, vol. 16, no. 3, pp. 275\u0026ndash;285, Mar. 2018, doi: 10.6004/jnccn.2017.7202.\u003c/li\u003e\n\u003cli\u003eD. S. M. Chan \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Postdiagnosis body fatness, weight change and breast cancer prognosis: Global Cancer Update Program (CUP global) systematic literature review and meta-analysis,\u0026rdquo; \u003cem\u003eInt J Cancer\u003c/em\u003e, vol. 152, no. 4, pp. 572\u0026ndash;599, Feb. 2023, doi: 10.1002/ijc.34322.\u003c/li\u003e\n\u003cli\u003eC. M. Friedenreich, H. K. Neilson, M. S. Farris, and K. S. Courneya, \u0026ldquo;Physical Activity and Cancer Outcomes: A Precision Medicine Approach,\u0026rdquo; \u003cem\u003eClinical Cancer Research\u003c/em\u003e, vol. 22, no. 19, pp. 4766 LP \u0026ndash; 4775, Oct. 2016, doi: 10.1158/1078-0432.CCR-16-0067.\u003c/li\u003e\n\u003cli\u003eJ. A. Ligibel \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Attention to diet, exercise, and weight in oncology care: Results of an American Society of Clinical Oncology national patient survey,\u0026rdquo; \u003cem\u003eCancer\u003c/em\u003e, Apr. 2022, doi: 10.1002/cncr.34231.\u003c/li\u003e\n\u003cli\u003eJ. A. Ligibel \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Oncologists\u0026rsquo; Attitudes and Practice of Addressing Diet, Physical Activity, and Weight Management With Patients With Cancer: Findings of an ASCO Survey of the Oncology Workforce,\u0026rdquo; \u003cem\u003eJ Oncol Pract\u003c/em\u003e, vol. 15, no. 6, pp. e520\u0026ndash;e528, 2019, doi: 10.1200/JOP.19.00124.\u003c/li\u003e\n\u003cli\u003eNICE, \u0026ldquo;Behaviour change : digital and mobile health interventions,\u0026rdquo; no. October, 2020.\u003c/li\u003e\n\u003cli\u003eK. Furness, M. N. Sarkies, C. E. Huggins, D. Croagh, and T. P. Haines, \u0026ldquo;Impact of the Method of Delivering Electronic Health Behavior Change Interventions in Survivors of Cancer on Engagement, Health Behaviors, and Health Outcomes: Systematic Review and Meta-Analysis,\u0026rdquo; \u003cem\u003eJ Med Internet Res\u003c/em\u003e, vol. 22, no. 6, p. e16112, Jun. 2020, doi: 10.2196/16112.\u003c/li\u003e\n\u003cli\u003eA. L. Roberts, A. Fisher, L. Smith, M. Heinrich, and H. W. W. Potts, \u0026ldquo;Digital health behaviour change interventions targeting physical activity and diet in cancer survivors: a systematic review and meta-analysis,\u0026rdquo; Dec. 01, 2017, \u003cem\u003eSpringer New York LLC\u003c/em\u003e. doi: 10.1007/s11764-017-0632-1.\u003c/li\u003e\n\u003cli\u003eT. Jia, Y. Liu, Y. Fan, L. Wang, and E. Jiang, \u0026ldquo;Association of Healthy Diet and Physical Activity With Breast Cancer: Lifestyle Interventions and Oncology Education,\u0026rdquo; Mar. 23, 2022, \u003cem\u003eFrontiers Media S.A.\u003c/em\u003e doi: 10.3389/fpubh.2022.797794.\u003c/li\u003e\n\u003cli\u003eF. Kennedy \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Fatigue, quality of life and associations with adherence to the World Cancer Research Fund guidelines for health behaviours in 5835 adults living with and beyond breast, prostate and colorectal cancer in England: A cross-sectional study,\u0026rdquo; \u003cem\u003eCancer Med\u003c/em\u003e, vol. 12, no. 11, pp. 12705\u0026ndash;12716, Jun. 2023, doi: 10.1002/cam4.5899.\u003c/li\u003e\n\u003cli\u003eV. Braun and V. Clarke, \u0026ldquo;Using thematic analysis in psychology,\u0026rdquo; \u003cem\u003eQual Res Psychol\u003c/em\u003e, vol. 3, no. 2, pp. 77\u0026ndash;101, 2006, doi: 10.1191/1478088706qp063oa.\u003c/li\u003e\n\u003cli\u003eS. Cowan-Dickie \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;\u0026lsquo;Not another leaflet please\u0026rsquo;: Improving the delivery of physical activity information and interventions for people with breast cancer,\u0026rdquo; \u003cem\u003eThe Journal of Health Design; Vol 5, No 2 (2020): Treating people, not patients\u003c/em\u003e, 2020, [Online]. Available: https://www.journalofhealthdesign.com/JHD/article/view?path=\u003c/li\u003e\n\u003cli\u003eMacmillan Cancer Support, \u0026ldquo;Principles and guidance for prehabilitation within the management and support of people with cancer,\u0026rdquo; 2019.\u003c/li\u003e\n\u003cli\u003eD. Santa Mina \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Multiphasic Prehabilitation Across the Cancer Continuum: A Narrative Review and Conceptual Framework,\u0026rdquo; Jan. 11, 2021, \u003cem\u003eFrontiers Media S.A.\u003c/em\u003e doi: 10.3389/fonc.2020.598425.\u003c/li\u003e\n\u003cli\u003eJ. A. Ligibel, K. Basen-Engquist, and J. W. Bea, \u0026ldquo;Weight Management and Physical Activity for Breast Cancer Prevention and Control,\u0026rdquo; \u003cem\u003eAmerican Society of Clinical Oncology Educational Book\u003c/em\u003e, no. 39, pp. e22\u0026ndash;e33, 2019, doi: 10.1200/edbk_237423.\u003c/li\u003e\n\u003cli\u003eD. Cho and C. L. Park, \u0026ldquo;Barriers to physical activity and healthy diet among breast cancer survivors: A multilevel perspective,\u0026rdquo; \u003cem\u003eEur J Cancer Care (Engl)\u003c/em\u003e, vol. 27, no. 1, pp. 1\u0026ndash;8, 2018, doi: 10.1111/ecc.12772.\u003c/li\u003e\n\u003cli\u003eH. Beckenstein, M. Slim, H. Kim, H. Plourde, R. Kilgour, and T. R. Cohen, \u0026ldquo;Acceptability of a structured diet and exercise weight loss intervention in breast cancer survivors living with an overweight condition or obesity: A qualitative analysis,\u0026rdquo; \u003cem\u003eCancer Rep\u003c/em\u003e, vol. 4, no. 3, pp. 1\u0026ndash;8, 2021, doi: 10.1002/cnr2.1337.\u003c/li\u003e\n\u003cli\u003eM. M. Marques \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;The Behaviour Change Technique Ontology: Transforming the Behaviour Change Technique Taxonomy v1,\u0026rdquo; \u003cem\u003eWellcome Open Res\u003c/em\u003e, vol. 8, 2023, doi: 10.12688/wellcomeopenres.19363.1.\u003c/li\u003e\n\u003cli\u003eD. S. Mina \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Connecting people with cancer to physical activity and exercise programs: A pathway to create accessibility and engagement,\u0026rdquo; \u003cem\u003eCurrent Oncology\u003c/em\u003e, vol. 25, no. 2, pp. 149\u0026ndash;162, Apr. 2018, doi: 10.3747/co.25.3977.\u003c/li\u003e\n\u003cli\u003eV. Hailey, A. Rojas-Garcia, and A. P. Kassianos, \u0026ldquo;A systematic review of behaviour change techniques used in interventions to increase physical activity among breast cancer survivors,\u0026rdquo; Mar. 01, 2022, \u003cem\u003eSpringer Japan\u003c/em\u003e. doi: 10.1007/s12282-021-01323-z.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Breast Cancer, diet, physical activity, digital","lastPublishedDoi":"10.21203/rs.3.rs-5306355/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5306355/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e: The purpose of this clinical service evaluation was to explore the experiences of people treated for breast cancer of physical activity (PA) and diet support, and how to improve support through digital interventions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA mixed methods approach was used with a survey available online and in print, and two online focus groups. Participants were recruited through an online patient voices platform, in clinic, and through social media. Descriptive statistical analysis was used for survey responses, with thematic analysis for free text comments. Focus groups were recorded, transcribed, and analysed using thematic analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003eThere were 97 survey respondents, mainly white British background, all female, 58% within the 50-59 age bracket, all on treatment or within two years of treatment completion for breast cancer. \u0026nbsp;\u0026nbsp;Whilst 70% wanted information on PA, only 29% of those received it. For diet this was 76% and 26% respectively. Most participants (66%) were very or extremely interested in digital support for PA and diet. Priorities for digital content were strengthening exercise, management of side effects and underlying research evidence. Two focus groups were held, with 13 attendees in total. The main themes from the focus groups were desire for personalised support, perceived importance of PA and diet, facilitators and barriers to access, and describing good digital support which included a hybrid approach with face to face and mechanisms for accountability.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Participants were open to support on PA and diet being delivered digitally, but with emphasis on a hybrid model with face-to-face, and with some synchronous elements such as feedback or checking in.\u003c/p\u003e","manuscriptTitle":"Exploring digital support for physical activity and diet in breast cancer, a mixed methods service evaluation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-15 11:45:48","doi":"10.21203/rs.3.rs-5306355/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"27728241-6b7a-4f09-b1f8-b5d08ce01e7d","owner":[],"postedDate":"November 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-10T02:08:20+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-15 11:45:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5306355","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5306355","identity":"rs-5306355","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}