Strategies for promoting exercise adherence within a cancer exercise recovery program

Strategies for promoting exercise adherence within a cancer exercise recovery program | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Strategies for promoting exercise adherence within a cancer exercise recovery program Nadia Huynh, Ciera Torney, Novalyn Cruz, Rachel Ruggieri, Philip Chang, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6347715/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Physical activity (PA) can play an important role in physical health and well-being for cancer survivors. However, cancer survivors demonstrate low adherence to cancer PA guidelines. Research is needed to understand how to optimize delivery of cancer PA programs to enhance participation and adherence. In this study, we examined a clinical cancer exercise recovery program (CERP) demonstrating high adherence (over 90% session completion), with the goal of understanding implementation strategies that may be linked to higher program adherence. Methods Semi-structured interviews were conducted with CERP program trainers ( n = 2), as well as CERP program participants ( n = 18; n = 13 women) with diverse cancer diagnoses and treatments. Data were analyzed using thematic analysis. Results A series of strategies were identified that were linked by study participants to program adherence. These strategies were organized into three programmatic components: the physical environment, social environment, and activity characteristics. Conclusion The identified implementation strategies may support health care providers and exercise physiologists in the development of cancer PA programming that promotes quality participation experiences and high program adherence, allowing participants to experience the benefits of PA post-treatment. cancer survivorship exercise physical activity physical medicine and rehabilitation Introduction Physical activity (PA) can meaningfully improve physical health, mental health (and other critical quality of life indicators for cancer survivors [ 1 , 2 ]. Furthermore, studies investigating breast, colorectal, and prostate cancer survivors suggest that PA can lower the risk of cancer recurrence and improve survival [ 2 ]. However, despite the benefits of PA for cancer survivors, adherence to cancer-specific PA guidelines is low, with current estimates suggesting that 17–47% of cancer survivors meet PA guidelines [ 3 – 7 ]. Diverse factors may influence whether cancer survivors adhere to PA. At a societal and structural level, low adherence may be due to health policies and health system approaches. For example, PA resources are least represented of all supportive care services; thus, PA programs developed specifically for the unique needs of cancer survivors can be hard to access [ 8 ]. At a programmatic level, trainers’ knowledge about a survivor’s background, along with the availability of proper cancer PA education, are pivotal [ 9 ]. At the individual level, previous PA participation, knowledge, and skills, as well as cancer treatment effects can influence adherence [ 10 , 11 ]. Low PA adherence may also be due to program quality [ 12 ]. To assist in the development of quality PA programs, researchers developed the Quality Parasport Participation Framework [ 13 ]. The Framework identifies six experiential elements of quality participation: autonomy, belongingness, challenge, engagement, mastery, and meaning [ 13 ]. To foster these experiential elements, there are also programmatic conditions to consider, relating to the physical environment, social environment, and program environment. Initially developed for sport among people with disabilities, this Framework has since demonstrated applicability to diverse programs and communities, including PA for cancer survivors [ 14 , 15 ]. The purpose of this study was to understand participant and trainer experiences within a high adherence cancer PA program, with the goal of identifying program delivery that may be related to high program adherence. In contrast to the adherence rates identified in the literature, the program of interest (Cancer Exercise Recovery Program; CERP) has an adherence rate of over 90%, as well as extensive interest with an over 6-month waitlist. Ultimately, identifying factors that contribute to successful implementation of a high adherence cancer exercise program may support health care providers and exercise physiologists in developing and delivering cancer exercise programs that promote sustained participation so cancer survivors may experience the important benefits of PA. Methods Context CERP is delivered in a large medical research hospital. The space features approximately 2800 sq. ft. which includes the gym, and conference room space for individual assessments. The space has one wall of windows to allow for natural light and views of the city to look at while engage in exercise. Equipment includes a treadmill, elliptical machine, upright and recumbent bike, leg/chest press, leg curl extension, cable cross machine, rower, and free weights. The program was designed to be highly individualized for cancer survivors to ensure it is safe for their age, functional status, co-morbidities, and other clinical factors important in this population (e.g., cachexia, chemotherapy-induced peripheral neuropathy, bone metastasis, lymphedema, or negative changes in body composition). Upon enrollment, the participant undergoes a comprehensive fitness and medical evaluation led by the lead exercise physiologist (EP). During this evaluation, the patient’s personal goals are established to guide the development of their program. The assessment also includes strength testing, functional assessments, and measurement of body composition. The EP then creates a customized program that is gradually progressed over three-months. Sessions are tailored to rebuild strength, endurance, and flexibility. The intervention is supervised by a trainer (EP or technician with oncology certification through the American College of Sports Medicine). One trainer is assigned to a maximum of two participants per one-hour session, with sessions occurring two to three times per week. At the end of the 3-month program, the assessment is repeated to measure impact and to help plan a home program for maintenance. Philosophical assumptions This study was framed in ontological relativism and epistemological constructivism to gain an in-depth understanding of CERP program experiences and mechanisms of program delivery that support strong adherence. Our participant demographics represent significant heterogeneity in gender, cancer type, cancer treatment, physical activity history, family support, etc. We sought to embrace considerations of how these unique identities and experiences influence the data from data collection through to development of the current manuscript. Positionality Our research team consisted of researchers and clinicians trained in physical medicine and rehabilitation, as well as behavioral sciences, sport and exercise psychology, and exercise physiology. One member of our team (AA) created and leads the CERP program, while another member of our team (NC) is the lead exercise physiologist. To increase participant willingness to be honest and transparent, data collection and analysis was led by the other team members who are not involved in delivery of CERP or any clinical programming. Regular meetings were held with AA and NC to enhance understanding of program elements discussed in interviews and improve contextual knowledge. Given the closeness of two members of the research team to the program being examined, the research team continuously questioned how their experiences and identity influenced their interpretation of the transcripts and openness to participant responses. NH and CHS held ongoing weekly discussions about their perspectives of PA in survivorship throughout the analysis process. In addition, throughout analysis and preparation of this paper, transcripts were reviewed to ensure that findings were representative of participant experiences. Participants Ethics approval was received from the Cedars-Sinai Medical Center Institutional Review Board, which operates in accordance with the Belmont principles (STUDY00000627). Following receipt of this approval, CERP trainers and patients were recruited for interviews. CERP trainers ( n = 2) were current staff involved in CERP. They were invited to participate by email and in-person during their monthly meeting. Two of the three trainers agreed to participate. Former and current CERP patients ( n = 18) were recruited through an e-mail with study information sent by AA to a database of CERP patients and alumni. Prior to engaging in an interview, verbal informed consent was obtained from all participants (trainers and CERP patients). A total of 20 participants engaged in interviews. See Table 1 for full demographic information. Table 1 Demographic characteristics of CERP patients Pseudonym Age Race/ethnicity Gender Cancer Type Aaron 61 White/Non-Hispanic Male Multiple myeloma Barbara 55 White/Non-Hispanic Female Breast cancer Caroline 55 White/Non-Hispanic Female Breast cancer Davina 87 White/Non-Hispanic Female Breast and ovarian cancer, metastatic carcinoma Emily 55 Black/Non-Hispanic Female Breast and fallopian tube cancer Freya 59 White/Non-Hispanic Female Breast cancer Grace 49 White/Non-Hispanic Female Adenocarcinoma Hazel 50 White/Non-Hispanic Female Breast cancer Iris 73 White/Non-Hispanic Female Anal Cancer Jo 43 White/Non-Hispanic Female Breast cancer Kai 46 Black/Non-Hispanic Female Breast cancer Leanne 61 White/Non-Hispanic Female Breast and ovarian cancer, peritoneal carcinoma Mike 70 White/Non-Hispanic Male Mantle cell lymphoma Noel 74 White/Non-Hispanic Male Smoldering myeloma Oliva 34 White/Non-Hispanic Female Ovarian cancer Paul 79 White/Non-Hispanic Male Chronic lymphocytic leukemia, splenic marginal zone b-cell lymphoma Quinn 57 White/Non-Hispanic Female Breast, endometrial cancer, melanoma of the skin Richard 71 White/Non-Hispanic Male Head, neck, tonsil cancer [Insert Table 1 ] Procedure Semi-structured one-on-one virtual interviews were conducted by individuals unaffiliated with CERP to enable participants to share their experiences without concern of the impact of their feedback on their future healthcare experiences or employment. Interviews lasted approximately 45 minutes. Interviews were audio-recorded and subsequently transcribed verbatim by a member of the research team. The Interview Guide Interviews were tailored based on participant roles in the program. The patient interview guide was divided into three parts: (1) identifying their PA background prior to diagnosis; (2) CERP experience; and (3) program expectations. Participants who had completed CERP were also asked about their post-CERP PA participation. Meanwhile, the trainer interview guide was informed by the Quality Parasport Participation Framework [ 13 ], and focused on: (1) their background in PA and cancer survivorship; (2) the program environment; (3) their approach to building an optimal social environment; and (4) ideal outcomes for patients. Data analysis Data were analyzed using thematic analysis [ 16 ]. This consisted first of deep immersion in the transcripts. NH read and reread the data, taking notes on questions and thoughts that arose throughout. Throughout this process, NH had weekly meetings with CHS and RR, who had conducted the interviews, to ask questions about the interviews and engage in reflexive consideration of positionality and biases. An inductive coding process was then conducted during which meaningful extracts of data were identified and labeled. These codes were organized into themes indicative of program delivery strategies. These themes were then examined in relation to the Quality Parasport Participation Framework [ 13 ]. This additional analysis provided deeper consideration on the definitions and expression of the different quality elements that could be indicative of best practices in the context of CERP, and resulted in reorganization and relabeling of themes. NH and CHS then presented the refined themes to the rest of the team. During these meetings, the team members acted as critical friends, provoking further discussion and consideration of participant meanings. These meetings were important based on each attendee’s diverse backgrounds, roles in relation to the research project and CERP, and experiences with PA and cancer survivors. These diverse backgrounds allowed for a more thorough review and discussion of the data and findings. Following these meetings, themes were refined again, which was followed by the writing of the manuscript. In addition to the quality and methodological rigour practices identified above, the research team were further guided by 20 questions for assessing thematic analysis research quality [ 17 ]. Results and Discussion Three themes were identified: (1) facilitating the accessibility of exercise programs; (2) the importance of trainers and peers; and (3) tailored programming fosters long-lasting engagement. Within the context of the Quality Parasport Participation Framework, these themes correspond to the programmatic conditions (physical environment, social environment, and activity characteristics, respectively). For each theme, corresponding strategies are identified that were linked by CERP participants and trainers to quality participation and outcomes. Participant quotes are presented in Table 2 . Table 2 Participant and Trainer Quotes Theme Sub-theme Quote Source Quote Facilitating the Accessibility of Exercise Programs Differentiating cancer exercise programs from traditional commercial gyms Participant “It was wanting to do it in a place that was safe. I don't really care for gyms that much. There's so much grunting of all these showoff guys. I find that really distracting and then it kind of pisses me off. So [CERP] was like a safe environment for me.” (Caroline) Trainer “(…) at a commercial gym that makes it a lot more difficult to stay within the program for them compared to us. You know, one, gyms are packed. There's Sa lot of people. It can get very intimidating, and these people are all, look, seem very healthy and, (laughs) and strong. And I get that it can be very intimidating to folks who had cancer and had surgery and dealing with chemo and all that stuff.” (Eli) Financial toxicity and the importance of no-cost programming Participant “[CERP is] like a gift. There's not a lot of joy all the time. I mean, I get depressed a lot. But [CERP] helps, and [it] feels good that it's free and they care. It's just one less [financial] responsibility and it'll make you show up. You start financially …. you get depressed and then you start pulling away. Like it might not be that you don't want to go. There's too much financial burden so it makes you get into a bad head space. And then the head space makes you not wanna exercise. And it becomes an out-of-control spiral. 'Cause we're there so much for so many visits for doctors that we're paying so much money for so much else.” (Quinn) Flexible scheduling to accommodate integration of exercise into daily living Participant “He [CERP scheduler] was also really flexible in terms of scheduling. So kind of the issue is, I mean, I know there's a certain amount of time and obviously schedules everybody, someone's late they throw off everybody else's schedule (…) I had to make some changes. I had corporate meetings I had to be at and stuff. And as long as I emailed him, which I always did ahead of time— Super flexible with that. So that all made a really big difference. It really felt like a really high end paid personal training program. You know, where it wasn't like, you miss it, we can't make it up. We understand you're not in any trouble, but we have to move on. It was not like that. It was really, it's just such a thoughtful program.” (Freya) Trainer “A lot of participants we are working with have jobs still or are taking care of kids. So we try to work based on their preferred schedule time. (…) We're gonna see them for three months and we want to see them every [day they are scheduled]. If they're busy, if the time doesn't work, and they're gonna miss half the time, then what's the point?” (Trainer Melanie) The importance of trainers and peers for promoting adherence The importance of fostering social support amongst patients Participant “I just was so appreciative. (…) I do think it's helpful to be there with other patients going through maybe what you went through and maybe you talk about, you know, how you're feeling or who your oncologist is. I think that's important to have a sense of community (…) we all cheered each other on too. It's just like, keep going, you can do it that kind of thing.” (Barbara) Trainer “I've gotten the impression that when they're exercising, they get motivation from having to see other participants exercising. And, being able to be social with others has actually been helping them to continue exercising (…).” (Melanie) Trainer education and approach to cancer-focused rehabilitation Participant “I felt like she got me. She got it. Like she didn't let me off the hook, but she also took into consideration all the little collateral damage that I had from treatment. I'm like, ‘Okay. My shoulder is this, or like this...’ or ‘I have this spasm in my chest.’ I don't want to explain that to someone who just doesn't know or doesn't even get it. And like I could be doing well one day, and I could have a spasm. It's spontaneous. But I also don't want to be looked at like, ‘Oh you have cancer.’ I don't want that; I don't need that. But I do want an understanding that my body is different and sensitive. And I think that she had the perfect balance at that.” (Olivia) Trainer “And when you start just developing a relationship, so talking about things other than what they're going through. Something, interpersonal... Asking them about their life and where they come from. And I feel like that does help sort of reduce (…) the tension that most people will feel in the beginning. Because not only is exercise so foreign to them, but they're also still experiencing some of the side effects from treatment. So, they'll be afraid to try to move, maybe their shoulder, especially if they've had lymph nodes removed or, they’re afraid to do balancing exercises if they had neuropathy. So, it’s easier to get them to accept the program.” (Eli) Tailored programming fosters long-lasting engagement Participant “Going through a program that was tailored toward me in my experience of what I was going through with chemo is really important because I think it would be difficult to find a trainer that knows how to deal with some of the side effects of what I was going through. At the time, I still had a port in my arm as well. And they took that into consideration that it wasn't bothering that area that was still sore and tender. And work towards just like goals I had around balance and the neuropathy. It was important to me for that reason really improved my mental health as well…As a young person with cancer, it's hard to not be able to do things that [I] used [to do] easily.” (Olivia) Trainer “I had one participant, metastatic, and she was going through a rough time. She didn't think that exercise would help with her energy level. She [thought] that it was not gonna help at all. But then later she realized that she had more energy. She started at four exercises for the first couple of weeks. And then later she's doing 10 exercises. She starts telling me about things that she wants to start doing. She used to go surfing and it was hard for her to push up onto the board, you know to be able to surf in. So, she hasn't been able to do that. So, I've been incorporating exercises where it has helped her to be able to do those certain movements.” (Melanie) Facilitating the Accessibility of Exercise Programs Three sub-themes were identified indicative of strategies to promote an optimal physical environment: differentiating cancer exercise programs from traditional commercial gyms; financial toxicity and the importance of no-cost programming; and flexible scheduling to accommodate integration of exercise into daily living. Differentiating cancer exercise programs from traditional commercial gyms Consistent with existing research, participants mentioned bodily changes due to cancer treatment, which resulted in both physical and psychological barriers to PA [ 18 , 19 ]. Physical changes decreased self-efficacy because of low perceived ability to perform at the level they did before treatment. Learning how to be active with these changes elicited fear. CERP participants believed that a private exercise facility developed specifically for cancer survivors provided a safe venue for them to restart exercise post-active treatment. In contrast, participants suggested that commercial gym culture may discourage exercise engagement. Some participants found the environment conducive to negative comparison. The fitness culture fostered in these environments caters specifically to individuals without illnesses and many felt bad seeing others who could lift more or active in ways they couldn’t achieve following diagnosis and treatment. This perspective was reinforced by the trainers who noted that the physical appearance and fitness of individuals at commercial gyms had the potential to discourage cancer survivors. Meanwhile, participants noted that the CERP gym provided a sense of privacy that allows them to exercise at their own pace without fear of comparison to others. Although CERP’s facility is smaller than standard gyms, participants noted a particular benefit: more interaction. Privacy and intimacy were vital elements that were seen to minimize external distractions and facilitate relationship building with trainers and other participants. Financial toxicity and the importance of no-cost programming Participants discussed the poor mental health outcomes of financial toxicity and its larger impact on exercise. Cancer survivors who experience more financial toxicity report higher levels of depression and anxiety symptomology, greater unease, and lower self-efficacy in coping with cancer [ 20 ]. These depressive symptoms can influence a patient’s motivation to seek recovery activities [ 21 ]. The compounded effect of both financial restrictions and the emotional implications of financial restrictions discouraged many participants not only from trying to find programs but from participating in exercise at all. Incorporating exercise after treatment required emotional effort as cancer treatment required substantial financial and physical effort and exercise would have been another responsibility for participants to shoulder. Participants recognized the importance of PA as part of a supportive care plan and as a means, in some cases, to combat cancer recurrences and/or cancer effects. However, many discussed having little to no funds available to pay for programs resulting in a lack of PA participation despite willingness. It isn’t uncommon for cost of PA to deter PA participation [ 22 ]. With the financial burden shouldered by patients and their families due to cancer treatment, a key strategy was the fact that CERP is free. Not having to think about the cost of CERP or find funds to pay for the program decreased some of the mental load, allowing participants the freedom to choose to engage in exercise to support their recovery. Flexible scheduling to accommodate integration of exercise into daily living One of the barriers to PA consistently identified is time [ 23 ]. For many cancer survivors, life post-treatment means resuming all of life’s responsibilities from work, to family, and/or education [ 24 ]. As such, an important strategy used by CERP was placing the burden of scheduling on CERP rather than the participant. When participants joined the program, they had an initial call with a program coordinator who took note of their work schedule, commitments, and driving distance. Staff then created a flexible scheduling system to reflect these barriers and would be feasible for integrating CERP into daily life. While many praised these scheduling accommodations, limitations were identified based on CERP being a clinical program versus a commercial gym. As a clinical program, CERP is only open Monday to Friday during business hours. Participants who didn’t have regular employment, were on leave, or retired didn’t mind. However, others noted that adding timeslots outside working hours (mornings, evenings, weekends) would make their day smoother and less stressful, particularly as some had to submit special requests to their employers to allow for late arrival or early departures to engage in CERP. Timeslots outside working hours were also an important consideration given the heavy traffic often encountered in the city. More scheduling variety was viewed as creating better accessibility. The importance of trainers and peers for promoting adherence Two sub-themes were identified: the importance of fostering social support amongst patients; and trainer education and approach to cancer-focused rehabilitation. The importance of fostering social support amongst patients The social support received post-treatment can be integral for adaptive coping [ 25 – 27 ]. CERP offered an opportunity for participants to interact with individuals who shared their cancer experience. CERP staff reviewed patient files prior to scheduling sessions. When feasible, based on the discretion of the program coordinator and EP, participants were paired based on age, gender, or stage of cancer. This attention to social pairing had the intended effect. Participants discussed how CERP provided the foundation for community-building. Participants often spent their time discussing treatment or medication experiences and gaining emotional support from a fellow survivor’s perspective. These interactions allowed patients to feel comfortable expressing fears or hardships without judgement and helped to normalize the cancer experience [ 28 ]. Need for camaraderie between CERP participants was, however, dependent on the existence of available support elsewhere (e.g., other programs, family, friends) and whether participants viewed peer support as important prior to the program. Finally, peer interactions also provided opportunities for motivation and modeling of exercise participation. Consistent with the concept of vicarious experience being an important building block of self-efficacy [ 29 ], participants noted that observing other cancer survivors work hard in the gym gave them confidence and motivated them to do the same. Trainer education and approach to cancer-focused rehabilitation Staff and trainers may serve as pillars of support by fostering autonomous engagement, developing caring connections, instilling trust through expert instruction, managing conflict directly and effectively, and creating a climate where people want to attend a program [ 30 ]. Indeed, participants highlighted the importance of having knowledgeable and compassionate trainers to guide them during the rehabilitation process. Research suggests that cancer survivors prefer to receive instruction from trainers who are knowledgeable about cancer [ 31 ]. Working with trainers who have prior experience with cancer survivors was identified as essential as participants felt they would “[understand] psychologically what’s going on” (Paul) and have more empathy that would avoid “stupid conversations” (Jo). With this understanding, trainers can tailor their approach to each participant, adapting exercises to individual and/or daily needs as the program progresses. CERP staff receive extensive training in PA and cancer survivorship. For example, CERP EPs receive national certification in cancer and exercise training. In addition to this formal training, the Director of CERP also leads monthly team meetings to discuss recent scientific advancements on PA promotion and/or cancer survivorship. The CERP trainers’ understanding of the physiological components of post-treatment exercise, as well as psychosocial aspects of the cancer experience provided two benefits: 1) participants felt understood and respected with trainers finding a balance between being empathetic of their cancer diagnosis while still viewing them as capable individuals; and 2) participants felt comfortable openly communicating their concerns because the trainers are knowledgeable and capable of modifying activities as needed. Having trainers capable of recognizing how to adapt to the sometimes daily fluctuations of side and late effects allows participants to continue to engage in PA. For many participants it was also important that trainers did so without defining them by their diagnosis. Healthcare providers build trust by demonstrating competence, care, and communicating effectively [ 32 ]. The previous strategies demonstrated competence and caring; however, effective communication was also employed to support participant goals and bolster confidence. According to trainers, initial sessions are particularly important for acclimating participants to the space, reintroducing exercise, and building self-efficacy for PA post-treatment. Building rapport through methods including casual conversation can ease discomfort during those early stages of rehabilitation. As time went on, trainers provided constructive feedback for guidance and to celebrate improvements. This gave participants a practical assessment of progress, which motivated them to continue PA. Finally, trainers also used non-verbal communication like body language, and encouraging facial expressions and gestures to promote comfort and confidence. For the participant, the above communication techniques are important for reducing tension or fear [ 33 ], and have been demonstrated to help establish trust and promote engagement [ 34 ]. Tailored Programming Fosters Long-Lasting Engagement Cancer diagnosis and treatment may affect PA, so activities should be tailored to fit individual preference, age, type and stage of cancer, and other health considerations [ 35 ]. Participants felt it was important for trainers to customize activities to account for individual differences. The nuanced understanding that trainers attain from working with cancer survivors strengthen their ability to tailor activities to daily fluctuations in symptoms with precision and care. Beyond tailoring to treatment and cancer effects, it was viewed as equally important to tailor participation to individual goals both within and outside CERP. These goals and the subsequent tailoring of activities may not directly target treatment-related symptoms, but the ability to engage in patient-preferred activities. Being receptive to these requests through an autonomy-supportive approach has been demonstrated to promote adherence to PA guidelines [ 36 ]. Beyond autonomy, other quality elements were fostered, particularly an increased sense of mastery. CERP participants gained self-confidence in their abilities after consistently achieving and surpassing activity goals set during each session. As the participant becomes more confident in themself, they begin setting new goals. Besides tailored programming, certain techniques employed by staff also added to the participants overall experience during their time in the program. EPs utilized care planning techniques like coordinating with other providers and assigning one trainer per participant for the entirety of their journey through CERP. One participant noted that “the really great thing about CERP is that we were getting individual attention. And I couldn't wait to get there every day for that.” (Iris) Not only is having one on one time with a trainer important for building rapport, but it also makes participants eager for the next session. In addition, participants believed that it made them more accountable for session attendance. Conclusion This study identified three delivery strategies that were linked by CERP participants and staff with cancer exercise program adherence: facilitating the accessibility of programs; the importance of trainers and peers for promoting adherence; and tailored programming to foster long-term engagement. The strategies fostered quality participation elements in addition to alleviating many psycho-emotional barriers to post-treatment PA. These findings align with previous research on quality participation and PA for cancer survivors. For example, Fong and colleagues identified the quality participation elements of challenge and mastery, as well as social and physical environment conditions as being linked to quality experiences for breast cancer survivors in outdoor exercise programming [ 14 ]. A further study examining community-based exercise program participation for breast cancer survivors identified five quality components for program design: improve cancer literacy, provide opportunities to participate with peers, foster self-efficacy, prioritize program accessibility, and integrate program within a network of supportive cancer care [ 37 ]. These findings parallel the considerations identified in the current study, reinforcing their importance. While this study had many strengths, there are limitations that need to be considered. This analysis focused on in-person program considerations, as CERP is primarily an in-person program. However, virtual programs are gaining prominence as a means to increase reach and access to PA. Future research needs to explore delivery of virtual programming and whether strategies differ or need to be modified to promote program adherence. Other potential considerations that may limit applicability include the urban clinic-based setting of the program and, as a result, the lack of participant diversity in the sample. In sum, this case study examined CERP, an exercise program for cancer survivors that has demonstrated high participation and adherence, with a focus on identifying program strategies that may be associated with PA adherence. As the benefits of PA programming for cancer survivors continue to be reinforced, it is important that researchers examine methods for program implementation, in particular the delivery strategies and experiential aspects of participation that influence participation and adherence to optimize the benefits of supportive care programming. Declarations Acknowledgements We would like to thank Cedars-Sinai Cancer Exercise Recovery Program (CERP) and its participants for their involvement in this research. Author Contributions All contributed to the study conception and design. Material preparation and data collection were conducted by C.S. and R.R. Analysis was performed by N.H. The first draft of the manuscript was written by N.H., and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Funding This research was funded by Cedars-Sinai Cancer (CHS). Data availability The interview data generated and analyzed during the current study are available from the corresponding author upon request. Disclosure Statement Two of the authors are affiliated with CERP (XX and XX). 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Thousand Oaks, California: SAGE Publications LTD 338 p. Braun V, Clarke V (2021) One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qual Res Psychol 18(3):328–52. https://doi.org/10.1080/14780887.2020.1769238 Fassier P, Zelek L, Partula V, Srour B, Bachmann P, Touillaud M, et al (2016) Variations of physical activity and sedentary behavior between before and after cancer diagnosis. Medicine 95(40):e4629. https://doi.org/10.1097/MD.0000000000004629 Henriksson A, Arving C, Johansson B, Igelström H, Nordin K (2016) Perceived barriers to and facilitators of being physically active during adjuvant cancer treatment. Patient Educ Couns 99(7):1220–6. https://doi.org/10.1016/j.pec.2016.01.019 Thom B, Benedict C (2019) The Impact of Financial Toxicity on Psychological Well-Being, Coping Self-Efficacy, and Cost-Coping Behaviors in Young Adults with Cancer. J Adolesc Young Adult Oncol 8(3):236–42. https://doi.org/10.1089/jayao.2018.014 Frikkel J, Götte M, Beckmann M, Kasper S, Hense J, Teufel M, et al (2020) Fatigue, barriers to physical activity and predictors for motivation to exercise in advanced cancer patients. BMC Palliat Care 19(1):43. https://doi.org/10.1186/s12904-020-00542-z Hardcastle SJ, Maxwell-Smith C, Kamarova S, Lamb S, Millar L, Cohen PA (2018) Factors influencing non-participation in an exercise program and attitudes towards physical activity amongst cancer survivors. Support Care Cancer 26(4):1289–95. https://doi.org/10.1007/s00520-017-3952-9 Gildea G, Spence R, Jones T, Turner J, Macdonald E, Hayes S, et al (2023) Barriers, facilitators, perceptions and preferences influencing physical activity participation, and the similarities and differences between cancer types and treatment stages - A systematic rapid review. Prev Med Rep 34:102255. https://doi.org/10.1016/j.pmedr.2023.10225 Hefferon K, Murphy H, McLeod J, Mutrie N, Campbell A (2013) Understanding barriers to exercise implementation 5-year post-breast cancer diagnosis: a large-scale qualitative study. Health Educ Res 28(5):843–56. https://doi.org/10.1093/her/cyt083 Fong A (2017) Mind the (Knowledge-to-Action) Gap: Exploring Factors that Affect Physical Activity in Breast Cancer Survivors. Available from: https://www.semanticscholar.org/paper/Mind-the-(Knowledge-to-Action)-Gap%3A-Exploring-that-Fong/84aaacf1de68096c 18fc4380f2f6dcea190e9829 Kampshoff CS, van Mechelen W, Schep G, Nijziel MR, Witlox L, Bosman L, et al (2016) Participation in and adherence to physical exercise after completion of primary cancer treatment. Int J Behav Nutr Phys Act 13(1):100. https://doi.org/10.1186/s12966-016-0425-3 McDonough MH, Sabiston CM, Wrosch C (2014) Predicting changes in posttraumatic growth and subjective well-being among breast cancer survivors: the role of social support and stress. Psychooncology 23(1):114–20. https://doi.org/10.1002/pon.3380 Guida JL, Holt CL, Dallal CM, He X, Gold R, Liu H (2020) Social Relationships and Functional Impairment in Aging Cancer Survivors: A Longitudinal Social Network Study. Gerontologist 60(4):607–16. https://doi.org/10.1093/geront/gnz051 Rowland SA, Cohen MZ, Pullen CH, Schulz PS, Berg KE, Kupzyk KA, et al (2020) Vicarious Experience to Affect Physical Activity in Women: A Randomized Control Trial. West J Nurs Res 42(4):286–92. https://doi.org/10.1177/01939459198565 Morrison L, McDonough MH, Zimmer C, Din C, Hewson J, Toohey A, et al (2023) Instructor Social Support in the Group Physical Activity Context: Older Participants’ Perspectives. J Aging Phys Act 31(5):765–75. https://doi.org/10.1123/japa.2022-0140 Jones LW, Courneya KS (2002) Exercise counseling and programming preferences of cancer survivors. Cancer Pract 10(4):208–15. https://doi.org/10.1046/j.1523-5394.2002.104003.x Greene J, Ramos C (2021) A Mixed Methods Examination of Health Care Provider Behaviors That Build Patients’ Trust. Patient Educ Couns 104(5):1222–8. https://doi.org/10.1016/j.pec.2020.09.003 Morasso G, Caruso A, Belbusti V, Carucci T, Chiorri C, Clavarezza V, et al (2015) Improving Physicians’ Communication Skills and Reducing Cancer Patients’ Anxiety: A Quasi-Experimental Study. Tumori J 101(1):131–7. https://doi.org/10.5301/tj.5000230 Mechanic D, Meyer S (2000) Concepts of trust among patients with serious illness. Soc Sci Med 51(5):657–68. https://doi.org/10.1016/S0277-9536(00)00014-9 Campbell KL, Winters-Stone K, Wiskemann J, May AM, Schwartz AL, Courneya KS, et al (2019) Exercise Guidelines for Cancer Survivors: Consensus statement from International Multidisciplinary Roundtable. Med Sci Sports Exerc 51(11):2375–90. https://doi.org/10.1249/MSS.0000000000002116 Milne HM, Wallman KE, Guilfoyle A, Gordon S, Courneya KS (2008) Self-Determination Theory and Physical Activity among Breast Cancer Survivors. J Sport Exerc Psychol 30(1):23–38. https://doi.org/10.1123/jsep.30.1.23 Kauffeldt KD, Sabiston CM, Latimer-Cheung AE, Tomasone JR (2023) “It has to be more than exercise”: exploring multiple perspectives to community-based exercise program design for persons with breast cancer. Support Care Cancer 31(12):635. https://doi.org/10.1007/s00520-023-08089-4 Additional Declarations Competing interest reported. Two of the authors are affiliated with CERP (AA and NC). As such, data collection, analysis, and manuscript development were led by NH, RR, and CHS who are not engaged in the delivery of CERP and had no prior interactions with the trainers or participants. 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-6347715","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":456061880,"identity":"9b0f3a8e-c3db-4a01-a608-10ccf6382fd0","order_by":0,"name":"Nadia Huynh","email":"","orcid":"","institution":"Cedars-Sinai Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Nadia","middleName":"","lastName":"Huynh","suffix":""},{"id":456061881,"identity":"540e1787-df44-4145-887d-0cbdf8b5500d","order_by":1,"name":"Ciera Torney","email":"","orcid":"","institution":"University of Southern California","correspondingAuthor":false,"prefix":"","firstName":"Ciera","middleName":"","lastName":"Torney","suffix":""},{"id":456061882,"identity":"7a0452b3-163a-4345-84ab-b78888d739da","order_by":2,"name":"Novalyn Cruz","email":"","orcid":"","institution":"Cedars-Sinai Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Novalyn","middleName":"","lastName":"Cruz","suffix":""},{"id":456061883,"identity":"226b092f-3258-4303-9e97-a01c17eeb275","order_by":3,"name":"Rachel Ruggieri","email":"","orcid":"","institution":"Cedars-Sinai Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Rachel","middleName":"","lastName":"Ruggieri","suffix":""},{"id":456061884,"identity":"cb7ebdb4-b996-4c66-9d38-849a4240a16c","order_by":4,"name":"Philip Chang","email":"","orcid":"","institution":"Cedars-Sinai Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Philip","middleName":"","lastName":"Chang","suffix":""},{"id":456061885,"identity":"7096fe02-c079-4e2f-bc36-ffe0ef065b31","order_by":5,"name":"Arash Asher","email":"","orcid":"","institution":"Cedars-Sinai Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Arash","middleName":"","lastName":"Asher","suffix":""},{"id":456061886,"identity":"89aaa95a-7097-4c40-aa71-3ea506d4370d","order_by":6,"name":"Celina H. Shirazipour","email":"data:image/png;base64,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","orcid":"","institution":"Cedars-Sinai Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Celina","middleName":"H.","lastName":"Shirazipour","suffix":""}],"badges":[],"createdAt":"2025-03-31 20:53:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6347715/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6347715/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85128321,"identity":"cafbfc39-fe96-480f-af29-8c48a0f194ea","added_by":"auto","created_at":"2025-06-22 02:01:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":844746,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6347715/v1/46a245a7-f052-4d13-8cb5-ea18d3f2531b.pdf"}],"financialInterests":"Competing interest reported. Two of the authors are affiliated with CERP (AA and NC). As such, data collection, analysis, and manuscript development were led by NH, RR, and CHS who are not engaged in the delivery of CERP and had no prior interactions with the trainers or participants.","formattedTitle":"Strategies for promoting exercise adherence within a cancer exercise recovery program","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePhysical activity (PA) can meaningfully improve physical health, mental health (and other critical quality of life indicators for cancer survivors [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Furthermore, studies investigating breast, colorectal, and prostate cancer survivors suggest that PA can lower the risk of cancer recurrence and improve survival [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, despite the benefits of PA for cancer survivors, adherence to cancer-specific PA guidelines is low, with current estimates suggesting that 17\u0026ndash;47% of cancer survivors meet PA guidelines [\u003cspan additionalcitationids=\"CR4 CR5 CR6\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDiverse factors may influence whether cancer survivors adhere to PA. At a societal and structural level, low adherence may be due to health policies and health system approaches. For example, PA resources are least represented of all supportive care services; thus, PA programs developed specifically for the unique needs of cancer survivors can be hard to access [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. At a programmatic level, trainers\u0026rsquo; knowledge about a survivor\u0026rsquo;s background, along with the availability of proper cancer PA education, are pivotal [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. At the individual level, previous PA participation, knowledge, and skills, as well as cancer treatment effects can influence adherence [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLow PA adherence may also be due to program quality [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. To assist in the development of quality PA programs, researchers developed the Quality Parasport Participation Framework [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The Framework identifies six experiential elements of quality participation: autonomy, belongingness, challenge, engagement, mastery, and meaning [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. To foster these experiential elements, there are also programmatic conditions to consider, relating to the physical environment, social environment, and program environment. Initially developed for sport among people with disabilities, this Framework has since demonstrated applicability to diverse programs and communities, including PA for cancer survivors [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe purpose of this study was to understand participant and trainer experiences within a high adherence cancer PA program, with the goal of identifying program delivery that may be related to high program adherence. In contrast to the adherence rates identified in the literature, the program of interest (Cancer Exercise Recovery Program; CERP) has an adherence rate of over 90%, as well as extensive interest with an over 6-month waitlist. Ultimately, identifying factors that contribute to successful implementation of a high adherence cancer exercise program may support health care providers and exercise physiologists in developing and delivering cancer exercise programs that promote sustained participation so cancer survivors may experience the important benefits of PA.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eContext\u003c/h2\u003e \u003cp\u003eCERP is delivered in a large medical research hospital. The space features approximately 2800 sq. ft. which includes the gym, and conference room space for individual assessments. The space has one wall of windows to allow for natural light and views of the city to look at while engage in exercise. Equipment includes a treadmill, elliptical machine, upright and recumbent bike, leg/chest press, leg curl extension, cable cross machine, rower, and free weights. The program was designed to be highly individualized for cancer survivors to ensure it is safe for their age, functional status, co-morbidities, and other clinical factors important in this population (e.g., cachexia, chemotherapy-induced peripheral neuropathy, bone metastasis, lymphedema, or negative changes in body composition). Upon enrollment, the participant undergoes a comprehensive fitness and medical evaluation led by the lead exercise physiologist (EP). During this evaluation, the patient\u0026rsquo;s personal goals are established to guide the development of their program. The assessment also includes strength testing, functional assessments, and measurement of body composition. The EP then creates a customized program that is gradually progressed over three-months. Sessions are tailored to rebuild strength, endurance, and flexibility. The intervention is supervised by a trainer (EP or technician with oncology certification through the American College of Sports Medicine). One trainer is assigned to a maximum of two participants per one-hour session, with sessions occurring two to three times per week. At the end of the 3-month program, the assessment is repeated to measure impact and to help plan a home program for maintenance.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePhilosophical assumptions\u003c/h3\u003e\n\u003cp\u003eThis study was framed in ontological relativism and epistemological constructivism to gain an in-depth understanding of CERP program experiences and mechanisms of program delivery that support strong adherence. Our participant demographics represent significant heterogeneity in gender, cancer type, cancer treatment, physical activity history, family support, etc. We sought to embrace considerations of how these unique identities and experiences influence the data from data collection through to development of the current manuscript.\u003c/p\u003e\n\u003ch3\u003ePositionality\u003c/h3\u003e\n\u003cp\u003eOur research team consisted of researchers and clinicians trained in physical medicine and rehabilitation, as well as behavioral sciences, sport and exercise psychology, and exercise physiology. One member of our team (AA) created and leads the CERP program, while another member of our team (NC) is the lead exercise physiologist. To increase participant willingness to be honest and transparent, data collection and analysis was led by the other team members who are not involved in delivery of CERP or any clinical programming. Regular meetings were held with AA and NC to enhance understanding of program elements discussed in interviews and improve contextual knowledge. Given the closeness of two members of the research team to the program being examined, the research team continuously questioned how their experiences and identity influenced their interpretation of the transcripts and openness to participant responses. NH and CHS held ongoing weekly discussions about their perspectives of PA in survivorship throughout the analysis process. In addition, throughout analysis and preparation of this paper, transcripts were reviewed to ensure that findings were representative of participant experiences.\u003c/p\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eEthics approval\u003c/strong\u003e was received from the Cedars-Sinai Medical Center Institutional Review Board, which operates in accordance with the Belmont principles (STUDY00000627). Following receipt of this approval, CERP trainers and patients were recruited for interviews. CERP trainers (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2) were current staff involved in CERP. They were invited to participate by email and in-person during their monthly meeting. Two of the three trainers agreed to participate. Former and current CERP patients (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;18) were recruited through an e-mail with study information sent by AA to a database of CERP patients and alumni. Prior to engaging in an interview, verbal informed consent was obtained from all participants (trainers and CERP patients). A total of 20 participants engaged in interviews. See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for full demographic information.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic characteristics of CERP patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePseudonym\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRace/ethnicity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCancer Type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAaron\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhite/Non-Hispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMultiple myeloma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBarbara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhite/Non-Hispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBreast cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaroline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhite/Non-Hispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBreast cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDavina\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhite/Non-Hispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBreast and ovarian cancer, metastatic carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmily\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBlack/Non-Hispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBreast and fallopian tube cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFreya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhite/Non-Hispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBreast cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrace\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhite/Non-Hispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAdenocarcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHazel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhite/Non-Hispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBreast cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIris\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhite/Non-Hispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAnal Cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhite/Non-Hispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBreast cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKai\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBlack/Non-Hispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBreast cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeanne\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhite/Non-Hispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBreast and ovarian cancer, peritoneal carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMike\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhite/Non-Hispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMantle cell lymphoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNoel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhite/Non-Hispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSmoldering myeloma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOliva\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhite/Non-Hispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOvarian cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaul\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhite/Non-Hispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChronic lymphocytic leukemia, splenic marginal zone b-cell lymphoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuinn\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhite/Non-Hispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBreast, endometrial cancer, melanoma of the skin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRichard\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhite/Non-Hispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHead, neck, tonsil cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003e[Insert Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003eSemi-structured one-on-one virtual interviews were conducted by individuals unaffiliated with CERP to enable participants to share their experiences without concern of the impact of their feedback on their future healthcare experiences or employment. Interviews lasted approximately 45 minutes. Interviews were audio-recorded and subsequently transcribed verbatim by a member of the research team.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eThe Interview Guide\u003c/h2\u003e \u003cp\u003e Interviews were tailored based on participant roles in the program. The patient interview guide was divided into three parts: (1) identifying their PA background prior to diagnosis; (2) CERP experience; and (3) program expectations. Participants who had completed CERP were also asked about their post-CERP PA participation. Meanwhile, the trainer interview guide was informed by the Quality Parasport Participation Framework [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], and focused on: (1) their background in PA and cancer survivorship; (2) the program environment; (3) their approach to building an optimal social environment; and (4) ideal outcomes for patients.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eData were analyzed using thematic analysis [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This consisted first of deep immersion in the transcripts. NH read and reread the data, taking notes on questions and thoughts that arose throughout. Throughout this process, NH had weekly meetings with CHS and RR, who had conducted the interviews, to ask questions about the interviews and engage in reflexive consideration of positionality and biases. An inductive coding process was then conducted during which meaningful extracts of data were identified and labeled. These codes were organized into themes indicative of program delivery strategies. These themes were then examined in relation to the Quality Parasport Participation Framework [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This additional analysis provided deeper consideration on the definitions and expression of the different quality elements that could be indicative of best practices in the context of CERP, and resulted in reorganization and relabeling of themes. NH and CHS then presented the refined themes to the rest of the team. During these meetings, the team members acted as critical friends, provoking further discussion and consideration of participant meanings. These meetings were important based on each attendee\u0026rsquo;s diverse backgrounds, roles in relation to the research project and CERP, and experiences with PA and cancer survivors. These diverse backgrounds allowed for a more thorough review and discussion of the data and findings. Following these meetings, themes were refined again, which was followed by the writing of the manuscript. In addition to the quality and methodological rigour practices identified above, the research team were further guided by 20 questions for assessing thematic analysis research quality [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Results and Discussion","content":"\u003cp\u003eThree themes were identified: (1) facilitating the accessibility of exercise programs; (2) the importance of trainers and peers; and (3) tailored programming fosters long-lasting engagement. Within the context of the Quality Parasport Participation Framework, these themes correspond to the programmatic conditions (physical environment, social environment, and activity characteristics, respectively). For each theme, corresponding strategies are identified that were linked by CERP participants and trainers to quality participation and outcomes. Participant quotes are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant and Trainer Quotes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSub-theme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote Source\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQuote\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacilitating the Accessibility of Exercise Programs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDifferentiating cancer exercise programs from traditional commercial gyms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;It was wanting to do it in a place that was safe. I don't really care for gyms that much. There's so much grunting of all these showoff guys. I find that really distracting and then it kind of pisses me off. So [CERP] was like a safe environment for me.\u0026rdquo; (Caroline)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTrainer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;(\u0026hellip;) at a commercial gym that makes it a lot more difficult to stay within the program for them compared to us. You know, one, gyms are packed. There's Sa lot of people. It can get very intimidating, and these people are all, look, seem very healthy and, (laughs) and strong. And I get that it can be very intimidating to folks who had cancer and had surgery and dealing with chemo and all that stuff.\u0026rdquo; (Eli)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFinancial toxicity and the importance of no-cost programming\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;[CERP is] like a gift. There's not a lot of joy all the time. I mean, I get depressed a lot. But [CERP] helps, and [it] feels good that it's free and they care. It's just one less [financial] responsibility and it'll make you show up. You start financially \u0026hellip;. you get depressed and then you start pulling away. Like it might not be that you don't want to go. There's too much financial burden so it makes you get into a bad head space. And then the head space makes you not wanna exercise. And it becomes an out-of-control spiral. 'Cause we're there so much for so many visits for doctors that we're paying so much money for so much else.\u0026rdquo; (Quinn)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFlexible scheduling to accommodate integration of exercise into daily living\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;He [CERP scheduler] was also really flexible in terms of scheduling. So kind of the issue is, I mean, I know there's a certain amount of time and obviously schedules everybody, someone's late they throw off everybody else's schedule (\u0026hellip;) I had to make some changes. I had corporate meetings I had to be at and stuff. And as long as I emailed him, which I always did ahead of time\u0026mdash; Super flexible with that. So that all made a really big difference. It really felt like a really high end paid personal training program. You know, where it wasn't like, you miss it, we can't make it up. We understand you're not in any trouble, but we have to move on. It was not like that. It was really, it's just such a thoughtful program.\u0026rdquo; (Freya)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTrainer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;A lot of participants we are working with have jobs still or are taking care of kids. So we try to work based on their preferred schedule time. (\u0026hellip;) We're gonna see them for three months and we want to see them every [day they are scheduled]. If they're busy, if the time doesn't work, and they're gonna miss half the time, then what's the point?\u0026rdquo; (Trainer Melanie)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe importance of trainers and peers for promoting adherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe importance of fostering social support amongst patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;I just was so appreciative. (\u0026hellip;) I do think it's helpful to be there with other patients going through maybe what you went through and maybe you talk about, you know, how you're feeling or who your oncologist is. I think that's important to have a sense of community (\u0026hellip;) we all cheered each other on too. It's just like, keep going, you can do it that kind of thing.\u0026rdquo; (Barbara)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTrainer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;I've gotten the impression that when they're exercising, they get motivation from having to see other participants exercising. And, being able to be social with others has actually been helping them to continue exercising (\u0026hellip;).\u0026rdquo; (Melanie)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrainer education and approach to cancer-focused rehabilitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;I felt like she got me. She got it. Like she didn't let me off the hook, but she also took into consideration all the little collateral damage that I had from treatment. I'm like, \u0026lsquo;Okay. My shoulder is this, or like this...\u0026rsquo; or \u0026lsquo;I have this spasm in my chest.\u0026rsquo; I don't want to explain that to someone who just doesn't know or doesn't even get it. And like I could be doing well one day, and I could have a spasm. It's spontaneous. But I also don't want to be looked at like, \u0026lsquo;Oh you have cancer.\u0026rsquo; I don't want that; I don't need that. But I do want an understanding that my body is different and sensitive. And I think that she had the perfect balance at that.\u0026rdquo; (Olivia)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTrainer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;And when you start just developing a relationship, so talking about things other than what they're going through. Something, interpersonal... Asking them about their life and where they come from. And I feel like that does help sort of reduce (\u0026hellip;) the tension that most people will feel in the beginning. Because not only is exercise so foreign to them, but they're also still experiencing some of the side effects from treatment. So, they'll be afraid to try to move, maybe their shoulder, especially if they've had lymph nodes removed or, they\u0026rsquo;re afraid to do balancing exercises if they had neuropathy. So, it\u0026rsquo;s easier to get them to accept the program.\u0026rdquo; (Eli)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTailored programming fosters long-lasting engagement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;Going through a program that was tailored toward me in my experience of what I was going through with chemo is really important because I think it would be difficult to find a trainer that knows how to deal with some of the side effects of what I was going through. At the time, I still had a port in my arm as well. And they took that into consideration that it wasn't bothering that area that was still sore and tender. And work towards just like goals I had around balance and the neuropathy. It was important to me for that reason really improved my mental health as well\u0026hellip;As a young person with cancer, it's hard to not be able to do things that [I] used [to do] easily.\u0026rdquo; (Olivia)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTrainer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;I had one participant, metastatic, and she was going through a rough time. She didn't think that exercise would help with her energy level. She [thought] that it was not gonna help at all. But then later she realized that she had more energy. She started at four exercises for the first couple of weeks. And then later she's doing 10 exercises. She starts telling me about things that she wants to start doing. She used to go surfing and it was hard for her to push up onto the board, you know to be able to surf in. So, she hasn't been able to do that. So, I've been incorporating exercises where it has helped her to be able to do those certain movements.\u0026rdquo; (Melanie)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eFacilitating the Accessibility of Exercise Programs\u003c/h2\u003e \u003cp\u003eThree sub-themes were identified indicative of strategies to promote an optimal physical environment: differentiating cancer exercise programs from traditional commercial gyms; financial toxicity and the importance of no-cost programming; and flexible scheduling to accommodate integration of exercise into daily living.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eDifferentiating cancer exercise programs from traditional commercial gyms\u003c/h2\u003e \u003cp\u003eConsistent with existing research, participants mentioned bodily changes due to cancer treatment, which resulted in both physical and psychological barriers to PA [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Physical changes decreased self-efficacy because of low perceived ability to perform at the level they did before treatment. Learning how to be active with these changes elicited fear. CERP participants believed that a private exercise facility developed specifically for cancer survivors provided a safe venue for them to restart exercise post-active treatment. In contrast, participants suggested that commercial gym culture may discourage exercise engagement. Some participants found the environment conducive to negative comparison. The fitness culture fostered in these environments caters specifically to individuals without illnesses and many felt bad seeing others who could lift more or active in ways they couldn\u0026rsquo;t achieve following diagnosis and treatment. This perspective was reinforced by the trainers who noted that the physical appearance and fitness of individuals at commercial gyms had the potential to discourage cancer survivors. Meanwhile, participants noted that the CERP gym provided a sense of privacy that allows them to exercise at their own pace without fear of comparison to others. Although CERP\u0026rsquo;s facility is smaller than standard gyms, participants noted a particular benefit: more interaction. Privacy and intimacy were vital elements that were seen to minimize external distractions and facilitate relationship building with trainers and other participants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eFinancial toxicity and the importance of no-cost programming\u003c/h2\u003e \u003cp\u003eParticipants discussed the poor mental health outcomes of financial toxicity and its larger impact on exercise. Cancer survivors who experience more financial toxicity report higher levels of depression and anxiety symptomology, greater unease, and lower self-efficacy in coping with cancer [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. These depressive symptoms can influence a patient\u0026rsquo;s motivation to seek recovery activities [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The compounded effect of both financial restrictions and the emotional implications of financial restrictions discouraged many participants not only from trying to find programs but from participating in exercise at all. Incorporating exercise after treatment required emotional effort as cancer treatment required substantial financial and physical effort and exercise would have been another responsibility for participants to shoulder. Participants recognized the importance of PA as part of a supportive care plan and as a means, in some cases, to combat cancer recurrences and/or cancer effects. However, many discussed having little to no funds available to pay for programs resulting in a lack of PA participation despite willingness. It isn\u0026rsquo;t uncommon for cost of PA to deter PA participation [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. With the financial burden shouldered by patients and their families due to cancer treatment, a key strategy was the fact that CERP is free. Not having to think about the cost of CERP or find funds to pay for the program decreased some of the mental load, allowing participants the freedom to choose to engage in exercise to support their recovery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eFlexible scheduling to accommodate integration of exercise into daily living\u003c/h2\u003e \u003cp\u003eOne of the barriers to PA consistently identified is time [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. For many cancer survivors, life post-treatment means resuming all of life\u0026rsquo;s responsibilities from work, to family, and/or education [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. As such, an important strategy used by CERP was placing the burden of scheduling on CERP rather than the participant. When participants joined the program, they had an initial call with a program coordinator who took note of their work schedule, commitments, and driving distance. Staff then created a flexible scheduling system to reflect these barriers and would be feasible for integrating CERP into daily life. While many praised these scheduling accommodations, limitations were identified based on CERP being a clinical program versus a commercial gym. As a clinical program, CERP is only open Monday to Friday during business hours. Participants who didn\u0026rsquo;t have regular employment, were on leave, or retired didn\u0026rsquo;t mind. However, others noted that adding timeslots outside working hours (mornings, evenings, weekends) would make their day smoother and less stressful, particularly as some had to submit special requests to their employers to allow for late arrival or early departures to engage in CERP. Timeslots outside working hours were also an important consideration given the heavy traffic often encountered in the city. More scheduling variety was viewed as creating better accessibility.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eThe importance of trainers and peers for promoting adherence\u003c/h2\u003e \u003cp\u003eTwo sub-themes were identified: the importance of fostering social support amongst patients; and trainer education and approach to cancer-focused rehabilitation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eThe importance of fostering social support amongst patients\u003c/h2\u003e \u003cp\u003eThe social support received post-treatment can be integral for adaptive coping [\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. CERP offered an opportunity for participants to interact with individuals who shared their cancer experience. CERP staff reviewed patient files prior to scheduling sessions. When feasible, based on the discretion of the program coordinator and EP, participants were paired based on age, gender, or stage of cancer. This attention to social pairing had the intended effect. Participants discussed how CERP provided the foundation for community-building. Participants often spent their time discussing treatment or medication experiences and gaining emotional support from a fellow survivor\u0026rsquo;s perspective. These interactions allowed patients to feel comfortable expressing fears or hardships without judgement and helped to normalize the cancer experience [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Need for camaraderie between CERP participants was, however, dependent on the existence of available support elsewhere (e.g., other programs, family, friends) and whether participants viewed peer support as important prior to the program. Finally, peer interactions also provided opportunities for motivation and modeling of exercise participation. Consistent with the concept of vicarious experience being an important building block of self-efficacy [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], participants noted that observing other cancer survivors work hard in the gym gave them confidence and motivated them to do the same.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eTrainer education and approach to cancer-focused rehabilitation\u003c/h2\u003e \u003cp\u003eStaff and trainers may serve as pillars of support by fostering autonomous engagement, developing caring connections, instilling trust through expert instruction, managing conflict directly and effectively, and creating a climate where people want to attend a program [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Indeed, participants highlighted the importance of having knowledgeable and compassionate trainers to guide them during the rehabilitation process. Research suggests that cancer survivors prefer to receive instruction from trainers who are knowledgeable about cancer [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Working with trainers who have prior experience with cancer survivors was identified as essential as participants felt they would \u0026ldquo;[understand] psychologically what\u0026rsquo;s going on\u0026rdquo; (Paul) and have more empathy that would avoid \u0026ldquo;stupid conversations\u0026rdquo; (Jo). With this understanding, trainers can tailor their approach to each participant, adapting exercises to individual and/or daily needs as the program progresses.\u003c/p\u003e \u003cp\u003eCERP staff receive extensive training in PA and cancer survivorship. For example, CERP EPs receive national certification in cancer and exercise training. In addition to this formal training, the Director of CERP also leads monthly team meetings to discuss recent scientific advancements on PA promotion and/or cancer survivorship. The CERP trainers\u0026rsquo; understanding of the physiological components of post-treatment exercise, as well as psychosocial aspects of the cancer experience provided two benefits: 1) participants felt understood and respected with trainers finding a balance between being empathetic of their cancer diagnosis while still viewing them as capable individuals; and 2) participants felt comfortable openly communicating their concerns because the trainers are knowledgeable and capable of modifying activities as needed. Having trainers capable of recognizing how to adapt to the sometimes daily fluctuations of side and late effects allows participants to continue to engage in PA. For many participants it was also important that trainers did so without defining them by their diagnosis.\u003c/p\u003e \u003cp\u003eHealthcare providers build trust by demonstrating competence, care, and communicating effectively [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The previous strategies demonstrated competence and caring; however, effective communication was also employed to support participant goals and bolster confidence. According to trainers, initial sessions are particularly important for acclimating participants to the space, reintroducing exercise, and building self-efficacy for PA post-treatment. Building rapport through methods including casual conversation can ease discomfort during those early stages of rehabilitation. As time went on, trainers provided constructive feedback for guidance and to celebrate improvements. This gave participants a practical assessment of progress, which motivated them to continue PA. Finally, trainers also used non-verbal communication like body language, and encouraging facial expressions and gestures to promote comfort and confidence. For the participant, the above communication techniques are important for reducing tension or fear [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], and have been demonstrated to help establish trust and promote engagement [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eTailored Programming Fosters Long-Lasting Engagement\u003c/h2\u003e \u003cp\u003eCancer diagnosis and treatment may affect PA, so activities should be tailored to fit individual preference, age, type and stage of cancer, and other health considerations [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Participants felt it was important for trainers to customize activities to account for individual differences. The nuanced understanding that trainers attain from working with cancer survivors strengthen their ability to tailor activities to daily fluctuations in symptoms with precision and care.\u003c/p\u003e \u003cp\u003eBeyond tailoring to treatment and cancer effects, it was viewed as equally important to tailor participation to individual goals both within and outside CERP. These goals and the subsequent tailoring of activities may not directly target treatment-related symptoms, but the ability to engage in patient-preferred activities. Being receptive to these requests through an autonomy-supportive approach has been demonstrated to promote adherence to PA guidelines [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Beyond autonomy, other quality elements were fostered, particularly an increased sense of mastery. CERP participants gained self-confidence in their abilities after consistently achieving and surpassing activity goals set during each session. As the participant becomes more confident in themself, they begin setting new goals.\u003c/p\u003e \u003cp\u003eBesides tailored programming, certain techniques employed by staff also added to the participants overall experience during their time in the program. EPs utilized care planning techniques like coordinating with other providers and assigning one trainer per participant for the entirety of their journey through CERP. One participant noted that \u0026ldquo;the really great thing about CERP is that we were getting individual attention. And I couldn't wait to get there every day for that.\u0026rdquo; (Iris) Not only is having one on one time with a trainer important for building rapport, but it also makes participants eager for the next session. In addition, participants believed that it made them more accountable for session attendance.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study identified three delivery strategies that were linked by CERP participants and staff with cancer exercise program adherence: facilitating the accessibility of programs; the importance of trainers and peers for promoting adherence; and tailored programming to foster long-term engagement. The strategies fostered quality participation elements in addition to alleviating many psycho-emotional barriers to post-treatment PA.\u003c/p\u003e \u003cp\u003eThese findings align with previous research on quality participation and PA for cancer survivors. For example, Fong and colleagues identified the quality participation elements of challenge and mastery, as well as social and physical environment conditions as being linked to quality experiences for breast cancer survivors in outdoor exercise programming [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. A further study examining community-based exercise program participation for breast cancer survivors identified five quality components for program design: improve cancer literacy, provide opportunities to participate with peers, foster self-efficacy, prioritize program accessibility, and integrate program within a network of supportive cancer care [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. These findings parallel the considerations identified in the current study, reinforcing their importance.\u003c/p\u003e \u003cp\u003eWhile this study had many strengths, there are limitations that need to be considered. This analysis focused on in-person program considerations, as CERP is primarily an in-person program. However, virtual programs are gaining prominence as a means to increase reach and access to PA. Future research needs to explore delivery of virtual programming and whether strategies differ or need to be modified to promote program adherence. Other potential considerations that may limit applicability include the urban clinic-based setting of the program and, as a result, the lack of participant diversity in the sample.\u003c/p\u003e \u003cp\u003eIn sum, this case study examined CERP, an exercise program for cancer survivors that has demonstrated high participation and adherence, with a focus on identifying program strategies that may be associated with PA adherence. As the benefits of PA programming for cancer survivors continue to be reinforced, it is important that researchers examine methods for program implementation, in particular the delivery strategies and experiential aspects of participation that influence participation and adherence to optimize the benefits of supportive care programming.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Cedars-Sinai Cancer Exercise Recovery Program (CERP) and its participants for their involvement in this research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll contributed to the study conception and design. Material preparation and data collection were conducted by C.S. and R.R. Analysis was performed by N.H. The first draft of the manuscript was written by N.H., 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\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by Cedars-Sinai Cancer (CHS).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe interview data generated and analyzed during the current study are available from the corresponding author upon request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo of the authors are affiliated with CERP (XX and XX). 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Support Care Cancer 31(12):635. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00520-023-08089-4\u003c/span\u003e\u003cspan address=\"10.1007/s00520-023-08089-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\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":"cancer survivorship, exercise, physical activity, physical medicine and rehabilitation","lastPublishedDoi":"10.21203/rs.3.rs-6347715/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6347715/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003ePhysical activity (PA) can play an important role in physical health and well-being for cancer survivors. However, cancer survivors demonstrate low adherence to cancer PA guidelines. Research is needed to understand how to optimize delivery of cancer PA programs to enhance participation and adherence. In this study, we examined a clinical cancer exercise recovery program (CERP) demonstrating high adherence (over 90% session completion), with the goal of understanding implementation strategies that may be linked to higher program adherence.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eSemi-structured interviews were conducted with CERP program trainers (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2), as well as CERP program participants (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;18; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;13 women) with diverse cancer diagnoses and treatments. Data were analyzed using thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA series of strategies were identified that were linked by study participants to program adherence. These strategies were organized into three programmatic components: the physical environment, social environment, and activity characteristics.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe identified implementation strategies may support health care providers and exercise physiologists in the development of cancer PA programming that promotes quality participation experiences and high program adherence, allowing participants to experience the benefits of PA post-treatment.\u003c/p\u003e","manuscriptTitle":"Strategies for promoting exercise adherence within a cancer exercise recovery program","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-15 14:24:17","doi":"10.21203/rs.3.rs-6347715/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":"2cb81b5c-e32f-458d-b253-1be8e306f0db","owner":[],"postedDate":"May 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-22T01:53:18+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-15 14:24:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6347715","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6347715","identity":"rs-6347715","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}