Maintaining long-term physical activity after cancer: A conceptual framework to inform intervention development

Maintaining long-term physical activity after cancer: A conceptual framework to inform intervention development | 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 Maintaining long-term physical activity after cancer: A conceptual framework to inform intervention development Chloe Grimmett, Teresa Corbett, Katherine Bradbury, Kate Morton, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2855117/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Aug, 2023 Read the published version in Journal of Cancer Survivorship → Version 1 posted 10 You are reading this latest preprint version Abstract Purpose: This paper describes a conceptual framework of maintenance of physical activity and its application to future intervention design. Methods: Evidence from systematic literature reviews and in-depth (N=27) qualitative interviews with individuals with cancer were used to develop a conceptual framework of long-term physical activity behaviour. Determinants of long-term PA were listed and linked with domains of the Theoretical Domains Framework which in turn were linked to associated behaviour change techniques (BCTs) and finally to proposed mechanisms of action (MoA). Results: The conceptual framework is presented within the context of non-modifiable contextual factors (such as demographic and material resources) and in the presence of learnt and adapted behavioural determinants of skills, competence and autonomous motivation that must be established as part of the initiation of physical activity behaviour. An inventory of 8 determinants of engagement in long-term PA after cancer was developed. Clusters of BCTs are presented along with proposed MoA which can be tested using mediation analysis in future trials. Conclusion: Understanding the processes of PA maintenance after cancer and presentation of implementable and testable intervention components and mechanisms of action to promote continued PA can inform future intervention development. Implications for cancer survivors. This resource can act as a starting point for selection of intervention components for those developing future interventions. This will facilitate effective support of individuals affected by cancer to maintain PA for the long term. Figures Figure 1 Introduction Each year more than 17 million people are diagnosed with cancer worldwide (1). Cancer and its treatment can result in numerous adverse physical and psychological consequences, some of which can persist for years after treatment completion. Individuals with a history of cancer are also at risk of cancer recurrence and developing other chronic conditions such as heart disease. Engaging in regular physical activity (PA) can mitigate many of these adverse effects including fatigue, anxiety, depression, physical functioning and health-related quality of life (2) and reduce cancer recurrence and improve survival (3). Despite this around 70% of people with cancer are not meeting physical activity guidelines (4–7). Systematic reviews and meta-analysis have found clinically significant effects of interventions to support initiation of physical activity behaviour change with substantial increases in activity levels from baseline to end of intervention (8–10). However, to sustain the health benefits of physical activity individuals must be habitually physical active for the long term. There is some evidence of modest maintenance effects (11) in people with cancer but activity levels typically regress towards baseline as the time from end of intervention increases (12). There are scant examples of interventions developed with an explicit aim to support sustained increases in physical activity in people affected by cancer and further research is required. Key to developing effective interventions is to identify determinants of the target behaviour in the population in question as well as potential processes of change. Intervention components that influence those determinants can then be identified. This can be achieved by reviewing existing literature and consultation with the intervention development team. It is also increasingly recognised that empirical research with the specific population is imperative to fully understand the ‘problem’ and identify potential solutions. These are core principles of intervention development frameworks such as Intervention Mapping and the MRC Guidance for development of complex interventions (13). Such development frameworks also recommended the use of theory of behaviour/behaviour change to guide the identification of pathways of change and appropriate intervention components. The Theory of Planned Behaviour, Social Cognitive Theory and the Transtheoretical Model have received much attention within the PA and cancer literature (14–16). However empirical evidence suggests no one theory is superior and that theory-based interventions are as effective as those without explicit theoretical underpinning (17, 18). This may be because both types of intervention include similar behaviour change techniques (the main catalysts of intervention effects) (13, 17) and existing theories have multiple overlapping constructs. To address the latter, issue the Theoretical Domains Framework (TDF) was developed. It brings together 33 models of behaviour/behaviour change, including 128 separate constructs and is increasingly used by researcher developing complex interventions that target health behaviour change (19). The TDF has 14 theoretical domains from which researchers can draw on to support identification of pathways of behaviour change. Furthermore, for optimal transparency of the intervention development process, and to advance our understanding of not just what works, but how it works, researchers are encouraged to identify the proposed mechanisms of action (MoA) through which interventions are hypothesised to exert their effects. MoA are ‘the processes through which behaviour change techniques affect behaviour’ (20). For example, a barrier to engagement in physical activity might be a lack of belief in one’s capability to perform the behaviour. Intervention developers would select BCTs believed to impact the MoA ‘belief in capability’, for example, verbal persuasion and focus on past success. Subsequent evaluation of the intervention would include measuring change in this MoA and conducting mediation analysis to determine its impact on behaviour (21). Central to such endeavours is an agreed matrix of BCTs and hypothesised MoA which can act as a standardised resource, enabling synthesis of data. This has been achieved through a series of studies of literature synthesis (22) and expert consensus (23), triangulated to develop a Theory and Technique tool linking BCTs and their MoA (24). To date there is a lack of empirical data, conceptual or theoretical understanding of the process of engaging in sustained physical activity that can inform the identification of behavioural determinants. Indeed, in concluding remarks following their recent meta-analysis of sustaining physical activity behaviour after intervention completion, McEwan et al. (2021) recommend ‘future efforts to develop and test theoretical frameworks that specially focus on maintenance of health behaviour could help optimise interventions that are concerned with supporting long-term physical activity adherence”(p8). This paper describes the development of a conceptual framework of sustained physical activity engagement in people with cancer through meta-analysis and primary qualitative research. This led to the generation of an inventory of determinants of this behaviour and a corresponding matrix BCTs and associated MoA that can be used as a basis for developing future interventions. Methods A modified version of French et al’s (25) approach to developing theory informed behaviour change interventions was used and involved four phases: 1: Who needs to do what, differently? A systematic review and meta-analysis of long-term physical activity behaviour change in cancer survivors was conducted by our group (11). We explored factors associated with success (or lack thereof) including context, population characteristics and behaviour change techniques. 2. What barriers, enablers and processes need to be addressed? To afford an in-depth understanding of the barriers, enablers and processes involved in long-term PA behaviour change a qualitative study of 27 cancer patients who had taken part in a previous PA programme in the UK was conducted (26). Inductive thematic analysis was conducted, and findings were combined with those from the aforementioned systematic review and meta-analysis (15) and evidence from relevant qualitative meta-syntheses and reviews (12, 27–29), selecting and structuring factors to create constructs that informed the development of an inventory of key determinants of sustained PA behaviour. These data also informed the development of a conceptual framework describing the processes of sustained PA engagement. 3. Using a theoretical framework, what intervention components could address these barriers and enablers? In consultation with co-authors, barriers and enablers were mapped to the associated domains of the Theoretical Domains Framework. Using published expert consensus linking BCTs to the TDF domains (30) BCTs were identified that might address these barriers and enablers. In addition, we reviewed the recently published compendium of ‘self-enacted techniques’ (31) and selected additional intervention components hypothesised to impact on the target determinants. 4. How can the behaviour change be understood? Using the Theory and Techniques Tool we identified key MoA associated with each behaviour change technique which could be used to assess intervention causal pathways (mediating behaviour change). This was an iterative process involving regular meetings and revisions at all stages with co-authors. Results 1. Who needs to do what differently? The systematic review and meta-analysis, including 19 studies, concluded that existing interventions with a long-term follow-up were successful in achieving moderate improvements in sustained behaviour change (11). Older adults, those with existing functional limitations and who had fewer contacts with those delivering the PA programme were less likely to sustain PA increases. Furthermore, PA programmes included in the review with poorer long-term behaviour outcomes were less likely to include the BCTs of action planning, graded tasks, and social support (unspecified) (see (11) for full details). These findings were triangulated with the qualitative data (26) and relevant reviews (12, 27–29) generating hypotheses of the processes at play and informing step 2; generation of an inventory of barriers and enablers and conceptual framework. 2. What barriers and enablers need to be addressed? Findings from the qualitative study and systematic reviews were selected and structured to identify an inventory of 8 determinants of engagement in long-term PA behaviour after cancer and a conceptual framework illustrating the processes at play was developed (see Fig. 1). Central to the conceptual framework are the founding factors related to initiation of behaviour required before long-term maintenance can be achieved (depicted in the outer segment of Fig. 1). Such factors are vital for consideration during the initiation of PA behaviour before maintenance can be achieved. Contextual factors are key and include socioeconomic status, demographics (including age, sex, education level) material resources and environment (i.e. access to facilities and/or appealing outdoor space). Appropriate attention must be paid to these factors when identifying when, where, and how an individual will engage in a physically active behaviour. This will ensure the chosen activity is appropriate to the individual’s personal context and resources. Furthermore, the initial intervention must result in motivation to initiate change. The participant must develop the necessary skills to engage with their new activity and that activity must be appropriate to their pathophysiological status. A case study: A participant in the qualitative study described how the practice nurse at her GP surgery repeatedly told her she needed to do more exercise and suggested walking. No support or consultation was provided. The participant reported walking on a handful of occasions but then stopped. Reasons included pain on walking, concerns about breathlessness and difficulties accessing suitable walking routes. On taking part in the Move More intervention she engaged in a conversation with the practitioner regarding her history of PA, likes, and dislikes, her priorities, and commitments as well as existing health condition, which included obesity, mobility issues/joint pain and COPD. A local weekly yoga class was identified which, on the date of interview, the participant had been attending for more than 2 years. Once PA behaviour is initiated, the individual experiences the consequences of that behaviour, including an impact on their affective state and physiological outcomes. When engaging in PA with others this will also include social interaction. If the behaviour results in desired/positive outcomes that behaviour is reinforced and is more likely to be sustained. Inevitably at some point the behaviour will be disrupted. This may be due to affective factors, such as low mood or boredom, or practical, e.g. discontinuation of an exercise class. Alternatively, a life stressor event such as ill health or caring responsibilities can disrupt engagement, as can change to the environment/ resources. Adaptation to this disruption then ensues. This will include a prioritisation process of physical and psychological resources. It may also involve problem solving, assessment and/or change regarding accessibility to local amenities and /or personal resources. Pros and cons of re-engaging with the discontinued activity including reflection on the consequences of behaviour (experienced outcomes) will be influenced by the degree of intrinsic motivation and self-efficacy (confidence) the individual has for that activity. For some social support will play a role here with some individuals requiring practical or emotional support to re-engage. Consequently, the behaviour remains ceased/reduced or resumption occurs. This is a cyclical process. The inventory of barriers and enablers are set out in Table 1 . Table 1 Inventory of Behaviour change techniques and mechanisms of action Determinants of engagement Subcategories of taxonomy TDF domain BCT linked to TDF domain MoA linked to BCT Self-enacted techniques Enjoyment/pleasure Emotion 11.2 Reduce negative emotions 5.4 Monitoring of emotional consequences 3.3 Social support (emotional) Emotion; behavioural regulation - - #19 Monitoring of emotional consequences #29 Task crafting (enjoyment) #109 Focus on enjoyment (pleasant aspects) of behaviour # 119 interpreting physiological and emotional states #98 - Reflect on desire to perform behaviour #100 - Reflect on reasons to perform the behaviour Exercise promoting feelings of empowerment Belief about capability 15.1 Verbal persuasion about capability 15.3 Focus on past success 15.4 Self talk 5.4 Monitoring of emotional consequences Belief about capability Belief about capability Motivation - #107 verbal self-persuasion about own capability #106 valued self-identity (personal strengths) #111 focus on past success #112 looking back Perceived value/outcome Extrinsic outcomes to include maintaining health/function and independence Belief about consequences 5.2. Salience of consequences Belief about consequences; perceived susceptibility/vulnerability #42 contrast/compare pros and cons #40 Make consequences more memorable # 32 Goal integration - modify behaviour to simultaneously engage in another valued behaviour #104 incompatible beliefs #102 find meaning in target behaviour #105 Associate identity with changed behaviour Intrinsic outcomes (e.g. feelings of wellbeing) 5.5 Anticipated regret 9.3 Comparative imagining of future outcomes 16.3 Vicarious consequences 9.2 Pros and cons Belief about consequences Belief about consequences None Belief about consequences; attitude towards behaviour; motivation; general attitude/belief Exercise as a means of social interaction Environmental context 7.1 Prompts/cues 12.2 Restructuring social environment Memory, attention and decision process; environmental context and resources; behavioural cueing Environmental context and resources #54 obtain practical social support Disruption Affective (boredom, anxiety, low mood) Emotion 11.2 Reduce negative emotions 5.4 monitoring of emotional consequences 3.3 Social support (emotional) Emotion; behavioural regulation - - #19 Monitoring of emotional consequences #29 Task crafting (enjoyment) #109 Focus on enjoyment (pleasant aspects) of behaviour # 119 interpreting physiological and emotional states,#31 Add challenge (stops behaviour becoming boring) # 102 find meaning in target behaviour # 32 Goal integration # 114 Normalise difficulty #115 self-kindness #manage negative emotions External disruption (exercise class cancelled) Environmental context 12.1 Restructuring the physical environment 12.2 Restructuring the social environment Environmental Context and Resources; behavioural cueing Environmental context and resources #25 Restructuring the physical environment #26 Restructuring social environment Ill health as a disruption – cancer specific/comorbid conditions/minor illness Environmental context 1.2 Problem solving 1.4 Action planning Belief about capability; behavioural regulation Behavioural cueing Life stressors – i.e. caring responsibilities/work commitments Environmental context 1.2 Problem solving 1.4 Action planning Belief about capability; behavioural regulation Behavioural cueing Perceived appropriateness for age Social influence 6.2 Social Comparison 10.4 Social reward norms; subjective norms; feedback processes Reinforcement; social influence #30 - Task crafting (skills and ability) Confidence/self-efficacy Belief about capability 15.1 Verbal persuasion 15.3 Focus on past success Belief about capability Belief about capability #112 Looking back Monitoring Self-monitoring Behavioural regulation 2.3 Self monitoring of behaviour Feedback processes; behavioural regulation #17 self-monitoring # Reflect on desire to perform behaviour Monitoring by others Social influence 2.2 Feedback on behaviour Motivation; feedback processes #15 obtain feedback on behaviour #60 prompts/cues #55 obtain emotional support [INSERT Table 1 ] Finding pleasure/enjoyment in the chosen activities was a key enabler of maintenance identified in the qualitative data and wider literature. Those individuals who were habitually active talked about the fun they had and enjoyment they felt from being physically active. Individuals engaging regularly in physical activity describe feelings of empowerment as a result, seeing it as evidence that they have overcome the physical challenges of cancer and its treatment and regaining a sense of ownership and control of their bodies. This is linked to a feeling of confidence in their ability to engage in these activities. An individual’s sense of perceived value/experienced outcomes is also integral to motivation to continue to engage in PA participation. Such outcomes included extrinsic factors such as the importance of PA in maintaining health, function, and independence, as well as intrinsic factors such as a sense of wellbeing. For those who participate in group activities social interaction is an important facilitator to engagement. Disruption to PA engagement can typically be divided into affective factors, such as low mood, anxiety and boredom and external factors including terminated exercise classes, ill health of life stressors. The perceived appropriateness of PA to an individual’s age is also important with individuals less inclined to engage if social comparison or personal identity are not aligned with the activities. Finally monitoring of engagement by self or others is an important element of participation. This process enables individuals to track progress and identify reductions in PA that can then be addressed. [INSERT FIGURE 1] 3. Using a theoretical framework, what intervention components could address these barriers and enablers? To identify appropriate intervention components, the inventory of determinants was mapped to domains of the TDF and in turn to associated BCTs (per the Behaviour Change Techniques Taxonomy V1 (32) as determined by published expert consensus (30). Cane et al. (2015) did not include the full list of BCTs as per the V1. Those missing were reviewed and included if, through consensus, they were felt to be appropriate. Intervention components as specified in the Compendium of self-enacted techniques (31) were also selected by identifying techniques that were theorised to influence the identified barriers and enablers and associated MoA. See Table 1 for details. The TDF domains captured include emotion (positive/negative affect), environmental context and resources, social influences, beliefs about consequences, beliefs about capabilities and behavioural regulation. Accompanying BCT clusters (as per the BCT taxonomy) include natural consequences, antecedents, goals and planning, social support, self-belief, feedback and monitoring. Knittle et al’s (31) compendium of self-enacted techniques has several overlapping techniques with Michie’s taxonomy but also includes some important additions which we hypothesize would impact some of the barriers and enablers identified here. For example, boredom was a barrier to continued PA engagement. This might be overcome with the use of the self-enactment technique “add challenge (stops behaviour becoming boring)”. Enjoyment was an important enabler to continued PA and the technique of “task crafting (enjoyment)” and “focus on enjoyment (pleasant aspects)” are likely to facilitate this. 4. How can the behaviour change be understood? Mechanisms of Action associated with the BCTs were identified using the Theory and Techniques tool (33). See Table 1 . Measuring them in future interventions would enable calculation of mediating mechanisms of behaviour change. Discussion This paper presents a novel conceptual model of long-term engagement in physical activity after a cancer diagnosis, with accompanying inventory of determinants and suggested behaviour change techniques. This resource can act as a starting point for selection of intervention components for those developing future interventions. It is essential that it is used alongside a robust development process, using qualitative and co-design approaches to understand the local context and specific participant group, working with multidisciplinary teams to choose methods and modes of delivery that are locally feasible. This conceptual framework is a holistic appreciation of the problem of sustained PA participation after a cancer diagnosis. The outer elements of the framework, including contextual factors such as environment, socioeconomic status, material resources are key, shaping the possibility of initial PA engagement necessary before sustained action can be achieved. Historically, consideration of these contextual factors has often been absent from intervention development. A personalised approach, assessing pathophysiological state and evaluating these contextual factors at an individual level is key to establishing initial PA engagement that has the potential to be sustained. This perspective is in keeping with the recently updated MRC Framework for the Development and Evaluation of Complex Interventions (13). A key addition to which was the inclusion of context in the definition of complex interventions as well as considerations for the systems within which the intervention sits. Comparisons can be drawn between the conceptual model, inventory of behavioural determinants and associated intervention components presented here and Kwasnicka et al’s review of the theoretical explanations for maintenance of physical activity behaviour (34). Kwasnicka and colleagues coded constructs of 100 theories of behaviour and set out five theoretical themes they deem relevant to PA maintenance, four of which are also captured in our work. These include ‘maintenance motives’; regular gratification is more likely to lead to sustained engagement, ‘self-regulation’; including the need for high coping self-efficacy, ‘resources’; psychological and physical assets, and environmental and social influences. In recent years the concept of behavioural maintenance in physical activity has received considerable attention with thought paid to the way maintenance is conceptualised and operationalised. The conceptual model presented here aligns with the evolution in thinking from maintenance of a behaviour as a specific state, to consideration of the underlying mechanisms of action that determine behaviour. This includes shifts back and forth between reflective and reactive processes (35). Rhodes & Sui (35) present a new, working definition of physical activity maintenance as ‘a dynamic development of mechanisms of action that engender greater perceived behavioural enactment efficiency that partially supplant prior mechanisms of action that required greater perceived cognitive recourses to enact physical activity”. They argue that some constructs that were critical to the initiation of a behaviour will still be important for engagement in the longer-term. This is reflected in the conceptual model and associated BCTs presented here where constructs and techniques are essential to embed in the process of initial behaviour enactment to support longer term maintenance. Whilst it has been argued that maintained behaviours are characterised by intrinsic motivations and self-determined actions, self-regulatory skills are still required over time as inevitable disruptions occur and more effortful regulation is required. Hence the suggested inclusion of BCTs that consolidate self-regulatory processes and skills in the initiation of behaviour change, as well as considering long-term behaviour change where these skills may need to be revisited to manage a period of disruption. Furthermore, some individuals may spend longer in a phase of effortful self-regulation than others and need to revisit these skills more frequently. This is also supported by evidence from a review of determinants of physical activity behaviour in older adults which found that self-regulatory strategies such as action planning and coping planning were positively associated with both activity initiation and maintenance (36). Development of a typology of sustained physical activity that proceeded and informed this model argues that individuals fall into three ‘types’ (26). Those who, after initial support to engage successful maintain increased levels of PA through planning and prioritisation. Those who are ‘intermittently active’ with cycles of action and inaction with frequent periods of effortful self-regulation, and those with consistently low levels of PA with minimal engagement in PA during or after intervention participation. Reviewing individuals after 12 weeks of intervention participation to ascertain which of these ‘types’ they most align with could help personalise the intervention components/BCTs that need to be emphasised to support maintenance of behaviour. An important consideration when developing interventions including evidence derived BCTs is to have confidence that these strategies are being delivered and utilised by recipients as intended. Knittle et al (31) recently published the compendium of self-enactable techniques v1.0 to change and self-manage motivation and behaviour. The focus of this taxonomy is that of techniques which individuals can enact themselves, rather than those which are delivered or enacted by the intervention providers. They point to evidence that suggests maintenance of behaviour change following interventions is dependent on the extent to which individuals can enact the BCTs involved (37–39). They also argue that existing taxonomies have insufficient focus on the way techniques are delivered, received (comprehended and understood) and enacted in everyday lives. This new classification also includes techniques from additional behavioural domains that may have utility in affecting behaviour and/or it’s determinants, from sport and occupational psychology. Finally, it is written in ‘plain, accessible language’ and includes ‘adequate instructions and examples to facilitate ease of use by practitioners and the general public’. In this paper we have selected techniques that map to determinants of long-term PA engagement after cancer. Some have considerable overlap with those derived from Michie’s BCT taxonomy (but with accessible examples/definitions to optimise delivery and enactment) whereas others are unique and with intuitive application. For example, ‘task crafting (enjoyment)’ which specifically addresses the concept of making the target behaviour enjoyable. A behavioural determinant for long-term physical activity that is consistently reported in the literature but not explicitly addressed in previous taxonomies. Similarly, ‘normalize difficulty’ – defined as ‘recognise (or remind yourself) that is it common to face difficulties when pursuing behavioural changes’. Consideration of how chosen BCTs are both delivered and received, may help those developing and delivering interventions to maximise fidelity of both delivery and individual enactment. Examples of this include Miles et al (40) who used qualitative methods to explore participant’s understanding of the specific BCTs included in the Diabetes Prevention Program. The focus was self-regulatory strategies such as problem solving, action planning, self-monitoring of behaviour and goal setting. Some techniques, including self-monitoring were well understood and participants accurately described their use. Others, including action planning and problem solving were harder to understand and additional support was needed to enable participants to operationalise these intervention components. It is therefore imperative that those designing and delivering interventions to support long-term PA behaviour change provide appropriate and accessible explanations of the fundamental BCTs to ensure they can be enacted. Assessing this during and after intervention delivery is also important. In addition to the need for evidence informed intervention components it is important to understand how these components exert their effects on behaviour. This paper identifies potentially effective intervention components/BCTs linked to the constructs of the conceptual model and goes on to state the hypothesised MoA through which these BCTs/groups of BCTs exert their effect on behaviour. This was achieved by using a publicly available database where links between BCTs and proposed MoA have been collated based on expert-verified consensus (ref). It has been widely acknowledged that research exploring potential MoA as mediators of behaviour change in specific context with specific populations is necessary to advance the field of behavioural science. Haggar et al (41) describe a process model, including the type of data and analysis needed to contribute to the evidence base of testing proposed MoA. Such contributions will provide data that can be synthesised and increase our collective knowledge of the MoA of interventions. This is important work given the current lack of such evidence, as demonstrated in a recent series of meta-reviews (42). Conclusion This conceptual model and accompanying inventory of potential intervention components is intended to inform those developing novel interventions to promote long term engagement in physical activity after a cancer diagnosis. The model and its proposed MoA could be tested in future, using methods outlined by Haggar and colleagues. Use of this model alongside participatory approaches, consulting with end users and key stakeholders to ensure relevance and appropriateness are encouraged. Abbreviations PA Physical activity BCT Behaviour change technique TDF Theoretical domains framework SCT Social Cognitive Theory TTM Transtheoretical Model MoA Mechanism of Action Declarations Funding : This study was funded by a National Institute for Health Research (NIHR), postdoctoral fellowship. The publication presents the independent research funded by the NIHR. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. Competing interests: The authors declare that they have no competing interests. Authors contributions: Chloe Grimmett was responsible for the conception, design, data interpretation and drafting of the manuscript. Claire Foster and Bernardine Pinto made substantial contributions to the conception of the manuscript. Carl May, Teresa Corbet, Kate Morton and Katherine Bradbury made substantial contributions to the conception and data interpretation of the manuscript. All authors read, revised, and approved the final manuscript. Data availability: The data generated during the current study are available from the corresponding author on reasonable request. Ethics approval and consent to participate: Not applicable to this paper. Ethics approvals were given for the qualitative work proceeding this publication. Consent: Not applicable Availability of data and materials: Not applicable Acknowledgements: Not applicable References UK CR. World Wide Cancer Statistics 2020 [Available from: https://www.cancerresearchuk.org/health-professional/cancer-statistics/worldwide-cancer#:~:text=There%20were%2017%20million%20new,cancer%20each%20year%20by%202040. Campbell KL, Winters-Stone KM, Wiskemann J, May AM, Schwartz AL, Courneya KS, et al. Exercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary Roundtable. Med Sci Sports Exerc. 2019;51(11):2375-90. McTiernan A, Friedenreich CM, Katzmarzyk PT, Powell KE, Macko R, Buchner D, et al. Physical Activity in Cancer Prevention and Survival: A Systematic Review. Med Sci Sports Exerc. 2019;51(6):1252-61. Blanchard CM, Courneya KS, Stein K. Cancer survivors' adherence to lifestyle behavior recommendations and associations with health-related quality of life: results from the American Cancer Society's SCS-II. J Clin Oncol. 2008;26(13):2198-204. Courneya KS, Katzmarzyk PT, Bacon E. Physical activity and obesity in Canadian cancer survivors: population-based estimates from the 2005 Canadian Community Health Survey. Cancer. 2008;112(11):2475-82. Krok-Schoen JL, Pisegna J, Arthur E, Ridgway E, Stephens C, Rosko AE. Prevalence of lifestyle behaviors and associations with health-related quality of life among older female cancer survivors. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer. 2021;29(6):3049-59. SPEED-ANDREWS AE, RHODES RE, BLANCHARD CM, CULOS-REED SN, FRIEDENREICH CM, BELANGER LJ, et al. Medical, demographic and social cognitive correlates of physical activity in a population-based sample of colorectal cancer survivors. European Journal of Cancer Care. 2012;21(2):187-96. Jung Y, Chung J, Son H. Physical Activity Interventions for Colorectal Cancer Survivors: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Cancer Nursing. 2021;44(6):E414-E28. Liu MG, Davis GM, Kilbreath SL, Yee J. Physical activity interventions using behaviour change theories for women with breast cancer: a systematic review and meta-analysis. J Cancer Surviv. 2021. Roberts AL, Fisher A, Smith L, Heinrich M, Potts HWW. Digital health behaviour change interventions targeting physical activity and diet in cancer survivors: a systematic review and meta-analysis. J Cancer Surviv. 2017;11(6):704-19. Grimmett C, Corbett T, Brunet J, Shepherd J, Pinto BM, May CR, et al. Systematic review and meta-analysis of maintenance of physical activity behaviour change in cancer survivors. International Journal of Behavioral Nutrition and Physical Activity. 2019;16(1):37. McEwan D, Rhodes RE, Beauchamp MR. What Happens When the Party is Over?: Sustaining Physical Activity Behaviors after Intervention Cessation. Behav Med. 2020:1-9. Skivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM, et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. BMJ. 2021;374:n2061. Trinh L, Plotnikoff RC, Rhodes RE, North S, Courneya KS. Correlates of physical activity in a population-based sample of kidney cancer survivors: an application of the theory of planned behavior. International Journal of Behavioral Nutrition and Physical Activity. 2012;9(1):96. Stacey FG, James EL, Chapman K, Courneya KS, Lubans DR. A systematic review and meta-analysis of social cognitive theory-based physical activity and/or nutrition behavior change interventions for cancer survivors. J Cancer Surviv. 2015;9(2):305-38. Loprinzi PD, Cardinal BJ, Si Q, Bennett JA, Winters-Stone KM. Theory-based predictors of follow-up exercise behavior after a supervised exercise intervention in older breast cancer survivors. Support Care Cancer. 2012;20(10):2511-21. McEwan D, Beauchamp MR, Kouvousis C, Ray CM, Wyrough A, Rhodes RE. Examining the active ingredients of physical activity interventions underpinned by theory versus no stated theory: a meta-analysis. Health Psychol Rev. 2019;13(1):1-17. Prestwich A, Sniehotta FF, Whittington C, Dombrowski SU, Rogers L, Michie S. Does theory influence the effectiveness of health behavior interventions? Meta-analysis. Health Psychol. 2014;33(5):465-74. Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implementation Science. 2012;7(1):37. Michie S, Carey RN, Johnston M, Rothman AJ, de Bruin M, Kelly MP, et al. From Theory-Inspired to Theory-Based Interventions: A Protocol for Developing and Testing a Methodology for Linking Behaviour Change Techniques to Theoretical Mechanisms of Action. Ann Behav Med. 2018;52(6):501-12. Sheeran P, Klein WM, Rothman AJ. Health Behavior Change: Moving from Observation to Intervention. Annu Rev Psychol. 2017;68:573-600. Carey RN, Connell LE, Johnston M, Rothman AJ, de Bruin M, Kelly MP, et al. Behavior Change Techniques and Their Mechanisms of Action: A Synthesis of Links Described in Published Intervention Literature. Ann Behav Med. 2019;53(8):693-707. Connell LE, Carey RN, de Bruin M, Rothman AJ, Johnston M, Kelly MP, et al. Links Between Behavior Change Techniques and Mechanisms of Action: An Expert Consensus Study. Ann Behav Med. 2019;53(8):708-20. Johnston M, Carey RN, Connell Bohlen LE, Johnston DW, Rothman AJ, de Bruin M, et al. Development of an online tool for linking behavior change techniques and mechanisms of action based on triangulation of findings from literature synthesis and expert consensus. Translational Behavioral Medicine. 2020;11(5):1049-65. French SD, Green SE, O’Connor DA, McKenzie JE, Francis JJ, Michie S, et al. Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework. Implementation Science. 2012;7(1):38. Grimmett C, Foster C, Bradbury K, Lally P, May CR, Myall M, et al. Exploring maintenance of physical activity behaviour change among people living with and beyond gastrointestinal cancer: a cross-sectional qualitative study and typology. BMJ Open. 2020;10(10):e037136. Devereux-Fitzgerald A, Powell R, Dewhurst A, French DP. The acceptability of physical activity interventions to older adults: A systematic review and meta-synthesis. Soc Sci Med. 2016;158:14-23. Elshahat S, Treanor C, Donnelly M. Factors influencing physical activity participation among people living with or beyond cancer: a systematic scoping review. International Journal of Behavioral Nutrition and Physical Activity. 2021;18(1). McGowan LJ, Devereux-Fitzgerald A, Powell R, French DP. How acceptable do older adults find the concept of being physically active? A systematic review and meta-synthesis. International Review of Sport and Exercise Psychology. 2018;11(1):1-24. Cane J, Richardson M, Johnston M, Ladha R, Michie S. From lists of behaviour change techniques (BCTs) to structured hierarchies: comparison of two methods of developing a hierarchy of BCTs. Br J Health Psychol. 2015;20(1):130-50. Knittle K, Heino M, Marques MM, Stenius M, Beattie M, Ehbrecht F, et al. The compendium of self-enactable techniques to change and self-manage motivation and behaviour v.1.0. Nat Hum Behav. 2020;4(2):215-23. Michie S, Richardson M, Johnston M, Abraham C, Francis J, Hardeman W, et al. The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Ann Behav Med. 2013;46(1):81-95. Project HBC. Theory and Technique Tool [Available from: https://theoryandtechniquetool.humanbehaviourchange.org/. Kwasnicka D, Dombrowski SU, White M, Sniehotta F. Theoretical explanations for maintenance of behaviour change: a systematic review of behaviour theories. Health Psychol Rev. 2016;10(3):277-96. Rhodes RE, Sui W. Physical Activity Maintenance: A Critical Narrative Review and Directions for Future Research. Front Psychol. 2021;12:725671. van Stralen MM, De Vries H, Mudde AN, Bolman C, Lechner L. Determinants of initiation and maintenance of physical activity among older adults: a literature review. Health Psychology Review. 2009;3(2):147-207. Knittle K, De Gucht V, Hurkmans E, Vlieland TV, Maes S. Explaining Physical Activity Maintenance After a Theory-Based Intervention Among Patients With Rheumatoid Arthritis: Process Evaluation of a Randomized Controlled Trial. Arthritis Care Res (Hoboken). 2016;68(2):203-10. Hankonen N, Sutton S, Prevost AT, Simmons RK, Griffin SJ, Kinmonth AL, et al. Which behavior change techniques are associated with changes in physical activity, diet and body mass index in people with recently diagnosed diabetes? Ann Behav Med. 2015;49(1):7-17. Burke LE, Wang J, Sevick MA. Self-monitoring in weight loss: a systematic review of the literature. J Am Diet Assoc. 2011;111(1):92-102. Miles LM, Hawkes RE, French DP. How is the Behavior Change Technique Content of the NHS Diabetes Prevention Program Understood by Participants? A Qualitative Study of Fidelity, With a Focus on Receipt. Annals of Behavioral Medicine. 2021;56(7):749-59. Hagger MS, Moyers S, McAnally K, McKinley LE. Known knowns and known unknowns on behavior change interventions and mechanisms of action. Health Psychol Rev. 2020;14(1):199-212. Davidson KW, Scholz U. Understanding and predicting health behaviour change: a contemporary view through the lenses of meta-reviews. Health Psychology Review. 2020;14(1):1-5. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 14 Aug, 2023 Read the published version in Journal of Cancer Survivorship → Version 1 posted Editorial decision: Major revision 04 Jul, 2023 Reviews received at journal 04 Jul, 2023 Reviewers agreed at journal 27 Jun, 2023 Reviews received at journal 20 Jun, 2023 Reviewers agreed at journal 08 Jun, 2023 Reviewers agreed at journal 19 May, 2023 Reviewers invited by journal 15 May, 2023 Editor assigned by journal 24 Apr, 2023 Submission checks completed at journal 24 Apr, 2023 First submitted to journal 24 Apr, 2023 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-2855117","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":194710473,"identity":"8f4c70e1-1ce3-42da-8f87-281119f9f271","order_by":0,"name":"Chloe Grimmett","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYLCCBDDJfABJ6AAWZehaeNjYEmCaidDCANbCY0CcFv4G9msfHuZsk7OX7/n84eMPmzwG9sMPmHnO4NYicYCneEbittvGPGy82yRnJKQVM/CkGTDz3MCtxYCBJ5kBqCWxB6iFmSfhcGIDQw4DM88Hwlrqe9h4Hn8Ga+F/Q0gL+2GQlgSg9xmkwVokQLbgcZjEYR5mkBbDnmNpZpIz0tIS2ySeGRycg8f7/O3tjxl/brstz958+PGHDzY2if38yQ8fvDmGWwvQDQaoAmwMBCOS/QF++VEwCkbBKBgFADdsTQTCo0nIAAAAAElFTkSuQmCC","orcid":"","institution":"University of Southampton","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Chloe","middleName":"","lastName":"Grimmett","suffix":""},{"id":194710477,"identity":"1cd603bf-ee11-42c8-8261-49858c6789cb","order_by":1,"name":"Teresa Corbett","email":"","orcid":"","institution":"Solent University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Teresa","middleName":"","lastName":"Corbett","suffix":""},{"id":194710479,"identity":"5d9c2f7c-fd24-45bd-90cd-f3f93ca4b97e","order_by":2,"name":"Katherine Bradbury","email":"","orcid":"","institution":"University of Southampton","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Katherine","middleName":"","lastName":"Bradbury","suffix":""},{"id":194710481,"identity":"b859fd7a-f397-4b35-866e-d489c926e0ac","order_by":3,"name":"Kate Morton","email":"","orcid":"","institution":"University of Southampton","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kate","middleName":"","lastName":"Morton","suffix":""},{"id":194710483,"identity":"12f8869c-7b50-45c6-9d69-23f8ca3a7cdd","order_by":4,"name":"Carl R May","email":"","orcid":"","institution":"London School of Hygiene \u0026 Tropical Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Carl","middleName":"R","lastName":"May","suffix":""},{"id":194710485,"identity":"ae428a86-d243-4983-a885-cd946064073d","order_by":5,"name":"Bernardine M Pinto","email":"","orcid":"","institution":"University of South Carolina","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Bernardine","middleName":"M","lastName":"Pinto","suffix":""},{"id":194710487,"identity":"8b84b05c-84b5-42df-bcd4-97705cba32f3","order_by":6,"name":"Claire Foster","email":"","orcid":"","institution":"University of Southampton","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Claire","middleName":"","lastName":"Foster","suffix":""}],"badges":[],"createdAt":"2023-04-24 13:59:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2855117/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2855117/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11764-023-01434-w","type":"published","date":"2023-08-14T22:01:02+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":36338703,"identity":"a837e804-ac33-4ee6-8f12-942cff1d27ae","added_by":"auto","created_at":"2023-04-26 17:42:34","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":345508,"visible":true,"origin":"","legend":"\u003cp\u003eConceptual framework of long-term engagement in PA after cancer\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-2855117/v1/bd759f1bd4209d253eaf0d6b.jpg"},{"id":44735612,"identity":"07a8d58b-9c6f-4b70-b720-dc9cc186047e","added_by":"auto","created_at":"2023-10-16 22:26:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":389983,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2855117/v1/400d0856-6d46-41c4-8f20-83dd8aae6f35.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eMaintaining long-term physical activity after cancer: A conceptual framework to inform intervention development\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEach year more than 17\u0026nbsp;million people are diagnosed with cancer worldwide (1). Cancer and its treatment can result in numerous adverse physical and psychological consequences, some of which can persist for years after treatment completion. Individuals with a history of cancer are also at risk of cancer recurrence and developing other chronic conditions such as heart disease. Engaging in regular physical activity (PA) can mitigate many of these adverse effects including fatigue, anxiety, depression, physical functioning and health-related quality of life (2) and reduce cancer recurrence and improve survival (3).\u003c/p\u003e \u003cp\u003e Despite this around 70% of people with cancer are not meeting physical activity guidelines (4\u0026ndash;7). Systematic reviews and meta-analysis have found clinically significant effects of interventions to support initiation of physical activity behaviour change with substantial increases in activity levels from baseline to end of intervention (8\u0026ndash;10). However, to sustain the health benefits of physical activity individuals must be habitually physical active for the long term. There is some evidence of modest maintenance effects (11) in people with cancer but activity levels typically regress towards baseline as the time from end of intervention increases (12). There are scant examples of interventions developed with an explicit aim to support sustained increases in physical activity in people affected by cancer and further research is required.\u003c/p\u003e \u003cp\u003eKey to developing effective interventions is to identify determinants of the target behaviour in the population in question as well as potential processes of change. Intervention components that influence those determinants can then be identified. This can be achieved by reviewing existing literature and consultation with the intervention development team. It is also increasingly recognised that empirical research with the specific population is imperative to fully understand the \u0026lsquo;problem\u0026rsquo; and identify potential solutions. These are core principles of intervention development frameworks such as Intervention Mapping and the MRC Guidance for development of complex interventions (13).\u003c/p\u003e \u003cp\u003eSuch development frameworks also recommended the use of theory of behaviour/behaviour change to guide the identification of pathways of change and appropriate intervention components. The Theory of Planned Behaviour, Social Cognitive Theory and the Transtheoretical Model have received much attention within the PA and cancer literature (14\u0026ndash;16). However empirical evidence suggests no one theory is superior and that theory-based interventions are as effective as those without explicit theoretical underpinning (17, 18). This may be because both types of intervention include similar behaviour change techniques (the main catalysts of intervention effects) (13, 17) and existing theories have multiple overlapping constructs. To address the latter, issue the Theoretical Domains Framework (TDF) was developed. It brings together 33 models of behaviour/behaviour change, including 128 separate constructs and is increasingly used by researcher developing complex interventions that target health behaviour change (19). The TDF has 14 theoretical domains from which researchers can draw on to support identification of pathways of behaviour change.\u003c/p\u003e \u003cp\u003eFurthermore, for optimal transparency of the intervention development process, and to advance our understanding of not just \u003cem\u003ewhat\u003c/em\u003e works, but \u003cem\u003ehow\u003c/em\u003e it works, researchers are encouraged to identify the proposed mechanisms of action (MoA) through which interventions are hypothesised to exert their effects. MoA are \u0026lsquo;the processes through which behaviour change techniques affect behaviour\u0026rsquo; (20). For example, a barrier to engagement in physical activity might be a lack of belief in one\u0026rsquo;s capability to perform the behaviour. Intervention developers would select BCTs believed to impact the MoA \u0026lsquo;belief in capability\u0026rsquo;, for example, verbal persuasion and focus on past success. Subsequent evaluation of the intervention would include measuring change in this MoA and conducting mediation analysis to determine its impact on behaviour (21). Central to such endeavours is an agreed matrix of BCTs and hypothesised MoA which can act as a standardised resource, enabling synthesis of data. This has been achieved through a series of studies of literature synthesis (22) and expert consensus (23), triangulated to develop a Theory and Technique tool linking BCTs and their MoA (24).\u003c/p\u003e \u003cp\u003eTo date there is a lack of empirical data, conceptual or theoretical understanding of the process of engaging in sustained physical activity that can inform the identification of behavioural determinants. Indeed, in concluding remarks following their recent meta-analysis of sustaining physical activity behaviour after intervention completion, McEwan et al. (2021) recommend \u0026lsquo;future efforts to develop and test theoretical frameworks that specially focus on maintenance of health behaviour could help optimise interventions that are concerned with supporting long-term physical activity adherence\u0026rdquo;(p8).\u003c/p\u003e \u003cp\u003eThis paper describes the development of a conceptual framework of sustained physical activity engagement in people with cancer through meta-analysis and primary qualitative research. This led to the generation of an inventory of determinants of this behaviour and a corresponding matrix BCTs and associated MoA that can be used as a basis for developing future interventions.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA modified version of French et al\u0026rsquo;s (25) approach to developing theory informed behaviour change interventions was used and involved four phases:\u003c/p\u003e \u003cp\u003e1: \u003cem\u003eWho needs to do what, differently?\u003c/em\u003e\u003c/p\u003e \u003cp\u003e A systematic review and meta-analysis of long-term physical activity behaviour change in cancer survivors was conducted by our group (11). We explored factors associated with success (or lack thereof) including context, population characteristics and behaviour change techniques.\u003c/p\u003e \u003cp\u003e2. \u003cem\u003eWhat barriers, enablers and processes need to be addressed?\u003c/em\u003e\u003c/p\u003e \u003cp\u003eTo afford an in-depth understanding of the barriers, enablers and processes involved in long-term PA behaviour change a qualitative study of 27 cancer patients who had taken part in a previous PA programme in the UK was conducted (26). Inductive thematic analysis was conducted, and findings were combined with those from the aforementioned systematic review and meta-analysis (15) and evidence from relevant qualitative meta-syntheses and reviews (12, 27\u0026ndash;29), selecting and structuring factors to create constructs that informed the development of an inventory of key determinants of sustained PA behaviour. These data also informed the development of a conceptual framework describing the processes of sustained PA engagement.\u003c/p\u003e \u003cp\u003e3. \u003cem\u003eUsing a theoretical framework, what intervention components could address these barriers and enablers?\u003c/em\u003e\u003c/p\u003e \u003cp\u003eIn consultation with co-authors, barriers and enablers were mapped to the associated domains of the Theoretical Domains Framework. Using published expert consensus linking BCTs to the TDF domains (30) BCTs were identified that might address these barriers and enablers. In addition, we reviewed the recently published compendium of \u0026lsquo;self-enacted techniques\u0026rsquo; (31) and selected additional intervention components hypothesised to impact on the target determinants.\u003c/p\u003e \u003cp\u003e4. \u003cem\u003eHow can the behaviour change be understood?\u003c/em\u003e\u003c/p\u003e \u003cp\u003eUsing the Theory and Techniques Tool we identified key MoA associated with each behaviour change technique which could be used to assess intervention causal pathways (mediating behaviour change).\u003c/p\u003e \u003cp\u003eThis was an iterative process involving regular meetings and revisions at all stages with co-authors.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e1. Who needs to do what differently?\u003c/h2\u003e \u003cp\u003eThe systematic review and meta-analysis, including 19 studies, concluded that existing interventions with a long-term follow-up were successful in achieving moderate improvements in sustained behaviour change (11). Older adults, those with existing functional limitations and who had fewer contacts with those delivering the PA programme were less likely to sustain PA increases. Furthermore, PA programmes included in the review with poorer long-term behaviour outcomes were less likely to include the BCTs of action planning, graded tasks, and social support (unspecified) (see (11) for full details). These findings were triangulated with the qualitative data (26) and relevant reviews (12, 27\u0026ndash;29) generating hypotheses of the processes at play and informing step 2; generation of an inventory of barriers and enablers and conceptual framework.\u003c/p\u003e \u003cp\u003e2. \u003cem\u003eWhat barriers and enablers need to be addressed?\u003c/em\u003e\u003c/p\u003e \u003cp\u003e Findings from the qualitative study and systematic reviews were selected and structured to identify an inventory of 8 determinants of engagement in long-term PA behaviour after cancer and a conceptual framework illustrating the processes at play was developed (see Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003eCentral to the conceptual framework are the founding factors related to initiation of behaviour required before long-term maintenance can be achieved (depicted in the outer segment of Fig.\u0026nbsp;1). Such factors are vital for consideration during the initiation of PA behaviour before maintenance can be achieved. Contextual factors are key and include socioeconomic status, demographics (including age, sex, education level) material resources and environment (i.e. access to facilities and/or appealing outdoor space). Appropriate attention must be paid to these factors when identifying when, where, and how an individual will engage in a physically active behaviour. This will ensure the chosen activity is appropriate to the individual\u0026rsquo;s personal context and resources. Furthermore, the initial intervention must result in \u003cem\u003emotivation\u003c/em\u003e to initiate change. The participant must develop the necessary \u003cem\u003eskills\u003c/em\u003e to engage with their new activity and that activity must be appropriate to their pathophysiological status.\u003c/p\u003e \u003cp\u003e \u003cem\u003eA case study: A participant in the qualitative study described how the practice nurse at her GP surgery repeatedly told her she needed to do more exercise and suggested walking. No support or consultation was provided. The participant reported walking on a handful of occasions but then stopped. Reasons included pain on walking, concerns about breathlessness and difficulties accessing suitable walking routes. On taking part in the Move More intervention she engaged in a conversation with the practitioner regarding her history of PA, likes, and dislikes, her priorities, and commitments as well as existing health condition, which included obesity, mobility issues/joint pain and COPD. A local weekly yoga class was identified which, on the date of interview, the participant had been attending for more than 2 years.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eOnce PA behaviour is initiated, the individual experiences the consequences of that behaviour, including an impact on their affective state and physiological outcomes. When engaging in PA with others this will also include social interaction. If the behaviour results in desired/positive outcomes that behaviour is reinforced and is more likely to be sustained. Inevitably at some point the behaviour will be disrupted. This may be due to affective factors, such as low mood or boredom, or practical, e.g. discontinuation of an exercise class. Alternatively, a life stressor event such as ill health or caring responsibilities can disrupt engagement, as can change to the environment/ resources. Adaptation to this disruption then ensues. This will include a prioritisation process of physical and psychological resources. It may also involve problem solving, assessment and/or change regarding accessibility to local amenities and /or personal resources. Pros and cons of re-engaging with the discontinued activity including reflection on the consequences of behaviour (experienced outcomes) will be influenced by the degree of intrinsic motivation and self-efficacy (confidence) the individual has for that activity. For some social support will play a role here with some individuals requiring practical or emotional support to re-engage. Consequently, the behaviour remains ceased/reduced or resumption occurs. This is a cyclical process.\u003c/p\u003e \u003cp\u003eThe inventory of barriers and enablers are set out in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\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\u003eInventory of Behaviour change techniques and mechanisms of action\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=\"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 \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\u003eDeterminants of engagement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubcategories of taxonomy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTDF domain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBCT linked to TDF domain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMoA linked to BCT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSelf-enacted techniques\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnjoyment/pleasure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmotion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.2 Reduce negative emotions\u003c/p\u003e \u003cp\u003e5.4 Monitoring of emotional consequences\u003c/p\u003e \u003cp\u003e3.3 Social support (emotional)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEmotion; behavioural regulation\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e#19 Monitoring of emotional consequences #29 Task crafting (enjoyment) #109 Focus on enjoyment (pleasant aspects) of behaviour # 119 interpreting physiological and emotional states #98 - Reflect on desire to perform behaviour #100 - Reflect on reasons to perform the behaviour\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExercise promoting feelings of empowerment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBelief about capability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.1 Verbal persuasion about capability\u003c/p\u003e \u003cp\u003e15.3 Focus on past success\u003c/p\u003e \u003cp\u003e15.4 Self talk\u003c/p\u003e \u003cp\u003e5.4 Monitoring of emotional consequences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBelief about capability\u003c/p\u003e \u003cp\u003eBelief about capability\u003c/p\u003e \u003cp\u003eMotivation\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e#107 verbal self-persuasion about own capability #106 valued self-identity (personal strengths) #111 focus on past success #112 looking back\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived value/outcome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExtrinsic outcomes to include maintaining health/function and independence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBelief about consequences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.2. Salience of consequences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBelief about consequences; perceived susceptibility/vulnerability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e#42 contrast/compare pros and cons #40 Make consequences more memorable # 32 Goal integration - modify behaviour to simultaneously engage in another valued behaviour #104 incompatible beliefs #102 find meaning in target behaviour #105 Associate identity with changed behaviour\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\u003eIntrinsic outcomes (e.g. feelings of wellbeing)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.5 Anticipated regret\u003c/p\u003e \u003cp\u003e9.3 Comparative imagining of future outcomes\u003c/p\u003e \u003cp\u003e16.3 Vicarious consequences\u003c/p\u003e \u003cp\u003e9.2 Pros and cons\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBelief about consequences\u003c/p\u003e \u003cp\u003eBelief about consequences\u003c/p\u003e \u003cp\u003eNone\u003c/p\u003e \u003cp\u003eBelief about consequences; attitude towards behaviour; motivation; general attitude/belief\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\u003eExercise as a means of social interaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEnvironmental context\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.1 Prompts/cues\u003c/p\u003e \u003cp\u003e12.2 Restructuring social environment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMemory, attention and decision process; environmental context and resources; behavioural cueing\u003c/p\u003e \u003cp\u003eEnvironmental context and resources\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e#54 obtain practical social support\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisruption\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAffective (boredom, anxiety, low mood)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmotion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.2 Reduce negative emotions\u003c/p\u003e \u003cp\u003e5.4 monitoring of emotional consequences\u003c/p\u003e \u003cp\u003e3.3 Social support (emotional)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEmotion; behavioural regulation\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e#19 Monitoring of emotional consequences #29 Task crafting (enjoyment) #109 Focus on enjoyment (pleasant aspects) of behaviour # 119 interpreting physiological and emotional states,#31 Add challenge (stops behaviour becoming boring) # 102 find meaning in target behaviour # 32 Goal integration # 114 Normalise difficulty #115 self-kindness #manage negative emotions\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\u003eExternal disruption (exercise class cancelled)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEnvironmental context\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.1 Restructuring the physical environment\u003c/p\u003e \u003cp\u003e12.2 Restructuring the social environment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEnvironmental Context and Resources; behavioural cueing\u003c/p\u003e \u003cp\u003eEnvironmental context and resources\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e#25 Restructuring the physical environment\u003c/p\u003e \u003cp\u003e#26 Restructuring social environment\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\u003eIll health as a disruption \u0026ndash; cancer specific/comorbid conditions/minor illness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEnvironmental context\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.2 Problem solving\u003c/p\u003e \u003cp\u003e1.4 Action planning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBelief about capability; behavioural regulation\u003c/p\u003e \u003cp\u003eBehavioural cueing\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\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLife stressors \u0026ndash; i.e. caring responsibilities/work commitments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEnvironmental context\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.2 Problem solving\u003c/p\u003e \u003cp\u003e1.4 Action planning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBelief about capability; behavioural regulation\u003c/p\u003e \u003cp\u003eBehavioural cueing\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\u003ePerceived appropriateness for age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSocial influence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.2 Social Comparison\u003c/p\u003e \u003cp\u003e10.4 Social reward\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003enorms; subjective norms; feedback processes\u003c/p\u003e \u003cp\u003eReinforcement; social influence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e#30 - Task crafting (skills and ability)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConfidence/self-efficacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBelief about capability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.1 Verbal persuasion\u003c/p\u003e \u003cp\u003e15.3 Focus on past success\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBelief about capability\u003c/p\u003e \u003cp\u003eBelief about capability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e#112 Looking back\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMonitoring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-monitoring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBehavioural regulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.3 Self monitoring of behaviour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFeedback processes; behavioural regulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e#17 self-monitoring # Reflect on desire to perform behaviour\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\u003eMonitoring by others\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSocial influence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.2 Feedback on behaviour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMotivation; feedback processes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e#15 obtain feedback on behaviour #60 prompts/cues #55 obtain emotional support\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=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003e[INSERT Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e]\u003c/h2\u003e \u003cp\u003eFinding \u003cem\u003epleasure/enjoyment\u003c/em\u003e in the chosen activities was a key enabler of maintenance identified in the qualitative data and wider literature. Those individuals who were habitually active talked about the fun they had and enjoyment they felt from being physically active. Individuals engaging regularly in physical activity describe \u003cem\u003efeelings of empowerment\u003c/em\u003e as a result, seeing it as evidence that they have overcome the physical challenges of cancer and its treatment and regaining a sense of ownership and control of their bodies. This is linked to a feeling of \u003cem\u003econfidence\u003c/em\u003e in their ability to engage in these activities. An individual\u0026rsquo;s sense of \u003cem\u003eperceived value/experienced outcomes\u003c/em\u003e is also integral to motivation to continue to engage in PA participation. Such outcomes included extrinsic factors such as the importance of PA in maintaining health, function, and independence, as well as intrinsic factors such as a sense of wellbeing. For those who participate in group activities \u003cem\u003esocial interaction\u003c/em\u003e is an important facilitator to engagement. \u003cem\u003eDisruption\u003c/em\u003e to PA engagement can typically be divided into affective factors, such as low mood, anxiety and boredom and external factors including terminated exercise classes, ill health of life stressors. The \u003cem\u003eperceived appropriateness\u003c/em\u003e of PA to an individual\u0026rsquo;s age is also important with individuals less inclined to engage if social comparison or personal identity are not aligned with the activities. Finally \u003cem\u003emonitoring\u003c/em\u003e of engagement by self or others is an important element of participation. This process enables individuals to track progress and identify reductions in PA that can then be addressed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e[INSERT FIGURE 1]\u003c/h2\u003e \u003cp\u003e3. \u003cem\u003eUsing a theoretical framework, what intervention components could address these barriers and enablers?\u003c/em\u003e\u003c/p\u003e \u003cp\u003eTo identify appropriate intervention components, the inventory of determinants was mapped to domains of the TDF and in turn to associated BCTs (per the Behaviour Change Techniques Taxonomy V1 (32) as determined by published expert consensus (30). Cane et al. (2015) did not include the full list of BCTs as per the V1. Those missing were reviewed and included if, through consensus, they were felt to be appropriate. Intervention components as specified in the Compendium of self-enacted techniques (31) were also selected by identifying techniques that were theorised to influence the identified barriers and enablers and associated MoA. See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for details.\u003c/p\u003e \u003cp\u003eThe TDF domains captured include emotion (positive/negative affect), environmental context and resources, social influences, beliefs about consequences, beliefs about capabilities and behavioural regulation. Accompanying BCT clusters (as per the BCT taxonomy) include natural consequences, antecedents, goals and planning, social support, self-belief, feedback and monitoring. Knittle et al\u0026rsquo;s (31) compendium of self-enacted techniques has several overlapping techniques with Michie\u0026rsquo;s taxonomy but also includes some important additions which we hypothesize would impact some of the barriers and enablers identified here. For example, boredom was a barrier to continued PA engagement. This might be overcome with the use of the self-enactment technique \u0026ldquo;add challenge (stops behaviour becoming boring)\u0026rdquo;. Enjoyment was an important enabler to continued PA and the technique of \u0026ldquo;task crafting (enjoyment)\u0026rdquo; and \u0026ldquo;focus on enjoyment (pleasant aspects)\u0026rdquo; are likely to facilitate this.\u003c/p\u003e \u003cp\u003e4. \u003cem\u003eHow can the behaviour change be understood?\u003c/em\u003e\u003c/p\u003e \u003cp\u003eMechanisms of Action associated with the BCTs were identified using the Theory and Techniques tool (33). See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Measuring them in future interventions would enable calculation of mediating mechanisms of behaviour change.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis paper presents a novel conceptual model of long-term engagement in physical activity after a cancer diagnosis, with accompanying inventory of determinants and suggested behaviour change techniques. This resource can act as a starting point for selection of intervention components for those developing future interventions. It is essential that it is used alongside a robust development process, using qualitative and co-design approaches to understand the local context and specific participant group, working with multidisciplinary teams to choose methods and modes of delivery that are locally feasible.\u003c/p\u003e \u003cp\u003eThis conceptual framework is a holistic appreciation of the problem of sustained PA participation after a cancer diagnosis. The outer elements of the framework, including contextual factors such as environment, socioeconomic status, material resources are key, shaping the possibility of initial PA engagement necessary before sustained action can be achieved. Historically, consideration of these contextual factors has often been absent from intervention development. A personalised approach, assessing pathophysiological state and evaluating these contextual factors at an individual level is key to establishing initial PA engagement that has the potential to be sustained. This perspective is in keeping with the recently updated MRC Framework for the Development and Evaluation of Complex Interventions (13). A key addition to which was the inclusion of context in the definition of complex interventions as well as considerations for the systems within which the intervention sits.\u003c/p\u003e \u003cp\u003eComparisons can be drawn between the conceptual model, inventory of behavioural determinants and associated intervention components presented here and Kwasnicka et al\u0026rsquo;s review of the theoretical explanations for maintenance of physical activity behaviour (34). Kwasnicka and colleagues coded constructs of 100 theories of behaviour and set out five theoretical themes they deem relevant to PA maintenance, four of which are also captured in our work. These include \u0026lsquo;maintenance motives\u0026rsquo;; regular gratification is more likely to lead to sustained engagement, \u0026lsquo;self-regulation\u0026rsquo;; including the need for high coping self-efficacy, \u0026lsquo;resources\u0026rsquo;; psychological and physical assets, and environmental and social influences.\u003c/p\u003e \u003cp\u003eIn recent years the concept of behavioural maintenance in physical activity has received considerable attention with thought paid to the way maintenance is conceptualised and operationalised. The conceptual model presented here aligns with the evolution in thinking from maintenance of a behaviour as a specific state, to consideration of the underlying mechanisms of action that determine behaviour. This includes shifts back and forth between reflective and reactive processes (35). Rhodes \u0026amp; Sui (35) present a new, working definition of physical activity maintenance as \u0026lsquo;a dynamic development of mechanisms of action that engender greater perceived behavioural enactment efficiency that partially supplant prior mechanisms of action that required greater perceived cognitive recourses to enact physical activity\u0026rdquo;. They argue that some constructs that were critical to the initiation of a behaviour will still be important for engagement in the longer-term. This is reflected in the conceptual model and associated BCTs presented here where constructs and techniques are essential to embed in the process of initial behaviour enactment to support longer term maintenance. Whilst it has been argued that maintained behaviours are characterised by intrinsic motivations and self-determined actions, self-regulatory skills are still required over time as inevitable disruptions occur and more effortful regulation is required. Hence the suggested inclusion of BCTs that consolidate self-regulatory processes and skills in the initiation of behaviour change, as well as considering long-term behaviour change where these skills may need to be revisited to manage a period of disruption. Furthermore, some individuals may spend longer in a phase of effortful self-regulation than others and need to revisit these skills more frequently. This is also supported by evidence from a review of determinants of physical activity behaviour in older adults which found that self-regulatory strategies such as action planning and coping planning were positively associated with both activity initiation and maintenance (36). Development of a typology of sustained physical activity that proceeded and informed this model argues that individuals fall into three \u0026lsquo;types\u0026rsquo; (26). Those who, after initial support to engage successful maintain increased levels of PA through planning and prioritisation. Those who are \u0026lsquo;intermittently active\u0026rsquo; with cycles of action and inaction with frequent periods of effortful self-regulation, and those with consistently low levels of PA with minimal engagement in PA during or after intervention participation. Reviewing individuals after 12 weeks of intervention participation to ascertain which of these \u0026lsquo;types\u0026rsquo; they most align with could help personalise the intervention components/BCTs that need to be emphasised to support maintenance of behaviour.\u003c/p\u003e \u003cp\u003eAn important consideration when developing interventions including evidence derived BCTs is to have confidence that these strategies are being delivered and utilised by recipients as intended. Knittle et al (31) recently published the compendium of self-enactable techniques v1.0 to change and self-manage motivation and behaviour. The focus of this taxonomy is that of techniques which individuals can enact themselves, rather than those which are delivered or enacted by the intervention providers. They point to evidence that suggests maintenance of behaviour change following interventions is dependent on the extent to which individuals can enact the BCTs involved (37\u0026ndash;39). They also argue that existing taxonomies have insufficient focus on the way techniques are delivered, received (comprehended and understood) and enacted in everyday lives. This new classification also includes techniques from additional behavioural domains that may have utility in affecting behaviour and/or it\u0026rsquo;s determinants, from sport and occupational psychology. Finally, it is written in \u0026lsquo;plain, accessible language\u0026rsquo; and includes \u0026lsquo;adequate instructions and examples to facilitate ease of use by practitioners and the general public\u0026rsquo;. In this paper we have selected techniques that map to determinants of long-term PA engagement after cancer. Some have considerable overlap with those derived from Michie\u0026rsquo;s BCT taxonomy (but with accessible examples/definitions to optimise delivery and enactment) whereas others are unique and with intuitive application. For example, \u0026lsquo;task crafting (enjoyment)\u0026rsquo; which specifically addresses the concept of making the target behaviour enjoyable. A behavioural determinant for long-term physical activity that is consistently reported in the literature but not explicitly addressed in previous taxonomies. Similarly, \u0026lsquo;normalize difficulty\u0026rsquo; \u0026ndash; defined as \u0026lsquo;recognise (or remind yourself) that is it common to face difficulties when pursuing behavioural changes\u0026rsquo;.\u003c/p\u003e \u003cp\u003eConsideration of how chosen BCTs are both delivered and received, may help those developing and delivering interventions to maximise fidelity of both delivery and individual enactment. Examples of this include Miles et al (40) who used qualitative methods to explore participant\u0026rsquo;s understanding of the specific BCTs included in the Diabetes Prevention Program. The focus was self-regulatory strategies such as problem solving, action planning, self-monitoring of behaviour and goal setting. Some techniques, including self-monitoring were well understood and participants accurately described their use. Others, including action planning and problem solving were harder to understand and additional support was needed to enable participants to operationalise these intervention components. It is therefore imperative that those designing and delivering interventions to support long-term PA behaviour change provide appropriate and accessible explanations of the fundamental BCTs to ensure they can be enacted. Assessing this during and after intervention delivery is also important.\u003c/p\u003e \u003cp\u003eIn addition to the need for evidence informed intervention components it is important to understand \u003cem\u003ehow\u003c/em\u003e these components exert their effects on behaviour. This paper identifies potentially effective intervention components/BCTs linked to the constructs of the conceptual model and goes on to state the hypothesised MoA through which these BCTs/groups of BCTs exert their effect on behaviour. This was achieved by using a publicly available database where links between BCTs and proposed MoA have been collated based on expert-verified consensus (ref). It has been widely acknowledged that research exploring potential MoA as mediators of behaviour change in specific context with specific populations is necessary to advance the field of behavioural science. Haggar et al (41) describe a process model, including the type of data and analysis needed to contribute to the evidence base of testing proposed MoA. Such contributions will provide data that can be synthesised and increase our collective knowledge of the MoA of interventions. This is important work given the current lack of such evidence, as demonstrated in a recent series of meta-reviews (42).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis conceptual model and accompanying inventory of potential intervention components is intended to inform those developing novel interventions to promote long term engagement in physical activity after a cancer diagnosis. The model and its proposed MoA could be tested in future, using methods outlined by Haggar and colleagues. Use of this model alongside participatory approaches, consulting with end users and key stakeholders to ensure relevance and appropriateness are encouraged.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.69747899159664%\" valign=\"top\"\u003e\n \u003cp\u003ePA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.30252100840336%\" valign=\"top\"\u003e\n \u003cp\u003ePhysical activity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.69747899159664%\" valign=\"top\"\u003e\n \u003cp\u003eBCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.30252100840336%\" valign=\"top\"\u003e\n \u003cp\u003eBehaviour change technique\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.69747899159664%\" valign=\"top\"\u003e\n \u003cp\u003eTDF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.30252100840336%\" valign=\"top\"\u003e\n \u003cp\u003eTheoretical domains framework\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.69747899159664%\" valign=\"top\"\u003e\n \u003cp\u003eSCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.30252100840336%\" valign=\"top\"\u003e\n \u003cp\u003eSocial Cognitive Theory\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.69747899159664%\" valign=\"top\"\u003e\n \u003cp\u003eTTM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.30252100840336%\" valign=\"top\"\u003e\n \u003cp\u003eTranstheoretical Model\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.69747899159664%\" valign=\"top\"\u003e\n \u003cp\u003eMoA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.30252100840336%\" valign=\"top\"\u003e\n \u003cp\u003eMechanism of Action\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003eFunding\u003cstrong\u003e:\u003c/strong\u003e This study was funded by a National Institute for Health Research (NIHR), postdoctoral fellowship. The publication presents the independent research funded by the NIHR. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eAuthors contributions: Chloe Grimmett was responsible for the conception, design, data interpretation and drafting of the manuscript. Claire Foster and Bernardine Pinto made substantial contributions to the conception of the manuscript. Carl May, Teresa Corbet, Kate Morton and Katherine Bradbury made substantial contributions to the conception and data interpretation of the manuscript. All authors read, revised, and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eData availability: The data generated during the current study are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate: Not applicable to this paper. Ethics approvals were given for the qualitative work proceeding this publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent: Not applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: Not applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgements: Not applicable\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eUK CR. World Wide Cancer Statistics 2020 [Available from: https://www.cancerresearchuk.org/health-professional/cancer-statistics/worldwide-cancer#:~:text=There%20were%2017%20million%20new,cancer%20each%20year%20by%202040.\u003c/li\u003e\n\u003cli\u003eCampbell KL, Winters-Stone KM, Wiskemann J, May AM, Schwartz AL, Courneya KS, et al. Exercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary Roundtable. Med Sci Sports Exerc. 2019;51(11):2375-90.\u003c/li\u003e\n\u003cli\u003eMcTiernan A, Friedenreich CM, Katzmarzyk PT, Powell KE, Macko R, Buchner D, et al. Physical Activity in Cancer Prevention and Survival: A Systematic Review. Med Sci Sports Exerc. 2019;51(6):1252-61.\u003c/li\u003e\n\u003cli\u003eBlanchard CM, Courneya KS, Stein K. Cancer survivors\u0026apos; adherence to lifestyle behavior recommendations and associations with health-related quality of life: results from the American Cancer Society\u0026apos;s SCS-II. J Clin Oncol. 2008;26(13):2198-204.\u003c/li\u003e\n\u003cli\u003eCourneya KS, Katzmarzyk PT, Bacon E. Physical activity and obesity in Canadian cancer survivors: population-based estimates from the 2005 Canadian Community Health Survey. Cancer. 2008;112(11):2475-82.\u003c/li\u003e\n\u003cli\u003eKrok-Schoen JL, Pisegna J, Arthur E, Ridgway E, Stephens C, Rosko AE. Prevalence of lifestyle behaviors and associations with health-related quality of life among older female cancer survivors. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer. 2021;29(6):3049-59.\u003c/li\u003e\n\u003cli\u003eSPEED-ANDREWS AE, RHODES RE, BLANCHARD CM, CULOS-REED SN, FRIEDENREICH CM, BELANGER LJ, et al. Medical, demographic and social cognitive correlates of physical activity in a population-based sample of colorectal cancer survivors. European Journal of Cancer Care. 2012;21(2):187-96.\u003c/li\u003e\n\u003cli\u003eJung Y, Chung J, Son H. Physical Activity Interventions for Colorectal Cancer Survivors: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Cancer Nursing. 2021;44(6):E414-E28.\u003c/li\u003e\n\u003cli\u003eLiu MG, Davis GM, Kilbreath SL, Yee J. Physical activity interventions using behaviour change theories for women with breast cancer: a systematic review and meta-analysis. J Cancer Surviv. 2021.\u003c/li\u003e\n\u003cli\u003eRoberts AL, Fisher A, Smith L, Heinrich M, Potts HWW. Digital health behaviour change interventions targeting physical activity and diet in cancer survivors: a systematic review and meta-analysis. J Cancer Surviv. 2017;11(6):704-19.\u003c/li\u003e\n\u003cli\u003eGrimmett C, Corbett T, Brunet J, Shepherd J, Pinto BM, May CR, et al. Systematic review and meta-analysis of maintenance of physical activity behaviour change in cancer survivors. International Journal of Behavioral Nutrition and Physical Activity. 2019;16(1):37.\u003c/li\u003e\n\u003cli\u003eMcEwan D, Rhodes RE, Beauchamp MR. What Happens When the Party is Over?: Sustaining Physical Activity Behaviors after Intervention Cessation. Behav Med. 2020:1-9.\u003c/li\u003e\n\u003cli\u003eSkivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM, et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. BMJ. 2021;374:n2061.\u003c/li\u003e\n\u003cli\u003eTrinh L, Plotnikoff RC, Rhodes RE, North S, Courneya KS. Correlates of physical activity in a population-based sample of kidney cancer survivors: an application of the theory of planned behavior. International Journal of Behavioral Nutrition and Physical Activity. 2012;9(1):96.\u003c/li\u003e\n\u003cli\u003eStacey FG, James EL, Chapman K, Courneya KS, Lubans DR. A systematic review and meta-analysis of social cognitive theory-based physical activity and/or nutrition behavior change interventions for cancer survivors. J Cancer Surviv. 2015;9(2):305-38.\u003c/li\u003e\n\u003cli\u003eLoprinzi PD, Cardinal BJ, Si Q, Bennett JA, Winters-Stone KM. Theory-based predictors of follow-up exercise behavior after a supervised exercise intervention in older breast cancer survivors. Support Care Cancer. 2012;20(10):2511-21.\u003c/li\u003e\n\u003cli\u003eMcEwan D, Beauchamp MR, Kouvousis C, Ray CM, Wyrough A, Rhodes RE. Examining the active ingredients of physical activity interventions underpinned by theory versus no stated theory: a meta-analysis. Health Psychol Rev. 2019;13(1):1-17.\u003c/li\u003e\n\u003cli\u003ePrestwich A, Sniehotta FF, Whittington C, Dombrowski SU, Rogers L, Michie S. Does theory influence the effectiveness of health behavior interventions? Meta-analysis. Health Psychol. 2014;33(5):465-74.\u003c/li\u003e\n\u003cli\u003eCane J, O\u0026rsquo;Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implementation Science. 2012;7(1):37.\u003c/li\u003e\n\u003cli\u003eMichie S, Carey RN, Johnston M, Rothman AJ, de Bruin M, Kelly MP, et al. From Theory-Inspired to Theory-Based Interventions: A Protocol for Developing and Testing a Methodology for Linking Behaviour Change Techniques to Theoretical Mechanisms of Action. Ann Behav Med. 2018;52(6):501-12.\u003c/li\u003e\n\u003cli\u003eSheeran P, Klein WM, Rothman AJ. Health Behavior Change: Moving from Observation to Intervention. Annu Rev Psychol. 2017;68:573-600.\u003c/li\u003e\n\u003cli\u003eCarey RN, Connell LE, Johnston M, Rothman AJ, de Bruin M, Kelly MP, et al. Behavior Change Techniques and Their Mechanisms of Action: A Synthesis of Links Described in Published Intervention Literature. Ann Behav Med. 2019;53(8):693-707.\u003c/li\u003e\n\u003cli\u003eConnell LE, Carey RN, de Bruin M, Rothman AJ, Johnston M, Kelly MP, et al. Links Between Behavior Change Techniques and Mechanisms of Action: An Expert Consensus Study. Ann Behav Med. 2019;53(8):708-20.\u003c/li\u003e\n\u003cli\u003eJohnston M, Carey RN, Connell Bohlen LE, Johnston DW, Rothman AJ, de Bruin M, et al. Development of an online tool for linking behavior change techniques and mechanisms of action based on triangulation of findings from literature synthesis and expert consensus. Translational Behavioral Medicine. 2020;11(5):1049-65.\u003c/li\u003e\n\u003cli\u003eFrench SD, Green SE, O\u0026rsquo;Connor DA, McKenzie JE, Francis JJ, Michie S, et al. Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework. Implementation Science. 2012;7(1):38.\u003c/li\u003e\n\u003cli\u003eGrimmett C, Foster C, Bradbury K, Lally P, May CR, Myall M, et al. Exploring maintenance of physical activity behaviour change among people living with and beyond gastrointestinal cancer: a cross-sectional qualitative study and typology. BMJ Open. 2020;10(10):e037136.\u003c/li\u003e\n\u003cli\u003eDevereux-Fitzgerald A, Powell R, Dewhurst A, French DP. The acceptability of physical activity interventions to older adults: A systematic review and meta-synthesis. Soc Sci Med. 2016;158:14-23.\u003c/li\u003e\n\u003cli\u003eElshahat S, Treanor C, Donnelly M. Factors influencing physical activity participation among people living with or beyond cancer: a systematic scoping review. International Journal of Behavioral Nutrition and Physical Activity. 2021;18(1).\u003c/li\u003e\n\u003cli\u003eMcGowan LJ, Devereux-Fitzgerald A, Powell R, French DP. How acceptable do older adults find the concept of being physically active? A systematic review and meta-synthesis. International Review of Sport and Exercise Psychology. 2018;11(1):1-24.\u003c/li\u003e\n\u003cli\u003eCane J, Richardson M, Johnston M, Ladha R, Michie S. From lists of behaviour change techniques (BCTs) to structured hierarchies: comparison of two methods of developing a hierarchy of BCTs. Br J Health Psychol. 2015;20(1):130-50.\u003c/li\u003e\n\u003cli\u003eKnittle K, Heino M, Marques MM, Stenius M, Beattie M, Ehbrecht F, et al. The compendium of self-enactable techniques to change and self-manage motivation and behaviour v.1.0. Nat Hum Behav. 2020;4(2):215-23.\u003c/li\u003e\n\u003cli\u003eMichie S, Richardson M, Johnston M, Abraham C, Francis J, Hardeman W, et al. The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Ann Behav Med. 2013;46(1):81-95.\u003c/li\u003e\n\u003cli\u003eProject HBC. Theory and Technique Tool [Available from: https://theoryandtechniquetool.humanbehaviourchange.org/.\u003c/li\u003e\n\u003cli\u003eKwasnicka D, Dombrowski SU, White M, Sniehotta F. Theoretical explanations for maintenance of behaviour change: a systematic review of behaviour theories. Health Psychol Rev. 2016;10(3):277-96.\u003c/li\u003e\n\u003cli\u003eRhodes RE, Sui W. Physical Activity Maintenance: A Critical Narrative Review and Directions for Future Research. Front Psychol. 2021;12:725671.\u003c/li\u003e\n\u003cli\u003evan Stralen MM, De Vries H, Mudde AN, Bolman C, Lechner L. Determinants of initiation and maintenance of physical activity among older adults: a literature review. Health Psychology Review. 2009;3(2):147-207.\u003c/li\u003e\n\u003cli\u003eKnittle K, De Gucht V, Hurkmans E, Vlieland TV, Maes S. Explaining Physical Activity Maintenance After a Theory-Based Intervention Among Patients With Rheumatoid Arthritis: Process Evaluation of a Randomized Controlled Trial. Arthritis Care Res (Hoboken). 2016;68(2):203-10.\u003c/li\u003e\n\u003cli\u003eHankonen N, Sutton S, Prevost AT, Simmons RK, Griffin SJ, Kinmonth AL, et al. Which behavior change techniques are associated with changes in physical activity, diet and body mass index in people with recently diagnosed diabetes? Ann Behav Med. 2015;49(1):7-17.\u003c/li\u003e\n\u003cli\u003eBurke LE, Wang J, Sevick MA. Self-monitoring in weight loss: a systematic review of the literature. J Am Diet Assoc. 2011;111(1):92-102.\u003c/li\u003e\n\u003cli\u003eMiles LM, Hawkes RE, French DP. How is the Behavior Change Technique Content of the NHS Diabetes Prevention Program Understood by Participants? A Qualitative Study of Fidelity, With a Focus on Receipt. Annals of Behavioral Medicine. 2021;56(7):749-59.\u003c/li\u003e\n\u003cli\u003eHagger MS, Moyers S, McAnally K, McKinley LE. Known knowns and known unknowns on behavior change interventions and mechanisms of action. Health Psychol Rev. 2020;14(1):199-212.\u003c/li\u003e\n\u003cli\u003eDavidson KW, Scholz U. Understanding and predicting health behaviour change: a contemporary view through the lenses of meta-reviews. Health Psychology Review. 2020;14(1):1-5.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cancer-survivorship","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcsu","sideBox":"Learn more about [Journal of Cancer Survivorship](https://www.springer.com/journal/11764)","snPcode":"11764","submissionUrl":"https://submission.nature.com/new-submission/11764/3","title":"Journal of Cancer Survivorship","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-2855117/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2855117/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eThis paper describes a conceptual framework of maintenance of physical activity and its application to future intervention design.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Evidence from systematic literature reviews and in-depth (N=27) qualitative interviews with individuals with cancer were used to develop a conceptual framework of long-term physical activity behaviour. Determinants of long-term PA were listed and linked with domains of the Theoretical Domains Framework which in turn were linked to associated behaviour change techniques (BCTs) and finally to proposed mechanisms of action (MoA).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The conceptual framework is presented within the context of non-modifiable contextual factors (such as demographic and material resources) and in the presence of learnt and adapted behavioural determinants of skills, competence and autonomous motivation that must be established as part of the initiation of physical activity behaviour. An inventory of 8 determinants of engagement in long-term PA after cancer was developed. Clusters of BCTs are presented along with proposed MoA which can be tested using mediation analysis in future trials.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Understanding the processes of PA maintenance after cancer and presentation of implementable and testable intervention components and mechanisms of action to promote continued PA can inform future intervention development.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications for cancer survivors.\u003c/strong\u003e This resource can act as a starting point for selection of intervention components for those developing future interventions. This will facilitate effective support of individuals affected by cancer to maintain PA for the long term.\u003c/p\u003e","manuscriptTitle":"Maintaining long-term physical activity after cancer: A conceptual framework to inform intervention development","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-04-26 17:42:29","doi":"10.21203/rs.3.rs-2855117/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-07-04T22:39:13+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-07-04T20:27:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"102be12e-ca0c-4884-90f0-3f0d426adb39","date":"2023-06-27T23:09:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-06-20T08:27:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"e6cebcb5-cb09-4039-bfb2-f1fa94d07eb1","date":"2023-06-08T06:29:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"08a2f021-de4a-4f8f-9e1d-f5a6cc61be4a","date":"2023-05-19T08:16:22+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-05-15T12:01:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-04-24T18:00:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-04-24T18:00:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cancer Survivorship","date":"2023-04-24T13:57:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cancer-survivorship","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcsu","sideBox":"Learn more about [Journal of Cancer Survivorship](https://www.springer.com/journal/11764)","snPcode":"11764","submissionUrl":"https://submission.nature.com/new-submission/11764/3","title":"Journal of Cancer Survivorship","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"0a2cebaf-a8c8-4951-b976-5cab5337d765","owner":[],"postedDate":"April 26th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T22:12:52+00:00","versionOfRecord":{"articleIdentity":"rs-2855117","link":"https://doi.org/10.1007/s11764-023-01434-w","journal":{"identity":"journal-of-cancer-survivorship","isVorOnly":false,"title":"Journal of Cancer Survivorship"},"publishedOn":"2023-08-14 22:01:02","publishedOnDateReadable":"August 14th, 2023"},"versionCreatedAt":"2023-04-26 17:42:29","video":"","vorDoi":"10.1007/s11764-023-01434-w","vorDoiUrl":"https://doi.org/10.1007/s11764-023-01434-w","workflowStages":[]},"version":"v1","identity":"rs-2855117","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2855117","identity":"rs-2855117","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}