Is self-management feasible and acceptable for addressing nutrition and physical activity needs of cancer survivors?

This is the accepted version of the following article: [Lawn S, Zrim S, Leggett S, Miller M, Woodman R, Jones L, Kichenadasse G, Sukumaran S, Karapetis C and Koczwara B (2014) Is self-management feasible and acceptable for addressing nutrition and physical activity needs of cancer survivors? . Original Research Paper. Health Expectations], which has been published in final form at [DOI:10.1111/hex.12327]. Background: Self-management is recommended for patients with chronic conditions but its use with cancer survivors is underexplored. Optimal strategies for achieving lifestyle changes in cancer survivors are not known. Objective: We aimed to determine feasibility, acceptability and preliminary efficacy of self-management based nutrition and physical activity interventions for cancer survivors. Design, Setting and Participants: Adult survivors (n=25) during (Group1, n=11) or post (Group2, n=14) curative chemotherapy for solid tumours, most (n=20, 80%) with breast cancer, were recruited prospectively from a single clinical centre. Intervention: The Flinders Living Well Self-Management Program™, a generic self-management care planning program, was utilised to establish patient-led nutrition and exercise goals within a tailored 12-week intervention. Fortnightly progress reviews occurred with assessments at baseline, 6 and 12 weeks. Results: Most participants (84%) found the intervention acceptable/very acceptable. Both groups showed a trend towards significant improvement in the self-management capability ‘knowledge about changing risk factors’ (p=0.047); and Group2 showed a trend towards significantly improved ‘psychological impacts’ (p=0.007). Goal ratings improved for both groups (p=0.001). Quality of life improved for both groups for emotional functioning (p=0.03). Physical functioning improved for Group2 (p=0.05); however, most symptom domains worsened for Group1, as expected given their treatment stage. Discussion and Conclusions: Self-management interventions are feasible for this population. In particular, building self-management capacity during the active phase of patients’ cancer treatment provides health and psychosocial benefits. Larger randomised controlled trials are required to further determine efficacy. Further translational research is also needed to determine acceptability, feasibility, enablers and barriers for clinicians embedding this approach into routine cancer survivorship care

Integrating exercise interventions into routine care for mental illness and cancer : An implementation science approach

Exercise has been established as an effective intervention that can improve health outcomes in people living with a non-communicable disease (NCD), including mental illness and cancer. Despite the evidence, exercise is not routinely integrated into the treatment of most NCDs. This phenomenon is described as the research-to-practice gap with implementation science seeking to increase the uptake of evidence-based interventions (EBIs), such as exercise, in practice. Multiple factors and processes contribute to the suboptimal use of EBIs in practice. This includes the lack of formative approaches to establish research evidence that is relevant for implementation and scientific methods that explain EBI adoption, implementation, and sustainment. This thesis applies an implementation science approach to explore how exercise EBIs can be integrated into routine healthcare to treat NCDs. This is explored in two NCDs, mental illness and cancer, and through the two following sub-aims: • Conduct novel evidence synthesis for mental illness and cancer to understand how different synthesis methods can support improved implementation in practice. • Explore how healthcare organisations have successfully implemented exercise EBIs within the routine practice for treating mental illness and cancer. To address the first sub-aim, unique approaches were applied to two systematic reviews that were conducted in mental illness and cancer. For the first systematic review, a meta-review design was used to synthesise the evidence on the effectiveness of exercise EBIs for mental illness. effectiveness was defined in clinically useful terms including the anticipated health benefits, safety and cost of exercise EBIs. Although positive effects on health outcomes (i.e., symptoms of mental illness, quality of life, and physical health outcomes) were reported in the majority of reviews, limited safety information and no cost data were identified. For the second systematic review, efficacy studies were excluded to investigate the real-world implementation outcomes of exercise EBIs for cancer care. Implementation outcomes were aligned with Proctor and colleagues’ Implementation Outcomes Framework (IOF), and the review revealed that the most common implementation outcomes assessed were adoption and feasibility. Penetration and sustainability were infrequently measured, and implementation fidelity was difficult to establish because exercise protocols were poorly reported. In sum, the unique methods used in the two systematic reviews enabled the synthesis of broad and contextually relevant information valuable for implementation practice. The research gaps identified suggest that there is significant scope to produce more practice-relevant evidence. To address some of these gaps and the second sub-aim of this thesis, two implementation studies that explored how healthcare organisations have successfully implemented exercise EBI’s in mental health and cancer were conducted. For both studies, a case study design and theoretically-informed approach were used to develop an explanation for the implementation process that included the identification of determinants, implementation strategies, and implementation outcomes. Four data sources informed the studies: semi-structured interviews, document review, observations, and administering the Program Sustainability Assessment Tool (PSAT). Framework analysis was applied, and a theory-informed logic model was developed. Linking implementation science frameworks through the logic model elucidated the causal pathways of implementation. Second, the methods facilitated synthesis across sites to support generalisable knowledge. The first implementation study evaluated an exercise EBI implemented within a youth mental healthcare service. Over 40 determinants that influenced implementation of exercise EBIs and a similar number of implementation strategies were identified. Several activities aided implementation, including the creation of a new clinical team and the auditing and provision of feedback on physical healthcare practices (including exercise). Exercise acceptability was high, and many strengths (identified via the PSAT) contributed to EBI sustainability. However, implementation fidelity was challenging to establish, and penetration was low. The second implementation study was a multiple case study on the implementation of exercise EBIs across three cancer care settings. Across the sites, 18 determinants and 22 implementation strategies were consistent. Sixteen determinants, 24 implementation strategies, and implementation outcomes differed across the sites. Via the commonalities, 11 common causal pathways were developed, wherein the mechanisms theorised to support implementation include: 1) developing knowledge; 2) building skills and capability; 3) securing resources; 4) generating optimism and 5) simplified decision-making processes associated with exercise; 6) developing relationships (social and professional) and support for the workforce; 7) reinforcing positive outcomes; 8) developing capability to action plan through evaluations and 9) interactive learning; 10) aligning goals between the organisation and the EBI; and, 11) establishing a consumer-responsive service. These mechanisms represent transferable elements of the implementation process that can inform future implementation efforts. This thesis uses implementation science to increase our understanding of the evidence, factors, strategies and processes required to implement exercise EBIs in practice. Improved implementation knowledge will help shape healthcare so people living with a NCD can access evidence-based care, such as exercise

Facilitating healthcare practitioners to deliver self-management support in adult cancer survivors: a realist review

Background: Supporting cancer survivors in self-management can empower them to take an active role in managing the long-term physical and psychosocial consequences of cancer treatment. Healthcare practitioners are key to supporting patients to self-manage, however, they do not routinely engage in these discussions. Objective(s): This review aimed to establish what works for whom and in what circumstances in relation to facilitating healthcare practitioners to provide self-management support in people living with long-term consequences of cancer treatment. Methods: The review follows five steps: define the review's scope, develop initial programme theories, evidence search, selection and appraisal, and data extraction and synthesis. Database searches of Medline, EMBASE, CINAHL, Scopus, PsycINFO, ERIC and AMED databases, to September 2019 were supplemented with practitioner surveys. Insights into the mechanisms that operate in particular contexts to produce successful outcomes were illustrated using realist programme theories, developed using the Theoretical Domains Framework. Data selection was based on relevance and rigour. Data were extracted and synthesised iteratively to illuminate causal links between contexts, mechanisms and outcomes. Results: Five programme theories were identified from 20 included articles and seven practitioner surveys: practitioners will engage patients in discussions about self-management if they have appropriate (1) knowledge and (2) consultations skills, (3) a clear understanding of their self-management support role and responsibilities, and if (4) organisational strategies and (5) health system configuration enable integration into routine care. The mechanisms facilitating practitioners to support self-management were practitioner confidence, mutual trust and shared responsibility between practitioners and cancer survivors, organisational prioritisation and ease of delivery of self-management support. Conclusion: The findings articulate the necessary components for embedding self-management support into routine cancer care. Operationalisation of these components into effective self-management support interventions will require reconfiguration of pathways and adaptation for local context, using strategies such as quality improvement and co-design to guide intervention development, implementation and evaluation

Evaluating the feasibility of a weight management program for overweight and obese cancer survivors

Background: Obesity and low physical activity (PA) contribute to cancer survivors’ poorer disease and health outcomes. Guidelines for survivors are (1) remain physically active; (2) high fruit and vegetable diet; (3) maintain healthy weight. Despite these recommendations, access to lifestyle programs are not integrated into survivorship care. This study evaluated the feasibility of a weight management program (WMP) for overweight/obese cancer survivors at Sydney Survivorship Centre. Method: Overweight (BMI ≥25kg/m2) adult patients with localised cancer reviewed at Survivorship Clinic who had completed a 6-week lifestyle intervention, were eligible. The 6 month intervention comprised (1) clinic assessment and behaviour counselling consultation; (2) supervised exercise sessions (2/week); and (3) dietary sessions (n=12). Outcome measures were assessed at 0, 3 and 6 months. Primary outcome was attendance. Secondary outcomes included body composition, PA levels, nutritional quality, patient reported outcomes, blood biomarkers, and a qualitative interview. Results: All 12 participants were female; median age 56 (range 45-71). Tumour groups represented: breast 67%, colorectal 25%, Non-Hodgkin’s Lymphoma 8%. At baseline, 3 participants were overweight, 9 obese (≥30kg/m2), and 9 >1 comorbidity. Participants attended 97% clinics, 71% exercise, and 81% dietary sessions. Post-intervention, mean weight change was -4.9kg (range 0.1 to -19.6), 5% initial weight. Waist circumference reduced 3.8cm (range -13.2 to 4.8), 3% body fat mass reduced and 2% lean body mass increased. Participants improved aerobic fitness, maximal strength, and fruit and vegetable intake. No changes in fatigue, quality of life, depression, anxiety or stress were reported. There was no change in blood markers (fasting glucose, IGF-1, cholesterol, C-reactive protein). Program tailoring and support from facilitators and co-participants, were enablers of intervention attendance. Conclusion: This study confirms overweight cancer survivors are willing to attend a WMP. The program enabled positive changes to weight, body composition, fitness and nutritional quality despite impact of stress, anxiety, depression and fatigue. Longer follow up will determine if weight loss and healthy lifestyle behaviours are sustained

Navigating a Way Forward: How Women Survivors of Breast Cancer and Their Partners Face Challenges Adapting to Their Changed Lives

Many women survivors of breast cancer and their partners experience challenges while attempting to resume meaningful activities and important life roles following treatment cessation. This mixed method study aimed to explore these challenges and appraise the current services available to meet ongoing needs. Three major themes were determined; women and partners experience occupational disruption, use of a survivorship care plan and rehabilitation is warranted, occupational therapy has a role in assisting women and partners during survivorship

Facilitating practitioners to deliver self-management support to cancer survivors: development and co-design of a theory-based intervention informed by contexts and mechanisms

Background Older cancer survivors have physical and psychosocial problems after completing cancer treatment which are not adequately addressed by secondary care teams. Enabling older cancer survivors to self-manage problems after cancer treatment is essential for optimising their health and wellbeing. This thesis aimed to design an intervention to facilitate primary care teams to provide self-management support to older cancer survivors. Methods Underpinned by scientific realism and behavioural science, this research involved three empirical studies: a cross-sectional study to estimate the prevalence of cancer treatment-related problems in older cancer survivors and overall care satisfaction, a realist review, and a co-design study to understand and address the barriers and enablers for facilitating primary care practitioners to provide self-management support. Results Half of older cancer survivors experienced physical and psychosocial problems after cancer treatment. Of these, 82% experienced physical, 69% psychological and 51% social problems. Perceived support from secondary care teams to manage physical, psychological and social problems was rated as adequate by 64%, 50% and 28%, respectively. Key enablers for facilitating practitioners to provide self-management support were knowledge and communication skills to engage cancer survivors in discussions about self-management, practitioners feeling that their role and responsibilities included self-management support, the organisation prioritising self-management support, and health system configuration to integrate self-management support into routine care. A structured pathway was co-designed to facilitate primary care teams to provide self-management support. This will involve using the knowledge and skills of existing team members to identify patients with unmet needs who may benefit from additional support, identifying local self-management resources and signposting patients to existing provision of information and care, and a mechanism for annual patient follow-up. Conclusion The intervention developed maximises the role of existing primary care teams and optimises current processes. The next step is to operationalise the intervention and evaluate efficacy at facilitating delivery of self-management support

Addressing the Health Needs of an Aging America: New Opportunities for Evidence-Based Policy Solutions

This report systematically maps research findings to policy proposals intended to improve the health of the elderly. The study identified promising evidence-based policies, like those supporting prevention and care coordination, as well as areas where the research evidence is strong but policy activity is low, such as patient self-management and palliative care. Future work of the Stern Center will focus on these topics as well as long-term care financing, the health care workforce, and the role of family caregivers

Exploring the possible application of implementation intention on prospective memory of cancer patients

Prospective memory defines the ability to remember to perform an action related to a specific task planned for the future. Interventions aimed to improve prospective memory have an impact on the patient's quality of life. While most interventions are aimed to improve prospective memory in general, implementation intentions influence specific automatic processes related to prospective memory. The efficacy of this type of intervention has been proven on different samples of patients as well as on lay people. We argue that, while in cancer patients who suffer from perspective memory deficit this particular intervention has not been studied yet, it could be usefully implemented to foster patients' involvement, quality of life and adherence to care

Healing conversations: Developing a practical framework for clinical communication between Aboriginal communities and healthcare practitioners

In recognition of the ongoing health disparities experienced by Aboriginal and Torres Strait Islander peoples (hereafter Aboriginal), this scoping review explores the role and impact of the clinical communication process on Aboriginal healthcare provision. A medical education lens is applied, looking at the utility of a tailored clinical communication framework to assist health practitioners work more effectively with Aboriginal peoples and communities. The initial framework, building on existing communication guides, proposes four domains: content, process, relational and environmental. It places emphasis on critical self-reflection of the health practitioner’s own cultural identity and will be guided by collective Aboriginal world-views in select Australian settings. Using a two-eyed seeing approach the framework will be developed and tested in health professional education. The aim of this research journey is to enable health practitioners to have more effective healthcare conversations with Aboriginal peoples, working toward more socially just and equitable healthcare interactions and outcome