Patient and professional perspectives on physical activity promotion in routine cancer care: a qualitative study

Abstract

Backgrounds

Physical activity is associated with many benefits in reducing cancer symptoms and treatments side effects. Yet, studies consistently show that knowledge about physical activity is under-promoted among people diagnosed with cancer. Therefore, we aimed to contribute to filling this gap by ascertaining patient and professional perspectives regarding physical activity promotion.

Methods

This study took place in Montreal, Canada. We conducted individual, semi-structured interviews with cancer patients who participated in a physical activity program and professionals working in the healthcare system. Participants had to be aged over 18 years, be able to communicate verbally in either English or French, and consent to an audio-recorded interview. A hybrid deductive-inductive approach to content analysis was applied to analyze interview transcripts using Dedoose and Microsoft Excel software.

Results

Our sample comprised 21 patients (76.2% women) and 20 professionals (80% women). We identified 24 factors (barriers, facilitators, and improvement suggestions) influencing physical activity promotion across organizational, community, and social levels. Results suggest that to improve physical activity promotion in cancer care, it is necessary to showcase exercise specialists as a healthcare resource, to champion for this change within health organizations, to develop partnerships between public and private sectors of the health and fitness industries, and to reassess social norms concerning cancer survivorship and treatment.

Conclusion

These findings shed light on the gaps and the bright lights in physical activity promotion for people diagnosed with cancer across numerous levels.

Introduction

In Canada, two in five people will be diagnosed with cancer in their lifetime [1]. Cancer is the primary cause of premature death among Canadians [1], and its treatment often causes short- and long-term side effects. Much attention has been directed towards physical activity’s role in reducing cancer mortality and incidence [2,3,4]. More recent work has focused on physical activity benefits in reducing cancer symptoms and treatments side effects. That is, physical activity decreases cancer-related fatigue, depressive and anxious symptoms, improves quality of life and perceived physical function, and is associated with increased survival rates for some cancer types [5,6,7,8,9]. To achieve these health benefits, current evidence-based recommendations for people diagnosed with cancer suggest aiming for at least 90 min of aerobic activity at moderate intensity as well as two strength-training sessions per week [7]. Recommendations also emphasize the importance of avoiding inactivity [5]. Nevertheless, data show that people diagnosed with cancer do not reach these recommendations [10, 11]. Despite physical activity benefits, studies consistently show that it is under-promoted in clinical oncology settings, prompting scholars to declare that “Current practice is failing those diagnosed with cancer” (p. 21) [8]. This study aims to contribute to filling this gap by ascertaining patient, organizational and professional perspectives on how to promote physical activity among cancer patients.

In accordance with the World Health Organization’s definition of health promotion, physical activity promotion can be described as the process of enabling people to increase control over, and to improve, their physical activity [12]. The WHO further specifies that promotion “not only embraces actions directed at strengthening the skills and capabilities of individuals, but also action directed towards changing social, environmental, and economic determinants of health so as to optimize their positive impact on public and personal health.” (Nutbeam & Muscat, 2021, p. 1580). Physical activity promotion thus includes actions such as building infrastructure for guided exercise within clinical settings. It also includes one-on-one intervention such as the “5A”s”: Ask, Advise, Assist and Arrange” put forward by the Agency for Healthcare Research and Quality [13].

In keeping with that definition, guidelines for the implementation of chronic disease management [14] underscore the importance of assessing an encompassing list of factors when implementing physical activity promotion among people diagnosed with cancer. These factors range across numerous levels including individual (e.g., patient readiness), health professionals (e.g., practices and evidence), organizational (e.g., resources in the clinical setting), community (e.g., availability of programs and services), and the greater social environment (e.g., social norms) [5, 15,16,17,18,19,20,21,22,23]. Evidence suggests that an effective promotion strategy should address key ingredients at each of these levels. Key ingredients at the individual level include patients’ readiness, interest, and socioeconomic resources to engage in physical activity as well as their knowledge base about the subject [5, 16, 18,19,20]. For health professionals, the promotion of physical activity is facilitated by clinicians’ knowledge of and ease in promoting physical activity to people diagnosed with cancer, their access to promotional material, their knowledge of referral resources, and by solid program evaluation data [5, 16,17,18, 20, 22, 24]. At the organizational level, providing access to continuous healthcare training about physical activity and cancer, and support from organizational leadership and colleagues in hospital settings facilitate the implementation of physical activity promotion [5, 15, 17,18,19,20,21,22]. At the community level, an effective promotion strategy includes financial, geographic, and sociocultural access to physical activity outlets (private gyms, community clubs, etc.) or clinical physical activity programs [5, 18,19,20]. Finally, examples of social environment ingredients include government policies to support physical activity promotion including funding physical activity programs for people diagnosed with cancer, or privately funded initiatives to offer such programs [17, 20].

There is consensus that to maximize physical activity benefits for people diagnosed with cancer, physical activity promotion must be integrated into multiple levels of care targeting the multi-level factors such as those mentioned above holistically [25,26,27]. Yet, most evidence about the factors affecting implementation of physical activity promotion in clinical oncology settings comes from patients expressing the role of individual level factors and to a lesser extent health professionals expressing the role of organizational level factors [19]. That is, current knowledge underrepresents organizational stakeholders’ perspectives [21], organizational factors influencing program delivery [18], as well as factors occurring at the community or at the societal levels. To contribute to filling this gap and replicating existing findings, we ascertained patient and professional perspectives regarding barriers, facilitators, and suggestions to promote physical activity.

Methods

Design

A qualitative research design was used to identify barriers and facilitators to the implementation of physical activity promotion as well as suggestions for its improvement [28]. A deductive-inductive content analysis approach was chosen because it is well suited for preparing, organizing, and reporting a large corpus of complex data [28, 29]. One-on-one semi-structured interviews were conducted with patients and with health professionals.

Recruitment and ethical considerations

Participants had to be aged over 18 years, be able to communicate verbally in either English or French, and consent to an audio-recorded interview. They could not participate if they did not meet these criteria, or the ones described below. Two sampling strategies were used to recruit people diagnosed with cancer and health professionals respectively. First, to facilitate recruitment of people diagnosed with cancer, we randomly selected sixty patients (30 men, 30 women) who had or were participating in a physical activity program geared specifically for people diagnosed with cancer in the previous 2 years. This program was offered at no cost by the Virage Foundation, which operates within a large hospital center (CHUM, Centre hospitalier de l’université de Montréal) in the city of Montreal, Canada. Using the sixty randomly selected subsample of program attendees, we contacted potential participants sequentially via telephone and offered them to participate in the study. As for the professionals, the research team identified and invited via email known professionals as well as organizational managers and leaders having prior experience in oncology healthcare or providing physical activity services within a hospital environment. We solicited professionals with experience in promoting or providing physical activity to people diagnosed with cancer as well as those with experience in developing or providing cancer care.

This study is part of a larger project detailed elsewhere [30]. Potential participants were provided the study information and consent form, time to review it, and the opportunity to ask questions. Study participants provided written informed consent to audio recorded interviews. The CHUM Research Center Ethics Board reviewed and approved the study protocol (# 17.238).

Procedures for data collection

Our research team was composed entirely of women. It included five research assistants (four graduate students in public health (M. Sc.), community psychology (Ph. D., KSO), social psychology (B. Sc., JSC), and physical activity sciences (M. Sc.) as well as a research professional (MD). Lastly it also included two senior level researchers with extensive expertise in physical activity science as well as social and preventive medicine (Ph. D. University Professors, ID and LG). The research team adopted an epistemological position in which we aimed for objectivity recognizing that our work is influenced by the values conveyed in health promotion. These include benevolence, equity, usefulness and efficacy, transparency, common good, as well as empowerment.

Semi-structured individual interviews were conducted face-to-face at the hospital center before the COVID pandemic onset and via teleconference or telephone while confinement policies were in effect. The senior authors developed the interview guides (see Doré et al., 2022) for complete interview guides). The interview guides were geared to obtain information about the physical activity program as a part of the larger research project, but specific questions also targeted participants’ perceptions on existing promotion of physical activity to people diagnosed with cancer inside and outside the hospital setting as well as its improvement. Three research assistants trained in interviewing techniques conducted interviews with 21 patients and 20 professionals between June 3, 2019, and October 26, 2020. Data collection ended once theoretical saturation was achieved [31]. That is, we ceased to interview participants once no new information emerged and the data collected satisfactorily met the study objectives. On average, interviews lasted 35.05 min (MD = 35.00, SD = 10.48, Min = 17.00, Max = 57.00). They were digitally recorded then transcribed verbatim by an external service provider. Research assistants were tasked with keeping a journal of field notes which were discussed during weekly team meetings. To ensure participants’ anonymity, minimal sociodemographic data were collected, and data were stored on a secure server.

Data analysis

Interview transcripts were analyzed using a hybrid deductive-inductive approach to content analysis [28, 29, 32] with Dedoose and Microsoft Excel software. In the first preparation phase of coding [29], all researchers participated in a three-part training on content and thematic analysis to harmonize approaches, knowledge, and previous experiences with qualitative analysis. Four research assistants then coded deductively using an empirically based tool for health promotion implementation checklist as a guide. The “Tailored Implementation for Chronic Diseases” (TICD) checklist [14] served as the initial deductive coding grid [28]. The TICD checklist [14] covers a range of ecological factors influencing the implementation of promotion initiatives for chronic disease such as cancer. Specifically, it includes seven main domains relevant to implementing physical activity promotion in cancer healthcare practice: patient factors, individual health professional factors, professional interactions, capacity for organizational change, guideline factors, incentives and resources, as well as social, political, and legal factors. These domains served as the initial codes whereby research assistants applied them to relevant interview excerpts whilst also looking for new emerging codes not represented in the TICD checklist but answering our research question. Using the TCDI checklist as a coding grid facilitated the identification and labeling of multi-level facilitators and barriers.

In the second organization phase of coding [29], the two first authors abstracted initial codes into broader themes that better represented the data (organizational, community, and sociocultural factors influencing promotion implementation). The first author then refined codes and grouped them as a function of perceived factors that hinder (barriers), help (facilitators), or could improve (suggestions) physical activity promotion for people diagnosed with cancer. For Reporting, the third and last phase of coding, the research team met regularly to discuss and refine themes and sub-themes as well as to select illustrative quotes to depict each of them.

To support coding rigor and reproducibility, research assistants met weekly to discuss their coding strategies and challenges. For member-checking purposes [28], we presented preliminary data to professionals having participated in the study interviews and integrated their feedback.

Results

Our sample includes twenty professionals (80% women) working in oncology, nursing, cardiology, kinesiology, public health, and management as well as twenty-one patients (76.2% women) in cancer care of various sites: breast, prostate, thyroid, lung, and others. Below, we describe perceived barriers and facilitators as well as suggestions for improvement of physical activity promotion among people diagnosed with cancer as a function of three levels of analysis: (1) Organizational factors; (2) Community factors; (3) Sociocultural factors. Table 1 provides a detailed overview of these findings.

Table 1 List of barriers, facilitators, and improvement suggestions for physical activity promotion among people diagnosed with cancer as a function of organizational, community, and sociocultural factors

1. Organizational factors

This section presents the perceived factors influencing physical activity promotion among people diagnosed with cancer within the hospital setting. This includes factors influencing physical activity promotion such as professional practices, service provision (e.g., diversity and variety of physical activity programs), organizational resources, and functioning. Table 2 presents illustrative quotes describing each of these factors.

Table 2 Organizational level factors: quotes from patients (PAT) and professionals (PRO) describing barriers, facilitators, and improvement suggestions

1.A. Barriers

Both professionals and patients stated that clinicians need to be better prepared to promote physical activity to people diagnosed with cancer. 1.A.1 Limited knowledge transfer to health professionals included exposure to scientific literature on related benefits as well as lack of knowledge concerning how and where to refer patients. Professionals and a few patients emphasized that 1.A.2 Resource scarcity greatly reduced physical activity promotion for people diagnosed with cancer. Lack of physical space and human resources to host the program were especially commonly mentioned by exercise specialists and managers. Clinicians often mentioned lacking time to address and promote physical activity. Lastly, professionals and patients noted characteristics that 1.A.3 Constrained service offer. These characteristics were mainly but not exclusively mentioned by patients. Participants mentioned elements such as physical activity program time slots conflicting with treatment or daily life, and the need for more peer support and diversity in group makeup. For example, some participants mentioned the lack of groups exclusively for people of younger age, male gender, and diverse sociocultural backgrounds.

1.B. Facilitators

Both professionals and patients recognized the key role played by the presence of 1.B.1 Qualified exercise professionals specializing in oncology. Exercise specialists were said to be in short supply and high demand. They were especially crucial in facilitating patients’ transition out of the in-hospital physical activity program to being active in their communities. Participants also stated that implementing a physical activity program within clinical settings needs 1.B.2 Championing by all concerned parties. Notably, participants shared that “positive pressure” from the clinical team was key to securing plans for a clinical oncology gym. Indeed, passionate clinicians rallied their colleagues to promote physical activity to their patients; and a clear and shared vision at the higher organizational levels was said to be necessary to bring change to standard delivery of care. Some professionals were adamant that including patients with lived experience was essential to program implementation and especially promotion. Finally, many professionals mentioned the need for 1.B.3 Interprofessional collaboration among exercise specialists, nurses, doctors, and program managers to promote physical activity to people diagnosed with cancer. Participants stressed that having access to the patients’ data was critical for exercise specialists to tailor care accordingly and communicate with clinicians effectively. Managers were understood to be an essential part of the process namely in securing the necessary resources prospectively.

1.C. Suggestions

Many patients called for clinical settings to 1.C.1 Emphasize exercise professionals’ vital role in oncology. Various professionals stated that exercise specialists should be integrated into clinical teams. Furthermore, communication between all concerned parties should be improved, they said. To that end, participants suggested experts should 1.C.2 Develop tools and training opportunities. A list of these suggestions is provided in Table 2. Also, professionals wanted to 1.C.3 Measure physical activity program impact. They argued that solid data with positive short-, medium- and long-term results would help to boost their inclination to promote physical activity to people diagnosed with cancer as well as to secure funding for the program. Lastly, clinicians and managers indicated that accrued scientific data showing physical activity to be safe in given doses and cancer sites would also boost clinicians’ readiness to promote physical activity to their patients.

2. Community factors

These factors incorporate participants’ views concerning the influences operating outside the hospital setting on physical activity promotion for people diagnosed with cancer. They describe how private and philanthropic service offer relates to individual socioeconomic levels and suggestions to overcome challenges to equitable service provision beyond the medical milieu. Table 3 presents illustrative quotes to depict these factors.

Table 3 Community level factors: quotes from patients (PAT) and professionals (PRO) describing barriers, facilitators, and improvement suggestions

2.A. Barriers

Two clinicians perceived physical activity to be easily accessible in the community, noting it isn’t difficult to find outlets nearby (e.g., private gyms, paid exercise venues, public parks and swimming pools). Nevertheless, most participants mentioned 2.A.1 Sociodemographic inequities and the financial challenges people diagnosed with cancer face in adopting or maintaining physical activities. Some clinicians said they promoted physical activity in the community only to cancer patients they knew had the financial means to seek exercise professionals. Exercise specialists and physical activity program managers in our sample noted their clientele overrepresented more educated and wealthier individuals. Most professionals mentioned that physical activity outlets were scarce outside of the city, even more so specialized services for people diagnosed with cancer living in rural settings. Also, professionals and patients shared 2.A.2 Concerns about service availability and quality in the community. High turnover and labor shortage of exercise specialists working in gyms thwarted efforts to develop partnerships with popular private physical activity outlets in the community. Such ties between health professionals and community physical activity outlets were important to participants. The professionals especially wished to be able to monitor their patients’ progress and ensure that exercise plans were adapted accordingly. Lastly, professionals and patients feared that the quality and cleanliness standards in gyms were insufficient for immunocompromised patients.

2.B. Facilitators

Despite the challenges listed above, professionals noted a beneficial 2.B.2 Interest from the private sector. Namely, private gym owners showed interest in offering reduced rates for people diagnosed with cancer as well as training their staff to better serve this clientele. Participants noted that a select few insurance companies would reimburse certain of these costs granted the treating physicians provided medical clearance or a prescription to exercise. The 2.B.2 Involvement of philanthropic organizations was praised in facilitating physical activity promotion for people diagnosed with cancer. These entities were said to be strategically poised to offer tailored services thanks to community financial support. Their close ties with and physical presence in the hospital setting granted them the credibility, knowledge and access needed to offer services that can fill service gaps in physical activity promotion.

2.C. Suggestions

In line with all the above barriers and facilitators to physical activity promotion at the community level, participants called for involved parties to 2.C.1 Develop and nurture intersectoral collaboration. Most professionals especially indicated that the philanthropic sector’s relative decisional and financial autonomy and the potential for partnerships with the private sector could better be harnessed using tools such as an innovative business model and mentoring other exercise specialist teams remotely across the province. They also called for professionals to 2.C.2 Guide turnkey programs. That is, for ready to implement, detailed, oncology-adapted physical activity promotion programs to be developed and disseminated to interested community settings.

3. Sociocultural factors

Lastly, these factors encapsulate participants’ views concerning the how greater societal forces influence physical activity promotion for people diagnosed with cancer. They include influences such as social norms as well as general and medical culture. Table 4 presents illustrative quotes supporting each of these factors.

Table 4 Sociocultural level factors: quotes from patients (PAT) and professionals (PRO) describing barriers, facilitators, and improvement suggestions

3.A. Barriers

Participants named many 3.A.1 Social norms about cancer survivorship and physical activity that hinder physical activity promotion among people diagnosed with cancer. Namely, people diagnosed with cancer are viewed as fragile, needing passive rest and treatment. In other words, cancer treatment and physical activity can be perceived as antithetical. Moreover, participants noted that physical activity is often considered tedious and secondary to everyday life tasks. These views held particularly true regarding women, whom some clinicians noted were less interested in physical activity. Many women patients shared the challenges of remaining active while also attending to family duties expected of mothers. These social expectations were said to be exponential when in 3.A.2 Transition back to routine in a demanding world. Participants shared that patients feel pressure from their surroundings to quickly return to their previous self and routine before cancer. These social obligations were said to compete with time spent being physically active. This was especially true about patients returning to work. Finally, most participants perceived a 3.A.3 Lack of funding for physical activity in cancer care. In the private sector, they said, insurers are slow to fully recognize physical activity participation as a valid health reimbursement. Many professionals felt that prevention was underutilized in healthcare, minimizing the potential physical activity promotion could have on population health. Moreover, there is a lack of government engagement, many participants said, in funding physical activity promotion for people diagnosed with cancer and lack of funding in health in general. For example, one participant witnessed an ongoing debate between the health and the sports and leisure ministries to relinquish funding to another department, if it should ever occur.

3.B. Facilitators

In contrast, participants noted that general 3.B.1 Social support for participation in physical activity during cancer treatment greatly facilitates physical activity promotion to people diagnosed with cancer. Having a social environment that endorses of physical activity and gaining every day instrumental support helps making it an achievable priority. The same was said of 3.B.2 Medical culture gradually embracing adjunct treatments. Many participants felt that professionals of all disciplines were progressively more inclined to support complementary forms of treatment and thus to promote physical activity. Lastly, many participants noted that the 3.B.3 Population increasingly seeking health information increased general awareness of the benefits of physical activity.

3.C. Suggestions

Considering sociocultural barriers and facilitators to physical activity promotion for people diagnosed with cancer, participants suggested 3.C.1 Raise public awareness. Specifically, they called for raising awareness about physical activity’s benefits to cancer treatment and especially about exercise specialists’ important role in that. Professionals suggested using information technology to equitably target diverse groups of individuals. Second, many participants wished to 3.C.2 Standardize universal physical activity cancer care. They suggested integrating physical activity into standard cancer care practices province-wide so that all people diagnosed with cancer may have the best and most complete form of treatment. Finally, participants called for greater and shared 3.C.3 Funding physical activity programs in cancer care for people diagnosed with cancer. Some clinicians stated that individuals should take on the cost of their physical activity during cancer care because the cost to society would be too great otherwise. Some participants suggested that insurance companies be made to cover more costs associated with physical activity participation in cancer care. The greater part of participants felt that it was a governmental responsibility to fund physical activity promotion as a holistic approach to health.

Discussion

The present study aimed to ascertain patient and professional perspectives regarding physical activity promotion by identifying barriers and facilitators to physical activity promotion and suggestions for its improvement based jointly on patient- and professionals’ experiential and professional knowledge. We identified 24 factors (barriers, facilitators, and improvement suggestions) across the organizational, community, and social levels. We discuss each factor level broadly below.

Organizational level

A recent scoping review of organizational barriers to promoting physical activity, more specifically integrating structured exercise into cancer care, suggests that organizational barriers account for the larger part of challenges to physical activity promotion [21]. Our results converge with a host of studies showing that clinicians need a better knowledge of evidence-based guidelines on physical activity for cancer population (e.g. ACSM – American College of Sports Medicine Guidelines for Exercise and Cancer, ASCO - American Society for Clinical Oncology Clinical Practice Guidelines), access to clear and simple physical activity promotion tools, a universal referral pathway with standardized workflow tools, as well as champions to advocate for additional resources and to develop collaborative physical activity promotion in interdisciplinary clinical teams [15, 18, 21]. Managers in our sample supported previous work highlighting the importance of patient engagement in program development, implementation, and maintenance [25]. They were adamant about including patients as advocates about the program, especially in the initial phases of development to better coopt decision makers and funders. Our study shows signs of organizational readiness to integrate exercise specialists into interdisciplinary teams, as many clinicians explicitly made this suggestion. Because it could impact potential for program scale-up, it would be interesting to investigate whether this readiness was unique to this setting, the health system in which it exists or even the general population culture surrounding it. Some participants in this study also mentioned the need for physical activity programs designed for specific groups such as young adults, male gender, and diverse sociocultural backgrounds. Physical activity has been less researched in specific groups such as young adults diagnosed with cancer [33]. Tailoring physical activity programs to these groups might fill gaps in current research and practice, and thus achieve more optimal effects on the health and quality of life of these groups. Most importantly, our data shows urgency in showcasing the role that exercise specialists trained in oncology play in the health and survivorship of people diagnosed with cancer. Indeed, as pointed out by study participants, Virage exercise specialists trained in oncology accompany patients from as early as first diagnosis, through treatment and recovery, offering support and working collaboratively to foster a healthier future for patients. Much work needs to be done to highlight their importance and untapped potential in cancer care.

Community level

This study’s results show how crucial philanthropic entities are to program delivery of physical activity among people diagnosed with cancer. The Virage Foundation’s cost-free physical activity program fostered known levers to participation such as access to no-cost, tailored programs, and available educational materials [15, 19]. It also allowed cancer patients to circumvent certain barriers to participation in physical activity like lack of exercise specialists trained in oncology [18, 19, 21]. Our results additionally highlight opportunities, but also challenges for much-needed community development. Deepenbusch et al.’s review (2021) showed that the quality of the local environment was not a main deterrent of physical activity for people diagnosed with cancer [18]. Rather, in line with our data, lack of service offers specifically tailored for this population was a main barrier to their physical activity participation [18]. Furthermore, in their review, Elshasat et al. (2021) observed that people diagnosed with cancer preferred participating in physical activity at home, in fitness centers, and in hospital centers (in that order) [19]. Fitness centers being important opportunities for structured, supervised physical activity, improving ties with the private industry, and building its community capacity appear to be promising avenues [25].

The organizational managers and leaders in our sample emphasized the potential that well laid-out development plans based on business models could have in improving program sustainability and scale-up. Our data also show that collaboration with franchised fitness centers was hindered namely by high staff turnover despite there being interest from private managers. Moreover, most participants in our study noted that, even at reduced cost, private fitness centers were financially or geographically out of reach for a large number of people diagnosed with cancer. Addressing the concerns of accessibility, especially for rural residents, it is crucial to acknowledge barriers such as distance from physical activity outlets, transportation needs, and individual functional ability. Remotely delivered physical activity interventions have shown promise to mitigate these challenges. Studies have shown the efficacy of interventions using technologies like text messaging, wearable activity monitors, and online coaching [34], videoconferencing [35], as well as remote unsupervised exercise strategies [36] to successfully promote physical activity to people diagnosed with cancer. The integration of these technologies can enhance accessibility, providing tailored support and enabling people diagnosed with cancer in rural areas to engage in physical activity safely and independently, thus bridging the gap in access to community-based programs. To reduce these inequalities in access to physical activity for people diagnosed with cancer, our data points to the potential of applying entrepreneurial strategies to implementation science in guiding program development and maintenance on top of fostering remote video conferencing sessions in line with recent work [9]. Future research on this topic is clearly warranted.

Social level

Finally, our study sheds light on a crucial aspect of promoting physical activity for people diagnosed with cancer: patients and professionals’ perspectives on its wider social issues. Calls for government financial support for programs or incentives encouraging physical activity promotion for people diagnosed with cancer are widely reported [18, 19, 21]. Participants in the present study expressed ambiguous views concerning who should fund physical activity participation for people diagnosed with cancer. Some studies indicate a clear need for investment in government policies for universal physical activity promotion to people diagnosed with cancer [21, 25]. Given that public support for public policy increases its success rates, it appears relevant that future research should ascertain the general population’s support for such policies. Prioritizing health communication and education as well as promotion could also facilitate policy change implementation [25]. In line with previous work [15, 18], a few health professionals did not consider physical activity promotion to be in the scope of their medical practice, despite the evidence base supporting physical activity as an effective strategy to reduce cancer and treatment side effect and improve physical and mental health. Some health professionals interviewed shared that physical activity was not suitable for people diagnosed with cancer, at certain stages of cancer, or certain types of cancer. This could be due to limited knowledge of physical activity guidelines for cancer patients, perceptions and attitudes towards physical activity and cancer, or lack of tools and referral pathways to promote physical activity [37]. Our study further highlights how social norms and public perceptions concerning physical activity, cancer recovery and even gender roles and work performance shape how we consider physical activity as treatment for cancer despite the growing body of literature on the subject. Social perception studies and social marketing campaigns could be of great benefit to lay the groundwork for physical activity in cancer care to be included as standard cancer care and, thus, for the latest evidence base to be implemented.

Despite our efforts to recruit a diversity of profiles, our patient sample included mostly women with breast cancer, and older middle-aged participants who were active prior to diagnosis, data representativeness is limited. More work is needed to gather data among men, younger adults, and people from diverse ethnocultural groups. Along the same lines, we recruited patients having completed the physical activity program. It is likely that these individuals were the most motivated to be physically active. Further research should investigate structural barriers to physical activity promotion among people diagnosed with cancer who did not participate in such programs. Similarly, we focused on recruiting health professionals with experience in physical activity promotion to increase the opportunity of gaining insight into this practice. However, including those having not engaged in physical activity promotion could have produced more information about barriers to physical activity promotion. Lastly, although our study did include organizational managers, which allowed us to collect critical data, a larger sub-sample of these professionals as well as policymakers and health and fitness industry spokespersons could have allowed us to garner even more insightful perspectives. Future research should aim to fill this gap.

Conclusion

This study provides a list of 24 factors including barriers, facilitators, and improvement suggestions to consider in a strategy for promoting physical activity in cancer care in Quebec, Canada. It sheds light on the gaps and the bright lights in physical activity promotion for people diagnosed with cancer. Healthcare institutions and policymakers could better implement guidelines and develop a standardized process to direct all cancer patients to appropriate physical activity resources tailored to their needs. Our results suggest that to improve cancer care, it is necessary to showcase exercise specialists as a healthcare resource, to champion for this change within health organizations, to develop partnerships between public and private sectors of the health and fitness industry, and to reassess social standards concerning cancer survivorship and treatment. Scholars have suggested adopting multifaceted strategies that address various barriers to program implementation in clinical settings (e.g., combining social marketing, communication, partnership, and environmental transformations) despite these strategies having shown limited success in increasing physical activity participation in the general population [9]. Our data indicate that more attention should be paid to deconstructing social norms about cancer survivorship and treatment accessibility, physical activity, and gender roles and to constructing an agenda to support people diagnosed with cancer.