Citation
Predictors of physical activity interest among couples following a cancer diagnosis

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Title:
Predictors of physical activity interest among couples following a cancer diagnosis
Creator:
Lloyd, Gillian
Place of Publication:
Denver, CO
Publisher:
University of Colorado Denver
Publication Date:
Language:
English

Thesis/Dissertation Information

Degree:
Master's ( Master of arts)
Degree Grantor:
University of Colorado Denver
Degree Divisions:
Department of Psychology, CU Denver
Degree Disciplines:
Psychology
Committee Chair:
Ranby, Krista
Committee Members:
Allen, Beth
Kilbourn, Kristin

Notes

Abstract:
Physical activity is associated with improved health outcomes for cancer survivors, cancer caregivers, and romantic couples, yet few exercise interventions have aimed to simultaneously promote exercise within cancer-caregiver dyads. This research explored whether cancer survivors and their romantic partners are receptive to the idea of a couples-based exercise program and tested several predictors of survivors’ and partners’ reported interest in and importance and likelihood of couples-based exercise. Further, it examined if cancer-specific exercise education influenced survivors’ and partners’ exercise knowledge, outcome expectations, and intentions to join individual and couples-based exercise programs. The study involved one online survey. Half of the sample was randomly assigned to view an educational video on cancer-specific exercise benefits. Regardless of condition, all participants (N=406) completed all study measures. Most participants were interested in a couples-based exercise program, and partner support for exercise was a consistently strong predictor of survivors’ and partners’ couples-based exercise interest, importance and likelihood. Participants in the education condition were more likely to correctly report published exercise guidelines, survivors’ had more positive exercise outcome expectations and intentions, and partners were more likely to choose a couples-based program over other program types. This research is a foundational step toward the development of future, efficacious dyadic exercise programs in survivor populations.

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University of Colorado Denver
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Auraria Library
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Copyright [name of copyright holder or Creator or Publisher as appropriate]. Permission granted to University of Colorado Denver to digitize and display this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.

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Full Text
PREDICTORS OF PHYSICAL ACTIVITY INTEREST AMONG COUPLES FOLLOWING A
CANCER DIAGNOSIS by
GILLIAN LLOYD B.S., Wake Forest University, 2015
A thesis submitted to the Faculty of the Graduate School of the University of Colorado in partial fulfillment of the requirements for the degree of Master of Arts Psychology Program
2019


©2019
GILLIAN LLOYD
ALL RIGHTS RESERVED


This thesis for the Master of Arts degree by Gillian Lloyd has been approved for the Psychology Program by
Krista Ranby, Chair Beth Allen
Kristin Kilboum


Lloyd, Gillian (MA, Psychology Program)
Predictors of Physical Activity Interest Among Couples Following a Cancer Diagnosis Thesis directed by Associate Professor Krista Ranby
ABSTRACT
Physical activity is associated with improved health outcomes for cancer survivors, cancer caregivers, and romantic couples, yet few exercise interventions have aimed to simultaneously promote exercise within cancer-caregiver dyads. This research explored whether cancer survivors and their romantic partners are receptive to the idea of a couples-based exercise program and tested several predictors of survivors’ and partners’ reported interest in and importance and likelihood of couples-based exercise. Further, it examined if cancer-specific exercise education influenced survivors’ and partners’ exercise knowledge, outcome expectations, and intentions to join individual and couples-based exercise programs. The study involved one online survey. Half of the sample was randomly assigned to view an educational video on cancer-specific exercise benefits. Regardless of condition, all participants (N=406) completed all study measures. Most participants were interested in a couples-based exercise program, and partner support for exercise was a consistently strong predictor of survivors’ and partners’ couples-based exercise interest, importance and likelihood. Participants in the education condition were more likely to correctly report published exercise guidelines, survivors’ had more positive exercise outcome expectations and intentions, and partners were more likely to choose a couples-based program over other program types. This research is a foundational step toward the development of future, efficacious dyadic exercise programs in survivor populations.
The form and content of this abstract are approved. I recommend its publication.
Approved: Krista Ranby
IV


ACKNOWLEDGEMENTS
I would like to express my gratitude to my mentor, Krista Ranby, for her guidance and engagement throughout this project. I would also like to thank my other committee members, Beth Allen and Kristin Kilbourn, for their additional ideas and feedback. Furthermore, I would like to thank my study participants, who shared their time and experiences. Finally, I would like to thank my loved ones, especially Chris Ulrich, for their endless patience, support and encouragement.
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TABLE OF CONTENTS
CHAPTER
I. INTRODUCTION....................................................1
Cancer Survivors and Physical Activity......................... 1
Cancer Caregivers and Physical Activity.........................4
A Dyadic Approach to Physical Activity..........................6
Dyadic Exercise Interventions in Cancer Populations.............8
Summary........................................................10
II. SPECIFIC AIMS..................................................11
III. METHODOLOGY....................................................12
Participants and Recruitment.................................. 12
Randomization................................................. 13
Measures...................................................... 13
Data Analysis Plan............................................ 18
IV. RESULTS........................................................20
Participants...................................................20
Aim 1: Interest in Couples-Based Physical Activity.............22
Aim 2: Effects of the Educational Video........................26
V. DISCUSSION.....................................................31
Aim 1: Interest in Couples-Based Physical Activity.............31
Aim 2: Effects of the Educational Video........................35
Limitations and Strengths......................................38
VI. CONCLUSION.....................................................41
REFERENCES.................................................................52
APPENDIX...................................................................60
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LIST OF TABLES
TABLE
1. Demographics and Health History..............................................42
2. Cancer Characteristics.......................................................43
3. Relationship Factors.........................................................44
4. Physical Competency and Current Exercise.....................................45
5. Outcome Variables............................................................46
6. Correlations Between Predictors and Couples-based Exercise Interest..........48
7. Strongest Predictors of Couples-based Exercise Importance and Interest.......49
8. Couples’ Agreement Regarding Couples-based Exercise..........................50
9. Mean Comparisons Between Education and Control Conditions....................51
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CHAPTERI
INTRODUCTION
Cancer Survivors and Physical Activity
Researchers estimate that the lifetime risk of developing cancer (all invasive sites) in the U.S. is approximately 42.1% for men and 37.6% for women (Howlader et al., 2016). Due to early detection and advanced treatment options, individuals diagnosed with cancer are surviving at greater rates than ever before. It is projected that there are over 16.9 million cancer survivors alive in the U.S. today (Bluethmann, Mari otto, & Rowland, 2016), and this number is expected to increase to over 20 million in the next decade (Miller et al., 2016). Despite these encouraging statistics, survivors are at an increased risk for many health complications including cancer recurrence, secondary cancers, chronic illnesses (e.g., cardiovascular disease) and long-term side-effects (i.e., pain, fatigue, sexual dysfunction) (Warburton, Nicol, & Bredin, 2006). Therefore, in order to prevent or ameliorate these potentially adverse outcomes, survivorship research has focused on the promotion of daily positive health behaviors (i.e., nutrition, physical activity, smoking cessation) and efficacious mechanisms of health behavior change.
Physical activity is a modifiable behavior consistently associated with improved cancer-related outcomes (Courneya & Friedenreich, 2001). Physical activity, defined as any movement resulting from skeletal muscle that causes energy expenditure, may be achieved through household (e.g., grocery shopping, cleaning), occupational (e.g., walking, lifting), or leisure-time (e.g., sports, gardening) activities (Caspersen, Powell, & Christenson, 1985). Exercise is a type of physical activity that is planned and for the purpose of improving physical fitness (Caspersen et al., 1985). Regular physical activity engagement is associated with reductions in cancer recurrence, cancer-specific mortality, and all-cause mortality for multiple cancer sites (Arem,
1


2014) with the greatest evidence in breast (Holick et al., 2008), colorectal (Meyerhardt et al., 2006; Arem et al., 2015) and prostate (Kenfield, Stampfer, Giovannucci, & Chan, 2011; Bonn et al., 2015) cancer. Further, physical activity has been shown to improve cancer treatment-related side-effects including physiological (e.g., weight management, mobility, muscle strength), psychological (e.g., distress, self-efficacy, quality of life) and social (e.g., peer support, relationships) health outcomes (Sabiston & Brunet, 2012; Schmitz et al., 2005; Speck et al.,
2010; Courneya, 2003; Penedo & Dahn, 2005; Ferrer Huedo-Medina, Johnson, Ryan, & Pescatello, 2011; Vijayvergia & Denlinger, 2015). Despite these established benefits, up to 70% of cancer survivors do not meet the American College of Sports Medicine’s (ACSM) guidelines for physical activity (i.e., 150 minutes of moderate or 75 minutes of vigorous intensity aerobic physical activity and 2-3 days of strength exercise per week) (Bellizzi, Rowland, Jeffery, & McNeel, 2005; Schmitz et al., 2010).
Given that many cancer patients reduce their physical activity levels during treatment and fail to regain their pre-diagnosis activity levels post-treatment (Irwin et al., 2003; Courneya & Friendenreich, 1997), there exists a need to understand predictors of physical activity in survivor populations. A fundamental construct in theories of health behavior is the person’s belief that they will benefit from the behavior. According to self-determination theory, access to information may promote autonomous motivation, an individual’s valued importance of a behavior or health practice (Ryan & Deci, 2000; Hagger et., 2014). Because physical activity may not be inherently enjoyable, survivors must first endorse its importance in order to actualize the behavior outside of controlled settings (Ryan, Patrick, Deci, & Williams, 2008).
Additionally, the theory of planned behavior posits that information about physical activity may shape survivors’ attitudes toward exercise, which may influence their behavioral intentions and
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outcomes (Ajzen, 1985). Similarly, the health belief model posits that individuals will take action to prevent illness if they believe the perceived benefits of their actions will outweigh the perceived barriers (Rosenstock, 1974; Carpenter, 2010). Although most survivors are likely aware of physical activity’s general importance, they may be unfamiliar with the unique benefits of exercise for cancer survivors specifically. Therefore, an important initial question to explore is whether cancer-specific exercise education influences survivors’ interest in becoming more active.
Previous research has found that most patients prefer to receive exercise recommendations from their oncologist (Jones & Courneya, 2002), and receiving physical activity advice after a cancer diagnosis is associated with higher levels of engagement (Fisher, Williams, Beeken, & Wardle, 2015). However, many healthcare providers report a lack of awareness regarding the appropriate timing, level, and type of exercise programs for survivors as well as the availability of cancer-specific exercise programs (Schwartz, de Heer, & Bea, 2017). As a result, very few patients report receiving exercise recommendations as part of their cancer treatment plan (Demark-Wahnefried, Peterson, McBride, Lipkus, & Clipp, 2000; Smaradottir, Smith, Borgert, & Oettel, 2017; Smith et al., 2017), and many may be unaware that regular exercise may positively affect disease outcomes (Smaradottir et al., 2017). Emerging research suggests that cancer survivors desire greater exercise guidance and utilize the Internet and social media to obtain exercise information, which may not be evidence-based (Smith et al., 2017). Therefore, survivors' limited resources and knowledge of physical activity’s benefits may be a primary cause of their insufficient physical activity levels.
In addition to knowing whether a brief educational intervention can improve interest in physical activity, additional intervention strategies are needed to help people sustain activity
3


levels over time. Researchers have struggled to demonstrate sustained physical activity following exercise interventions. Among non-cancer populations, intervention effects on physical activity levels are rarely maintained long-term (Hobbs et al., 2013; Van der Bij, Laurant, & Wensing, 2002). Only about 50% of individuals continue participation in a physical activity program six months after they started (Dishman & Sallis, 1994; Stiggelbout, Hopman-Rock, Crone, Lechner, & Van Mechelen, 2005). Among cancer survivor populations, systematic reviews have concluded that survivors’ long-term maintenance of physical activity protocols is largely understudied (Kampshoff et al., 2014), as most exercise trials only measure physical activity change during the intervention period (Bluethmann, Vernon, Gabriel, Murphy, & Bartholomew, 2015). Of the few trials that included post-intervention follow-up measures, most focused exclusively on breast cancer survivors and failed to demonstrate physical activity adherence after 3 months (Spark, Reeves, Fjeldsoe, & Eakin, 2013; Bluethmann et al., 2015). Therefore, emerging research should focus on the sustainability of physical activity participation in real world settings (Bluethmann et al., 2015) by examining the influences of social and environmental factors (Kampshoff et al., 2014).
Cancer Caregivers and Physical Activity
Romantic partners of cancer survivors are one important aspect of survivors’ social environment. Further, because cancer-related events are interpersonal, affecting both survivors and those in their proximal social networks, researchers should explore how cancer diagnoses result in health behavior changes among cancer survivors’ significant others. Caring for a loved one with cancer often results in considerable physical (e.g., loss of physical strength, pain), psychological (e.g., fatigue, impaired sleep, and reduced cognitive functioning), social (e.g., limited personal relationships) and economic (e.g., reduced employment) hardships (Girgis,
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Lambert, Johnson, Waller, & Currow, 2012; Northouse, Katapodi, Song, Zhang, & Mood, 2010; Ross, Ranby, Wooldridge, Robertson, & Lipkus, 2016). Previous research has shown that family caregivers report comparable or greater emotional distress than cancer survivors at various time points throughout treatment (Kaye & Gracely, 1993; Northouse, Mood, Templin, Mellon, & George, 2000; Matthews, 2003) and often place patients’ needs above their own. As a result, many caregivers engage in less health promotion activities for themselves (i.e., exercise, cancer screenings), which may lead to negative health consequences and increased mortality (Vitaliano, Zhang, & Scanlan, 2003; Northouse et al., 2010). Specifically, recent research found that 42% of caregivers of patients with ovarian cancer reported decreasing their physical activity levels since their family member’s diagnosis (Girgis et al., 2012). Further, more than half of caregivers report chronic health problems (e.g., cardiovascular disease, hypertension, arthritis) of their own, which may be worsened by the burden of caregiving (Martire, Schulz, Helgeson, Small, & Saghafi, 2010).
In order to ameliorate many of the adverse, health-related side-effects of caregiving, caregiver’s handbooks often stress the importance of being physically active. However, nearly all of the handbooks fail to describe how much activity, how often and for how long caregivers should exercise to see health benefits (i.e., reduced fatigue and improved physical function). For healthy adults, the ACSM recommends at least 150 minutes of moderate-intensity exercise per week (Garber et al., 2011). However, most caregiver’s handbooks lack this recommendation, and, instead, provide brief, nonspecific instruction. For example, the only exercise guidance for caregivers in the American Cancer Society’s Caregiver Resource Guide: Caring for a Loved One with Cancer is, “Make time for regular exercise and be as active as you can” (p. 47). Thus, cancer caregivers may need more explicit physical activity guidance in order to fit exercise into
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their already taxing schedules. In addition, most cancer-related exercise programs have been designed exclusively for cancer patients, and interventions that have included cancer caregivers have largely focused on psychoeducation, skill development, and counseling rather than behavioral modification or exercise adoption (Northouse et al., 2010; Frambes, Given, Lehto, Sikorskii, & Wyatt, 2017). Therefore, cancer caregivers may not have adequate access to physical activity programs, or they may perceive that exercise is more important for survivors than for themselves.
Analogous to understanding cancer survivors’ beliefs about physical activity, exploring caregivers’ perceptions of physical activity may inform the likelihood of their participation in exercise programs. Presently, few studies have explored cancer caregivers’ intentions to become more physically active, and of those that exist, most have focused on caregivers of lung cancer patients. Preliminary evidence suggests that family caregivers not meeting physical activity recommendations are motivated to increase their physical activity (Cooley et al., 2016) and are willing to participate in lifestyle programs (Howell et al., 2016). However, little is known about what factors (i.e., exercise knowledge, health status) influence cancer caregivers’ motivation to become more physically active. Because caregiver’s handbooks fail to include formal exercise guidelines, examining whether greater exercise education affects caregivers’ attitudes is a necessary step in informing possible intervention targets and predicting caregivers’ physical activity participation.
A Dyadic Approach to Physical Activity
As previously discussed, cancer and its treatment may cause survivors and their romantic partners significant, negative side-effects, which in turn, may contribute to physical activity declines. Evidence suggests that physical activity interventions may substantially benefit both
6


cancer survivors and their romantic partners, but few interventions have demonstrated survivors’ long-term physical activity maintenance, and few exercise programs exist for survivors’ romantic partners. Taking a dyadic approach to physical activity promotion may mitigate issues of maintenance and partner exclusion as dyadic interventions target each individual and the relationship at large. Relationships are more than just the sum of two or more individuals; rather, relationships have their own specific norms, cultures, and behaviors, which may promote or impede behavior change efforts (La Guardia & Patrick, 2014). Further, romantic relationships in adulthood represent one of the strongest influences on both health behavior change and illness coping (Kiecolt-Glaser & Newton, 2001). Therefore, exercise interventions must acknowledge that change occurs within a context, and dyadic interventions account for the substantial impact of romantic partners.
Relationships as mechanisms for health behavior change have been conceptualized by interdependence theory (Lewis et al., 2006) and communal coping (Lyons, Mickelson, Sullivan, & Coyne, 1998). Interdependence theory examines between-partner effects, or the influence of one individual’s actions on his or her partner. Research has consistently shown that when one partner improves his or her health behavior, the other partner is significantly more likely to make a positive health change as well (Jackson, Steptoe, & Wardle, 2015). These spillover effects occur across multiple health behaviors (e.g., exercise, smoking, alcohol use) and remain when controlling for other factors (e.g., demographics, health status) (Falba & Sindelar, 2008). For example, Cobb et al. (2016) found that individual changes in exercise were positively correlated with spousal changes, and individuals had a greater likelihood of meeting physical activity guidelines if their spouse met the recommendations. Additionally, Ellis et al. (2017)
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demonstrated patient-caregiver interdependence such that increased patient exercise was associated with greater caregiver exercise.
According to Lewis et al. (2006), communal coping is an example of how interdependence theory applies to couples coping with a health threat. Communal coping describes how couples respond to stressors as a unit rather than isolated individuals, transforming a stressor into a shared problem instead of one person’s burden (Lyons, 1998). This communal motivation to relieve the health threat may prompt couples to act jointly in adopting healthenhancing behaviors, and thus, be more successful (Lewis et al., 2006). Specifically, the success of couple participation has been exemplified by lower drop-out rates (Raglin, 2011), greater physical activity adoption (Gellert, Ziegelmann, Warner, & Schwarzer, 2011) and improved long-term physical activity maintenance (La Guardia & Patrick, 2014). Therefore, interventions targeting couples as a unit may be more efficacious than interventions targeting only the cancer survivor or only the spousal caregiver.
Dyadic Exercise Interventions in Cancer Populations
Despite the evidence supporting dyadic designs for health behavior change, very few physical activity programs have aimed to simultaneously target exercise outcomes among cancer survivors and their romantic partners. Preliminary evidence suggests that dyadic strength training interventions for prostate cancer survivors and their wives may improve survivors’ upper-body strength and physical activity and wives’ muscle mass, upper and lower body strength, physical function and physical intimacy (Winters-Stone et al., 2016; Lyons, Winters-Stone, Bennett, & Beer, 2016). Additionally, a ballroom dance intervention for cancer survivors and their romantic partners found that couples experienced increased physical activity, vitality, trust and quality of life (Pisu et al., 2017). Further, participants viewed the program as a stepping-stone toward
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becoming more physically active (Pisu et al., 2017). Finally, a dyadic exercise intervention for gay and lesbian cancer survivors and their partners significantly improved depressive symptoms compared to survivor-only exercise (Kamen et al., 2015). Therefore, dyadic exercise interventions for cancer survivors and their romantic partners may not only improve activity levels but also physical (e.g., muscle mass), psychological (e.g., QOL, depression) and relationship (e.g., physical intimacy) outcomes.
Future research on dyadic exercise interventions for cancer survivors and their romantic partners should explore what works, for whom, and in what contexts (Norman, 2008). Adopting a patient-centered approach that engages both survivors and their partners in program development may reveal whether interest in dyadic exercise interventions is universal or correlated with participant characteristics (e.g., sex, age, current exercise, relationship satisfaction, partner support for exercise). Previous research has shown that female cancer survivors perceive less spousal support than male survivors (Ungar et al., 2016), and thus, may be more likely to prefer exercise programs with peers rather than a romantic partner. Therefore, researchers must consider cancer survivors with diverse cancer histories (i.e., type, stage, treatment received), sexual orientations (e.g., heterosexual, homosexual) and relationship factors (e.g., married vs. partnered, cohabitating vs. living apart) in order to adequately assess associations between various participant characteristics and dyadic exercise interest. Establishing which cancer survivors and partners are interested in dyadic exercise interventions, what types of dyadic interventions they prefer (i.e., exercise together vs exercise individually toward a shared goals), and their likelihood of joining a dyadic exercise program will provide a necessary and informative foundation upon which more tailored interventions may be successfully designed.
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Summary
Physical activity is associated with improved cancer-related side-effects (e.g., reduced distress, fatigue, and physical function), both for patients and their caregivers. However, few physical activity programs for cancer survivors have demonstrated long-term exercise adherence and even fewer exercise programs exist for cancer caregivers. There are many theoretical reasons (e.g., lower drop-out rates, improved long-term maintenance) for why exercise interventions would benefit from targeting both cancer survivors and their romantic caregivers concurrently, yet few physical activity interventions have aimed to simultaneously promote exercise within cancer-caregiver dyads. The success of couples-based exercise programs depends upon cancer survivors’ and their romantic partners’ shared interest in working together on becoming more active. Therefore, prior to designing and implementing a physical activity intervention, it is necessary to first identify which cancer survivors and romantic partners are interested in a couples-based physical activity intervention and potential factors (e.g., cancer-specific exercise education) that my influence exercise beliefs and intentions. Understanding both predictors of physical activity interest and the effects of greater exercise education are foundational steps in informing the design, utility and efficacy of future dyadic exercise interventions for cancer survivors and their romantic partners.
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CHAPTER II
SPECIFIC AIMS
The purpose of this research was two-fold. Aim 1. The first objective was to examine whether both survivors and their romantic partners are interested in a couples-based exercise program and determine predictors of couples-based exercise importance, interest, and likelihood. Predictors examined were study participation from both partners, gender, age, volume of MVP A, current exercise with their romantic partner, relationship satisfaction, and partner support for exercise. Aim 2. The second aim was to determine whether cancer-specific exercise education influences both cancer survivors’ and their romantic partners’ exercise knowledge, outcome expectations and beliefs, and intentions to join individual and couples-based exercise programs.
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CHAPTER III
METHODS
Participants and Recruitment
Study procedures were approved by the Colorado Multiple Institutions Review Board. The study was advertised in several ways. First, we partnered with the University of Colorado Cancer Center and publicized the study through the Survivorship Care office and BFitBWell, a cancer-specific exercise program. In addition, advertisements appeared on Facebook and listserv emails. All electronic advertisements contained a link to a secure, online survey, which included a brief study description and fields for potential participants to enter basic contact information for both themselves and their romantic partner. Potential participants could also provide their contact information on a paper version of this survey, which was distributed through the Survivorship Care office. Within 72 hours of completing this initial survey, the study team emailed both members of the couple individually with a personalized link to an online screening tool. Eligibility criteria included: (1) history of cancer or the romantic partner of a cancer survivor; (2) member of a committed, romantic relationship; (3) access to a computer or tablet with internet; (4) willingness to share an email address with the study team; (5) age >18 years and < 90 years.
Participation was not limited based on current levels of physical activity, cancer treatment received, recurrence(s), or time since diagnosis. Romantic partners did not need to be married, co-habiting, or in a relationship for a specific time-period in order to participate. Further, participation was open to couples in which both individuals were cancer survivors. If one member of a couple was not eligible or declined participation, his or her romantic partner could still participate.
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Eligible participants automatically proceeded to the informed consent, and if they consented, they automatically continued to the online questionnaire. Participants were instructed to complete the survey separately from their partner in a private location by themselves. The survey assessed demographics and health history, relationship factors and satisfaction, psychological well-being, current physical activity, knowledge of the American College of Sports Medicine’s exercise guidelines for cancer survivors, and interest in individual and couples-based exercise programs. Participants who completed the survey were entered into a drawing to receive a $100.00 Target gift card as compensation for their time and effort. Randomization
Randomization occurred at the couple level after the initial contact survey was complete. Couples randomly assigned to the exercise education condition watched a 15 minute, audio-recorded PowerPoint presentation on the specific benefits of exercise for cancer survivors, caregivers, and cancer-caregiver couples. This presentation was created by the study team and was embedded into the online survey. Those in the control condition proceeded through the online questionnaire without any video content. Regardless of condition (i.e., exercise education or control), all participants completed all study measures.
Measures
All of the measures analyzed are detailed below. All study outcome variables are included in Appendix A. In both the Measures and Results sections, outcome variables are labeled with their survey item number, so the reader may reference the full wording of each item in the appendix.
Demographics and Health History. Data was collected on participants’ current age, gender, race, ethnicity, employment status, education, and income. Regarding general health
13


history, participants were asked if they had been diagnosed with a list of 16 chronic conditions (e.g., diabetes, cardiovascular disease, depression) and information about their daily health behaviors (e.g., smoking and alcohol use). Additionally, participants were asked to rate their overall health status (from poor to excellent) using an item from the 36-Item Short Form Health Survey (SF-36) (McHorney, Ware, & Raczek, 1993). Participants with a cancer history were asked to indicate the type(s) of cancer they had been diagnosed with and provide information on when they were diagnosed, past and current treatments, and cancer recurrences.
Psychosocial Factors: Patient-Reported Outcomes Measurement Information System (PROMIS) measures assessed sleep-related impairment, fatigue, depression, and anxiety (Celia et al., 2007). Participants indicated the frequency of sleep-related impairment and fatigue symptoms over the last week from 1 (not at all) to 5 (very much) as well as fatigue interference from 1 (never) to 5 (always). The reliability of these measures ranged from a=0.834 to a=0.954 in survivors and from a=0.780 to a=0.939 in partners. Similarly, participants were asked to indicate their frequency of depression and anxiety symptoms over the last week on two separate scales each ranging from 1 (never) to 5 (always). The reliability of these measures ranged from a=0.952 to a=0.958 in survivors and from a=0.939 to a=0.955 in partners. Participants also completed the physical self-perception profile Physical Self-worth Subscale (Fox, 1989), indicating the degree to which each item (e.g., I am confident in the physical side of myself) is characteristic or true of them from 1 (not at all true) to 4 (completely true). This scale has acceptable internal consistency and convergent validity (Curbow & Somerfield, 1991). Additionally, it demonstrated good reliability in survivors (a=0.901) and partners (a=0.873).
Relationship Factors: Data was collected on participants’ relationship duration, marital status (if married, the duration), and living situation (if cohabitating, the duration). Participants
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completed the satisfaction subscale from the Investment Model Scale (Rusbult, 1998) by indicating whether their partner fulfills various needs (i.e., intimacy, companionship, emotional involvement) and if they are satisfied with their relationship on a scale from 1 (don’t agree at all) to 4 (completely agree). The internal consistency of this measure ranged from a=0.965 in survivors to a=0.958 in partners. Participants were asked how they view the responsibility of taking care of their own and their partner’s health. Specifically, participants indicated whether health goals and consequences of negative health habits are individual (“mine alone”/ “his or hers alone”) or shared (“ours”) challenges on a scale from 1 (strongly disagree) to 7 (strongly agree). These items were developed by the Healthy Couples Lab to assess a construct labeled “partner investment” and demonstrated good reliability (survivors a=0.904, partners a=0.897). Lastly, the Social Support for Exercise Scale (Sallis, 1987) was slightly modified to assess perceptions about the degree to which romantic partners (i.e., rather than all family members) have demonstrated support for exercise behaviors in the previous 3 months. The frequency for each item was rated on a 5-point scale ranging from 1 (never) to 5 (very often). The family subscale for the Social Support for Exercise Scale has demonstrated acceptable internal consistency (a=0.84). The modified subscale used in this research demonstrated good reliability in both survivors (a=0.949) and partners (a=0.954).
Physical Function and Current Exercise : Physical function was assessed using the PROMIS Physical Function Short Form (Celia et al., 2007). Participants indicated the degree to which their health limits them in specific activities (e.g., moderate work around the house like vacuuming, sweeping floors or carrying in groceries) on a scale from 1 (cannot do) to 5 (not at all). The reliability of this scale was a=0.889 for survivors and a=0.938 for partners. Lastly, participants completed the International Fitness Scale (Ortega, 2011), which assessed their level
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of overall and cardiorespiratory fitness, muscular strength and flexibility compared to others their age on a scale from 1 (very poor) to 5 (very good). The International Fitness Scale demonstrated good reliability in survivors (a=0.896) and partners (a=0.887). Additionally, participants indicated how many times per week (ranging from 0 to more than 7) they exercise in total, with and without their romantic partner. To assess exercise intensity, participants completed the Godin Leisure Time Exercise Questionnaire (GLTEQ) (Godin, 1985) and indicated the frequency (times per week) and average amount of time (in minutes) they had spent engaging in strenuous (e.g., jogging), moderate (e.g., fast walking), and mild (e.g., easy walking) exercise for at least 15 minutes over the past 7 days. The total volume of time spent in moderate to vigorous physical activity (MVPA) was calculated by multiplying the weekly frequency by duration for strenuous and moderate activities.
Exercise Knowledge and Beliefs: For half of the sample, these measures were preceded by the exercise education video. Participants were asked their knowledge of the American College of Sports Medicine’s exercise guidelines for cancer survivors (Schmitz et al., 2010) (items 1 and 2; see Appendix A). To assess participants’ physical (e.g., strengthen bones), psychological (e.g., improve mood), and social (e.g., provide companionship) outcome expectations for exercise, participants completed the Multidimensional Outcome Expectations for Exercise Scale (Wojcicki, 2009) (item 3a-r) by rating their expectations on a 5-point scale from 1 (strongly disagree) to 5 (strongly agree). This scale demonstrated good reliability for survivors (a=0.916) and partners (a=0.956). Participants also indicated their expectations and beliefs regarding couples-based exercise on a 6-point scale from 1 (strongly disagree) to 6 (strongly agree) (item 4a-j). This scale was created by the study team for the purpose of this research, and it demonstrated good reliability for both survivors (a=0.920) and partners
16


(a=0.934). Lastly, participants rated the importance of physical activity for themselves, their partner, and together as a couple on a 10-point scale from 1 (not at all important) to 10 (extremely important) (items 5-7).
Interest in Dyadic Exercise: Participants were asked to indicate their own and their partner’s interest in participating in a couples-based program as well as their interest in specific program formats (i.e., exercising together vs. sharing activity goals/progress on an app while exercising separately) on a 6-point scale from 1 (very uninterested) to 6 (very interested) (item 8-11). Participants were also asked which couples-based exercise program format they most prefer (item 12).
Intentions for Individual and Dyadic Exercise: The Exercise Self-efficacy Scale (McAuley, 1993) assessed participants’ beliefs in their ability to exercise three times per week at a moderate intensity for 30 or more minutes per session at two-week increments over the next 12 weeks (item 13a-f). Items were rated on a 100-point percentage scale with 10-point increments, ranging from 0% (not at all confident) to 100% (highly confident). The internal consistency for this measure was acceptable in survivors (a=0.986) and partners (a=0.992). Participants also completed the Barriers Self-efficacy Scale (McAuley, 1993), which assessed participants’ beliefs in their ability to exercise three times per week for the next 3 months in the face of commonly experienced barriers to activity (e.g., bad weather, feeling fatigued) from 0% (not at all confident) to 100% (highly confident) (item 14a-o). The internal consistency for this measure ranged from a=0.933 in survivors to a=0.953 in partners. Further, participants were asked to identify barriers that may prevent couples from exercising together (items 15-18) and their concerns about a couples-based exercise program on a 6-point scale from 1 (strongly disagree) to 6 (strongly agree) (item 19a-h). This scale demonstrated adequate reliability (survivors a=0.783;
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partners a=0.839). Finally, participants indicated their likelihood of joining an individual or couples-based exercise program on a 6-point scale from 1 (very unlikely) to 6 (very likely) (items 20 and 21) and the type of exercise program (i.e., individual or couples-based) they prefer to join (item 22).
Data Analysis Plan
Participant Subgroups: Individual level analyses were conducted on several subgroups within the sample in order to examine findings in conceptually distinct groups and ensure that assumptions of independence within the data were not violated. In this way, individual level analyses are presented for 1) survivors whose partner was not a survivor, 2) partners who are not cancer survivors, and 3) survivors who are partnered with another survivor, regardless of whether both partners completed the study. A large portion of the third group included both individuals within couples. For the analyses that included couples, MPLUS was used to generate estimates and significance tests that controlled for partners being nested within couples using the type=cluster command.
Sample characteristics: Descriptive statistics including frequencies, means, and standard deviations were calculated for all biographical variables (i.e., demographics and health history, relationship factors, and current physical activity) and outcome variables (i.e., exercise knowledge and beliefs, interest in dyadic exercise, and intentions for exercise).
Aim 1: Correlations and linear regression analyses for survivors, partners, and survivor couples were conducted to assess whether perceived importance of couples-based exercise (item 7) and interest in (items 8, 9) and intentions to join (item 21) a couples-based exercise program differed based on seven predictors: participation from both partners, gender, age, volume of MVP A, current exercise with their romantic partner, relationship satisfaction, and partner
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support for exercise. Further, multivariate tests were conducted to determine the strongest predictors while controlling for other predictors. Standardized betas were compared across predictors, but significance tests were not conducted. Only predictors with significant correlations were included in the regression analyses. Finally, intraclass correlations (ICC) were examined to determine the proportion of variance shared at the couple level on participants’ reported importance of couples-based exercise (item 7), interest in a couples-based program (item 8), perceived partner interest (item 9), and likelihood of couple-participation in a program (item 21). An ICC quantifies the proportion of variance on a measure that is shared at the between group level (i.e., couple level) and was calculated using mean squares estimates from analysis of variance in which the couples’ ID variable was the factor and all interval-scale measures of interest in joining a program were the dependent variables (MSbetween - MSwithin/ MSbetween "t" MSwithin).
Aim 2: Logistic regression assessed differences between participants randomized to the education versus control group on free response knowledge items coded as correct or incorrect (item 2a-c). ANOVA was used to compare group differences among survivors’ and partners’ exercise outcome expectations (item 3a-r), dyadic exercise expectations and beliefs (item 4a-j), exercise importance (item 5-7) and intentions to participate in individual and couples-based exercise programs (items 20 and 21) between the education and control groups. Finally, logistic regression was used to explore whether condition predicted individuals’ and couples’ interest in a couples-based exercise program versus any other type of exercise program (item 22). Analyses were conducted in MPLUS and SPSS V.25.
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CHAPTER IV
RESULTS
Participants
A total of 606 individuals (298 couples and 10 individuals that did not share partner information) were emailed the study link to the online screening. Of all individuals contacted, 406 (67%) individuals completed the study (i.e., 161 couples and 84 individuals). Of the 406 participants, 251 were cancer survivors, and 42 of those indicated that they were part of a survivor couple (i.e., both members of the couple were survivors). Fewer partners (n=155) completed the study. Half the sample (n=303) was randomized to receive the educational video and half (n=303) was randomized to the control group. Of those randomized to the educational video, 198 (65%) participants completed the study (i.e., 129 survivors and 69 partners). Further, of those 198 individuals, 177 (89%) indicated that they watched the entire video. Of those randomized to the control group, 208 (69%) participants completed the study (i.e., 122 survivors and 86 partners).
Descriptive statistics including means and standard deviations of survivors’ (n=209), partners’ (n=155), and survivor couples’ (n=42) demographic and health characteristics are presented in Table 1. Briefly, the majority of survivors (88.5%) were female, though gender was more evenly split among survivor couples (59.5% female). The mean age for survivors and partners was 54 years, and survivor couples were slightly older (60 years). Across the sample, age ranged from 23 years to 84 years. The vast majority of participants were White (90.5%-92.3%), not Hispanic/Latino (93.5%-97.6%), and college educated (71.4%-74.6%). Most participants were working at least part-time (54.8%-71.0%) with an annual household income greater than $100,000 (50.3%-73.5%). Very few participants were current smokers (2.4%-2.9%),
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and most consumed alcohol (70.3%-80.0%). The most frequently endorsed chronic condition for survivors was arthritis (29.2%), followed by a history of depression (27.3%), high blood pressure (21.1%), and anxiety (20.1.%). Among partners and survivor couples, the most frequently endorsed chronic conditions were high blood pressure (partners 32.2%; survivor couples 26.2%) and arthritis (partners 20.1%; survivor couples 21.4%). Regarding current psychosocial health factors, survivors, partners and survivor couples endorsed similar rates of sleep-related impairment, depression and anxiety symptoms. Partners endorsed less fatigue and fatigue interference and greater physical self-worth compared to survivors and survivor couples.
Survivors’ (n=251) cancer characteristics are presented in Table 2. The mean age at diagnosis was 46 years, and the range in age at diagnoses was from 3 to 73 years. The average time since diagnoses was 8.58 years, and 41.9% of survivors were within 5 years. The majority of survivors were diagnosed with breast cancer (67.9%), followed by skin cancer (10.2%).
Nearly all survivors received treatment (97.6%), with most receiving surgery (86.1%). Additionally, roughly half of survivors received chemotherapy (59%), radiation (57%) and/or hormone therapy (43.8%). The average time since primary treatment was 6.3 years, and 21.3% were within 1 year. Finally, 11.5% of survivors had been diagnosed with a cancer recurrence.
Participants’ relationship factors are presented in Table 3. Couple participation (i.e., both partners completed the study) was lowest for survivors (68.4%) and highest for survivor couples (92.3%). The average relationship length among survivors, partners, and survivor couples was 22.2 years to 27.9 years, with survivor couples reporting the longest relationship length. The majority of participants were married (82.9%-85.6%) for 20 or more years (55.4%-64.7%) and cohabitating (93.3%-100%) for 20 or more years (51.7%-56.1%). On average, survivors, partners, and survivor couples reported high relationship satisfaction and moderate partner
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investment in health. Finally, participants’ average reported support from their partner for exercise ranged from 3.1 to 3.5 on the 5-point scale ranging from 0-4, with survivor couples reporting the most support.
Lastly, participants’ physical function and current exercise are described in Table 4. The majority of survivors (63.7%), partners (72.3%), and survivor couples (64.2%) endorsed having good or very good general physical fitness. Approximately half of survivors (54.9%) and partners (48.4%) and approximately two-thirds of survivor couples (66.7%) met the exercise guidelines of at least 150 minutes of MVP A per week. Across the three participant groups, participants reported exercising with their romantic partner an average of 1.1 to 1.4 times per week. Approximately half of survivors (51.2%), partners (56.1%) and survivor couples (45.2%) exercised with their partner at least one time per week.
Aim 1. Interest in Couples-Based Physical Activity
A primary goal of this research was to determine whether cancer survivors and their romantic partners value couples-based exercise and show interest in a couples-based exercise program. To achieve this goal, survivors’, partners’, and survivor couples’ exercise knowledge and beliefs, interest in a couples-based program, and intentions for individual and couples-based exercise were assessed. Findings are presented in Table 5. Roughly half of participants believed that exercising with their romantic partner is important (51.3%-57.2%). About half of partners (54.6%) and two-thirds of survivors (68.4%) and survivor couples (66.7%) were personally interested in a couples-based exercise program. More partners (61.9%) and fewer survivors (40.4%) and survivor couples (52.4%) believed that their partner would be interested in a couples-based program. Considering the type of couples-based program, approximately two-fifths of participants (37.1%-40.4%) preferred exercising together over exercising individually
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and sharing exercise data with their partner via an app or website. Regarding intentions for couples-based exercise, all participant groups rated time or scheduling difficulties as the greatest barrier, and about a third of participants reported that it was likely for them and their partner to overcome this barrier. Approximately, 43.0% of survivors, 47.4% of partners, and 57.1% of survivor couples indicated that it was likely that they and their partner would join a couples-based exercise program. Finally, a greater portion of partners (48.3%), compared to survivors (26.7%) and survivor couples (35.0%), reported that they would join a couples-based exercise program over any other type of exercise program.
To determine what factors may influence perceived importance of and interest in couples-based exercise, seven predictors (i.e., participation from both partners, gender, age, current MVP A, frequency of exercise as a couple, relationship satisfaction, and partner support for exercise) were analyzed. Correlations between examined predictors and outcomes (i.e., importance of couples-based exercise (item 7), personal interest (item 8) and perceived partner interest (item 9) in a couples-based program, and likelihood of joining a couples-based program (item 21) are presented in Table 6. Overall, the three participant groups displayed fairly distinct patterns of significant correlations. Partner support for exercise was significantly related to all four outcome variables for survivors and partners; however, it was not significantly correlated with any outcome variable among survivor couples; several estimated correlations were of moderate size but did not reach statistical significance at the small sample size (n=42). Similarly, frequency of exercise as a couple and relationship satisfaction were significantly correlated with survivors’ and partners’ perceived partner interest in a couples-based program and their likelihood of joining a couples-based program, but these predictors were not significantly correlated with these two outcomes for survivor couples. However, frequency of exercise as a
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couple was significantly correlated with all three participant groups’ couples-based exercise importance. Volume of MVP A was only significantly related to survivor couples’ individual and perceived partner interest in a couples-based program. Gender was only significantly related to partners’ and survivor couples’ perceived partner interest in a couples-based program, with females partners being perceived as more interested. Participation from both partners was not significantly correlated with any outcome variable among partners. Finally, age was not significantly correlated with any of the four outcome variables for any participant group.
Beyond examining pairwise associations between each predictor and interest outcome, regression analyses were used to determined the strongest predictors of couples-based exercise importance and interest while controlling for other predictors (see Table 7). Whether participants were randomized to the education condition or not was not significantly correlated with these four outcome variables among survivors, partners, or survivor couples; thus, randomization was not controlled for in the following analyses. Frequency of exercise as a couple was the strongest predictor of survivors’ ((3=0.266) and survivor couples’ ((3=0.406) reported importance of couples-based exercise. Partner support for exercise ((3=0.333) was the strongest predictor of importance of couples-based exercise for partners. Regarding personal interest in a couples-based program, partner support for exercise was the only predictor in survivors ((3=0.207, R2=0.043) and partners ((3=0.185, R2=0.034), and volume of MVP A was the only predictor in survivor couples ((3=-0.409, R2=0.167). Volume of MVP A was the strongest predictor ((3=0.346) of survivor couples’ perceived partner interest in a couples-based program. However, for both survivors and partners, partner support for exercise was the strongest predictor of both perceived partner interest in a couples-based program (survivors: (3=0.472, partners: (3=0.380) and the likelihood of joining a couples-based program (survivors: (3=0.460, partners: (3=0.421).
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To explore whether couples (n=161) were aligned in their reported importance of couples-based exercise and interest in couples-based program, shared variance at the couple level (i.e., intraclass correlations) was examined for items 7, 8, 9, and 21. A significant proportion of variability was shared at the couple level for all four outcomes (see Table 8). Additionally, crosstabulations assessed the percent of couples aligned in their beliefs about the importance of couples-based exercise and interest in a couples-based exercise program (see Table 8). All outcome items were recoded into three response categories: for item 7, values 1-4 indicated not important, 5-6 indicated somewhat important, and 7-10 indicated important; for items 8 and 9, values 1-3 indicated uninterested, 4 indicated somewhat interested, and 5-6 indicated interested; for item 21, values 1-3 indicated unlikely, 4 indicated somewhat likely, and 5-6 indicated likely. Roughly half of couples demonstrated agreement in their responses for all four outcome variables. Further, approximately one-third of couples were in agreement that couples-based exercise is important (36.0%), that their partner would be interested in a couples-based program (32.5%) and that they were likely to join a couples-based program (31.0%). Almost half of couples (44.1%) were in agreement that they were personally interested in a couples-based program. Fewer couples were in agreement that couples-based exercise is unimportant (8.7%), they were uninterested (2.5%) and their partner would be uninterested (3.8%) in a couples-based program, and they were unlikely to join a couples-based program (8.9%). Approximately 10-20% of couples had extreme mismatch (i.e., couple members chose responses from the lowest and highest response categories) in their ratings of these four outcomes. Specifically, extreme mismatch was found in 10.6% of couples for dyadic exercise importance, in 11.8% of couples for personal interest and in 18.0% of couples for perceived partner interest in a couples-based program, and in 14.6% of couples for the likelihood of joining a couples-based program.
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Aim 2. Effects of the Educational Video
In order to test the effect of the educational video on survivors’ (n=251) and partners’ (n=155) knowledge of the ACSM’s exercise recommendations for cancer survivors, free response knowledge items were coded as correct or incorrect (item 2a-c) and compared across the education and control groups. Regarding moderate intensity exercise, 43.0% of survivors and 27.7% of partners correctly stated the ACSM’s guidelines of moderate intensity exercise (see Table 5). Specifically, survivors randomized to the educational video were 5.48 times more likely to correctly state that survivors should engage in 150 minutes of moderate intensity aerobic activity per week (OR=5.48, Wald z =36.52, p<0.001). Similarly, partners randomized to the educational video were 8.311 times more likely to correctly state that survivors should engage in 150 minutes of moderate intensity aerobic activity per week (OR=8.31, Wald z =24.63, p<0.001). Regarding vigorous intensity exercise, 22.3% of survivors and 10.3% of partners correctly stated the ACSM’s guidelines of vigorous intensity exercise. Specifically, survivors randomized to the educational video were 27.66 times more likely to correctly state that survivors should engage in 75 minutes of vigorous intensity aerobic activity per week (OR=27.66, Wald z =29.492, p<0.001). Additionally, partners randomized to the educational video were 10.69 times more likely to correctly state that survivors should engage in 75 minutes of vigorous intensity aerobic activity per week (OR=10.69, Wald z =9.33, p<0.01). Finally, regarding strength training, the ACSM recommends that survivors engage in at least 2 days of strength training per week. Thus, responses of 0 or 1 day per week were coded as incorrect and responses of 2-7 days per week were coded as correct. Only 4% of survivors and 5.7% of partners indicated that survivors should engage in less than 2 days of strength training per week.
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There were no significant differences found between the education and control groups for strength training for either survivors and partners.
Further, the effects of the educational video on survivors’ (n=209) and partners’ (n=155) individual (item 3a-r) and couples-based (item 4a-j) exercise outcome expectations were explored. Means and standard deviations of the two scales are presented in Table 5. Survivor couples were excluded from these analyses so that data did not violate the assumption of independence inherent in the analyses (e.g., ANOVA) conducted. Significant differences between survivors randomized to the education versus control group were found for the individual exercise outcome expectations scale (F(l,207)=9.84, p<0.01). When looking at individual items on this scale, between group differences were found on the following five items: exercise will improve the functioning of my cardiovascular system (p<0.01), exercise will increase my acceptance by others (p<0.01), exercise will give me a sense of personal accomplishment (p<0.05), exercise will help prevent cancer recurrence (p<0.001), and exercise will improve my quality of life (p<0.01). Additionally, significant differences were found between survivors randomized to the education versus control group for couples-based exercise outcomes and beliefs (item 4a-j) (F(l,207)=4.752, p<0.05). When exploring the effects of individual items on this scale, between group differences for survivors were found on three items: I want my significant other to encourage me to exercise (p<0.05), I want my significant other to remind me to exercise (p<0.05), and Fd rather exercise with my significant other than with peers (including fellow survivors) (p<0.01). When examining these items among survivors who indicated that they watched the entire video (92% of survivors randomized), two additional items became significant: I want my significant other to exercise with me (p<0.01) and Fd rather exercise with my significant other than alone (p<0.01). All mean differences were in the
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expected direction, such that survivors randomized to the education endorsed more positive individual and couples-based exercise outcome expectations and beliefs (see Table 9).
Among partners, no significant differences were found between the education and control groups for either the individual (F(l,153)=0.833, p=0.36) or couples-based (F(l,153)=2.696, p=0.103) exercise expectations scales. When assessing items on the individual exercise outcome expectations scale, between group differences for partners were found on three items: exercise will improve my social standing (p<0.05), exercise will provide companionship (p<0.05), and exercise will help prevent cancer recurrence (p<0.05). Similarly, three items on the couples-based exercise outcome expectations scale demonstrated significant group differences: exercising with my significant other will strengthen our relationship (p<0.05), exercising with my significant other will increase our attraction for each other (p<0.05), and Fd rather exercise with my significant other than alone (p<0.05). However, only partners’ belief that exercise will help prevent cancer recurrence was in the expected direction. Raw data was analyzed to understand why partners randomized to the education would report lower individual and couples-based exercise outcome expectations than those in the control group on five items. Two IDs were determined to be very extreme responders. Specifically, two partners both chose 1 (lowest response option) on 27 of the 28 items composing the individual (item 3a-r) and couples-based (item 4a-j) exercise outcome expectations scales. Further, these two IDs were the only two IDs of 155 partners to report a 1 on 13 of the 18 individual exercise outcome expectations items and on 4 of the 10 couples-based exercise expectations and beliefs items. Thus, these two IDs were considered outliers in the sample, and they were removed from the analyses. After exclusion, none of the significant effects that were in the unexpected direction remained significant. Group
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means for the one significant finding (i.e., exercise will help prevent cancer recurrence) are presented in Table 9.
Further, differences between the education and control groups on exercise importance (item 5-7) and intentions to participate in individual and couples-based exercise programs (items 20 and 21) were assessed for survivors and partners. Frequencies of these outcomes are presented in Table 5. Regarding personal exercise importance (item 5), significant differences were found between survivors randomized to the education versus control group (F(l,207)=4.184, p<0.05). However, no significant differences were found for partners (F(l,153)=2.909, p=0.090). Regarding the importance of exercise for your partner (item 6) and the importance of couples-based exercise (item 7), no significant differences were found between groups for either survivors (F(l,207)=0.112, p=0.736; F(l,207)=1.853, p=0.175) or partners (F(l,153)=0.033, p=0.850; F(l,153)=0.236, p=0.628). Regarding intentions to participate in an individual exercise program (item 20), significant differences were found between survivors randomized to the education versus control group (F(l,207)=6.079, p<0.05). However, no significant differences were found for partners F(l,152)=0.495, p=0.483). Lastly, no significant differences were found between groups for intentions to participate in a couples-based exercise program (item 21) for either survivors (F(l,205)=1.348, p=0.247) or partners (F(l,152)=0.002, p=0.960). The reported results represent all partners, and the findings remained not significant after examining the effect of removing the two outlier IDs. The significant group means for survivors were in the expected direction and are shown in Table 9.
Finally, this research explored whether condition predicted individuals’ and couples’ interest in a couples-based exercise program versus interest in other types of exercise programs (response 1 from item 22). Survivors and partners randomized to the educational video were not
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significantly more likely to choose a couples-based exercise program (survivors: OR=0.810, p=0.508; partners: OR=1.834, p=0.067). However, partners who indicated that they actually watched the entire video (87% of partners randomized) were 2.2 times more likely to choose a couples-based exercise program (OR=2.203, Wald z = 5.349, p<0.05). Specifically, 60.3% of partners who watched the video chose a couples-based program compared to 40.8% of partners who did not watch the video. For the couple-level analysis, each couple was coded 1 (yes) or 0 (no) based on whether both partners indicate interest in a couples-based program (response 1 from item 22). Additionally, a binary variable was created to indicate whether both partners watched the video or not. The effect of being assigned to the intervention on interest in a couples-based program was in the expected, positive direction (OR=1.724, p=0.195). Similarly, the effect of both partners watching the video on interest in a couples-based program was also in the expected, positive direction (OR=1.956, p=0.110).
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CHAPTER V
DISCUSSION
There are many theoretical reasons for why exercise interventions may benefit from targeting both cancer survivors and their romantic partners concurrently (Kiecolt-Glaser & Newton, 2001; Lewis et al., 2006; Lyons, Mickelson, Sullivan, & Coyne, 1998). However, a couples-based exercise intervention may not appeal to all couples, and the success of a couples-based program will hinge on couples’ shared motivation toward an exercise goal. Thus, a necessary step proceeding intervention design was to determine whether cancer survivors, romantic partners, and survivor-partner dyads were interested in a couples-based exercise program and elucidate demographic, relationship, exercise, and educational factors that may predict exercise interest and intentions.
Aim 1. Interest in Couples-Based Physical Activity
Findings from this study demonstrated that more than half of partners and approximately two-thirds of survivors and survivor couples were personally interested in a couples-based exercise program. Additionally, almost half of couples (44.1%) showed member agreement, such that both individuals within a couple chose a 5 or 6 on the 1-6 scale for interest in a couples-based program. Thus, the idea of a couples-based exercise program was attractive to the majority of survivors and their romantic partners and to almost half of participating couples.
It may be possible to further increase survivors’ and partners’ interest in and likelihood of joining a couples-based exercise program by fostering greater communication within couples. Data indicated that survivors and partners were unaware of their partners’ interest in a couples-based program. Couples had the lowest rates of overall agreement (44.4%) and greatest rates of extreme mismatch (18.0%) regarding their perceived partners’ interest in a couples-based
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program. When examining survivors’ and partners’ beliefs, both survivors and partners were roughly twice as likely to think that their romantic partner would be uninterested in a couples-based program compared to what romantic partners actually reported. Although these numbers reflect all survivors and partners, rather than within couple effects, this pattern illustrates that survivors and partners may have a negative bias about their partners’ interest in dyadic exercise.
One potential consequence of survivors and partners’ inaccurate ratings of their romantic partners’ interest may be a reduced belief regarding the likelihood that they and their partner would participate in a couples-based program. Although the majority of survivors (68.4%) and partners (54.6%) were personally interested in a couples-based exercise program, less than half of survivors (43.0%) and partners (47.4%) believed it was likely that both they and their partner would join a couples-based program. Further, survivors appeared more in doubt of couple participation in an exercise program compared to partners, suggesting that survivors were more affected by their negative perceptions of their partners’ interest. Perhaps survivors perceived that couple participation may burden partners, or they believed that their partner may be unable to overcome barriers (e.g., time or scheduling difficulties) in order for them to exercise together. Future research should examine whether more accurate knowledge of romantic partners’ exercise beliefs increases survivors’ and partners’ likelihood of joining a couples-based exercise program.
A primary goal of this research was to determine predictors of interest in couples-based exercise. Of the seven predictors examined (i.e., study participation from both partners, gender, age, volume of MVP A, current exercise with their romantic partner, relationship satisfaction, and partner support for exercise), only partner support for exercise was a consistent predictor of survivors’ and partners’ exercise importance, interest, and likelihood. Additionally, partner support for exercise was almost always the strongest predictor for survivors’ and partners’
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reported beliefs across the four outcomes (items 7-9, 21), regardless of the other predictors included in the regression equation. Thus, partner support for exercise was a better determinant of the likelihood of couple participation in an exercise program over couples’ current exercise together and their general relationship satisfaction. Partner support for exercise assessed partners’ recent (in the last 3 months) exercise communication (e.g., discussed physical activity with me, asked me for ideas on how he/she can get more physically active) and efforts (e.g., helped plan activities around my activity routine, changed their schedule so we could be active together). Therefore, partner support for exercise may, in part, capture frequency of couple exercise (survivors r=0.607, p<0.01; partners r=0.522, p<0.01) and relationship functioning (survivors r=0.490, p<0.01; partners r=0.480, p<0.01) and be the single best predictor of dyadic exercise behavior.
The finding that partner support for exercise was a strong predictor of couples-based exercise interest is consistent with the broader literature on the effects of social support for exercise behavior. Social support has been positively associated with the adoption and maintenance of physical activity in both cancer (Phillips & McAuley, 2013) and non-cancer populations (Darlow & Xu, 2011; Smith, Banting, Eime, O’Sullivan, & Van Uffelen, 2017). However, the construct of social support within exercise interventions may include broad social levels such as family, peer, or professional support (Lloyd et al., 2018), and the source of social support may influence physical activity outcomes (Smith et al., 2017). A strength of this research was that social support was specifically defined as partner support; thus, the modified use of the family subscale from the Social Support for Exercise Scale (Sallis, 1987) may be advantageous to dyadic researchers as it may be a more precise measure of couples-based support. Future
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research should further validate the use of this modified scale to assess support from romantic partners, rather than all family members.
Although partner support for exercise was the strongest predictor of survivors’ and partners’ interest in and likelihood of couples-based exercise, the small sample size of survivor couples (n=42) limits the ability to draw conclusions about the best predictors within this subsample. Among survivor couples, partner support for exercise and relationship satisfaction were not significantly correlated with any of the four outcomes for survivor couples; however, the magnitude of the correlations were of moderate size and followed a similar pattern to the correlations found for survivors and partners. Thus, it is likely that the small sample size of survivor couples resulted in less statistical power than the other subsamples, which reduced the ability to detect significant effects. An additional limitation of the small sample size was that a few participants’ extreme scores impacted the magnitude and direction of correlations estimates. For example, a small number of participants with a low volume of MVP A were highly interested in a couples-based exercise program, which resulted in a significant negative correlation; however, this relationship was not found in survivors or partners. Additionally, among survivor couples, only six survivors participated individually. Thus, not very much stake can be given to participation from both partners as a predictor within this participant subgroup.
A surprising finding from the exploration of the various predictors assessed was that age was not significantly correlated with survivors’, partners’, or survivor couples’ reported beliefs about dyadic exercise importance, interest, or likelihood. Further, the absence of a significant relationship cannot be attributed to a lack of variability on age, as all three participant subgroups had a large age range and spread. The finding that age does not predict dyadic exercise interest suggests that couples-based exercise interventions may appeal to couples of all ages, and thus,
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have large dissemination potential. Very few studies, if any, have examined couples-based exercise interest across adulthood. Rather, most research examining age in relation to couples-based exercise, especially within survivor populations, have focused on older adults (i.e., age > 60 or 65) (Winters-Stone et al., 2016). Future research should explore other predictors that may correlate with age (i.e., relationship length, retired employment status, number of chronic conditions) to more accurately and confidently determine the effects of age on survivors’ and partners’ interest in and intentions for couples-based exercise.
Aim 2. Effects of the Educational Video
Beyond examining various demographic, relationship, and exercise factors that may predict couples-based exercise interest, this research examined whether providing exercise education increased survivors’ and partners’ exercise knowledge, outcome expectations, and intentions. Survivors and partners randomized to the exercise education were significantly more likely to correctly report the ACSM physical activity recommendations for cancer survivors (Garber et al., 2011). Additionally, survivors randomized to the education reported greater personal exercise importance and outcome expectations, and they were more likely to join an exercise program offered to them only. These effects were not found for partners, indicating that greater cancer-specific exercise knowledge only increased survivors’ exercise beliefs. Overall, partners appeared to be less personally invested in exercise compared to survivors, and the educational video did not change their beliefs.
The one effect the educational video had on dyadic exercise beliefs was that survivors in the education condition had more positive dyadic exercise outcome expectations. The educational video did not influence survivors’ or partners’ reported importance of exercise for their partner or for exercising together, personal interest and perceived partner interest in a
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couples-based program, or reported likelihood that they and their partner would join a couples-based program. So although survivors in the education condition showed more positive dyadic exercise beliefs (e.g., I’d rather exercise with my significant other than with peers), these survivors still doubted the likelihood that they and their partner would participate in an exercise program together. This doubt in their partner may explain why survivors were highly likely (70.3%) to join an exercise program offered to them only. Further, survivors’ relatively low confidence in couple participation in an exercise program (43.0%) was not due to lack of interest. Nearly 70% of survivors were personally interested in a couples-based exercise program. Therefore, the educational video was effective at increasing survivors’ personal interest in exercise, but it was insufficient in changing survivors’ beliefs about their partners’ interest and their intentions to join a couples-based program. Future research should explore other intervention strategies that may reduce survivors’ negative perceptions of their partners’ commitment to couples-based exercise to increase survivors’ reported likelihood of joining a couples-based exercise program.
Despite the finding that the education condition did not affect partners’ exercise interest, outcome expectations, or intentions for both individual and couples-based exercise, when asked the type of exercise program they would choose if they had to sign up for an exercise program, partners who watched the educational video were more than twice as likely as those in the control group to choose a couples-based program format. This finding is particularly noteworthy because partners were almost twice as likely as survivors to choose a couples-based program (48.3% versus 26.7%), yet survivors were more interested than partners in couples-based exercise. Therefore, although partners were moderately interested in couples-based exercise, the educational video may have increased partners’ motivation to support survivors and participate
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in a couples-based program. One limitation of the educational component is that it is impossible to determine which video content (i.e., benefits of exercise for survivors, caregivers, or couples) shifted partners’ preference toward choosing a couples-based program format. Future research should examine which components of the exercise education were most influential for partners’ in order to further promote supportive exercise decisions among romantic caregivers.
There are many hypothesized reasons for why the educational video had fewer effects among partners compared to survivors. First, a large portion of the video focused on the benefits of exercise for preventing cancer and reducing many cancer-related side-effects. Thus, there may have been more content personally relevant to survivors. Second, the order of the video content flowed from the benefits of exercise for survivors to caregivers to survivor-caregiver dyads. If participants did not watch the entire video, they may have missed learning about the benefits of exercise for caregivers and couples affected by cancer. Third, the language in the video used the term romantic “caregiver” to be consistent with the terminology used in most of the published literature. Many partners of survivors may not consider themselves caregivers, especially if it has been many years since the survivor underwent cancer treatment. Finally, randomization may have been less successful in partners compared to survivors. Among partners that completed the study, 44.5% were randomized to the education condition. After removing the two partners that had an undue influence on the ANOVA analyses, the percent of partners randomized to the education dropped to 43.8% (n=67). Thus, the sample size was relatively small, which may have limited the ability to detect significant effects. Randomization was more evenly split among survivors (48.3% (n=101) received the education).
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Limitations and Strengths
In addition to the limitations previously described, the results of this study need to be interpreted within the context of the recruited sample. The majority of participants were white, non-Hispanic, college educated, employed at least part-time, and had an annual household income greater than $100,000.00. Additionally, the sample was very health minded, as over 90% of survivors, partners and survivor couples believed that it was important to engage in regular physical activity. About half of survivors and partners met the current exercise guidelines of at least 150 minutes of MVP A per week, and the majority of all participants rated their overall health status as very good or excellent. Thus, this sample may be more educated, of a higher socio-economic status, and more physically active than most survivor-partner dyads. This finding is consistent with the limitations described in a recent systematic review and metaanalysis on physical activity in cancer survivors; most research participants were well-educated, predominately white, and tended to already engage in some physical activity prior to enrolling in an intervention (Grimmett et al., 2019).
Additionally, the majority of cancer survivors were female, breast cancer survivors recruited from the Army of Women. Given this limitation, future research should re-analyze gender as a predictor of survivors’ and partners’ interest in couples-based exercise within a sample with an even gender split. Also, participants recruited from the Army of Women are often involved in other cancer research studies, so they may be more educated on current cancer prevention and treatment recommendations. Thus, the recruited sample of survivors may be more informed and may hold more positive exercise beliefs than typical populations of cancer survivors. Future research should re-examine the effects of the educational video in more research naive survivors and include a greater representation of survivors of diverse cancer types.
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Further, limitations are present at the couple level. As is common in dyadic research, it is likely that this study attracted couples with good relationships and common interests in health behaviors and goals (Varner & Ranby, 2019). Therefore, these findings may not extend to all couples coping with the long-term effects of cancer and its treatment. Additionally, most participants in this study were cohabitating and married, and the average relationship length for survivors and partners was about 22 years. Therefore, the results of this study may not generalize to couples in newer relationships. Finally, this study only briefly assessed survivors’ and partners’ concerns about couples-based exercise (items 19a-h) and how it may result in relationship conflict (e.g., I am concerned my significant other will nag me to exercise; I am concerned my significant other and I may argue over exercise). Although research has shown positive spillover effects for exercise within couples (i.e., one partner’s exercise increases the likelihood of their partner’s exercise) (Cobb et al., 2016; Jackson, Steptoe, & Wardle, 2015;
Falba & Sindelar, 2008), future research should address whether couples-based exercise interventions have the potential to negatively disrupt the social dynamics of couples’ systems, especially within couples with change-resistant partners (Rohrbaugh et al., 2001). Therefore, continued research is needed to examine whether this study’s findings are consistent in more heterogeneous cancer couples and to further explore the potential, negative consequences of exercising with a romantic partner.
Despite the noted limitations, this research has several strengths. Little work has been done exploring couples-based physical activity interventions, especially within the realm of cancer. Of the few studies that exist, most have focused on a single disease type (e.g., prostate cancer) and examined only married couples. By considering cancer survivors with various cancer histories and opening partner participation to partners of diverse sexual orientations (i.e.,
39


heterosexual and homosexual couples) and relationship statuses (i.e., couples that are married versus partnered; co-habituating versus living apart), findings from this study may inform more inclusive intervention designs with greater participation potential. Further, by assessing whether dyadic exercise importance, interest, and intentions differed based on study participation from both partners, gender, age, volume of MVP A, current exercise with their romantic partner, relationship satisfaction, and partner support for exercise, this research yields insight into how future interventions may tailor recruitment based on specific factors (e.g., recruit couples with high partner support for exercise). Additionally, the creative use of the experimental education component revealed that it is feasible to educate survivors and partners on the published exercise guidelines and that greater exercise knowledge increased survivors’ individual and dyadic exercise outcome expectations and individual exercise intentions as well as partners’ preference toward a couples-based program format. Thus, researchers may want to consider providing education on the cancer-specific benefits of exercise within individual and couples-based exercise interventions.
Further, a strength of this research was its exploratory nature and the volume of variables collected. Secondary analyses can be done with existing data to examine other predictors (e.g., partner investment in health, relationship length) of dyadic exercise interest and within other participant subgroups (e.g., survivors within 5 years of finishing treatment). Also, follow-up analyses may examine whether the education condition increased concordance within couples regarding dyadic exercise beliefs, which may further inform the use of education materials within couples-based exercise interventions. Finally, this research utilized a patient-centered approach by engaging both cancer survivors and their romantic partners from the outset, which may better inform the development and design of future dyadic exercise interventions.
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CHAPTER VI
CONCLUSION
In conclusion, the goals of this research were to examine whether both cancer survivors and their romantic partners were interested in a couples-based exercise intervention and explore factors that may predict interest. The majority of cancer survivors and partners were personally interested in a couples-based exercise program, partner support for exercise emerged as the strongest predictor of their likelihood of joining a couples-based program, and providing exercise education increased survivors’ dyadic exercise outcome expectations and partners’ preference for couples-based exercise over other program formats. This novel understanding of predictors of dyadic exercise interest and the effects of cancer-specific exercise education provides a strong foundation upon which future, efficacious exercise interventions may be designed and disseminated for cancer survivors and their romantic partners.
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Table 1. Demographics and Health History
Factor Frequency
Survivors (n=209) Partners (n=155) Survivor Couples (n=42)
Demographic Characteristics
Gender (Female) 88.5% 16.1% 59.5%
Age (M, SD) yrs 54.2 (SD=13.2) 54.8 (SD= 13.4) 60.0 (SD= 13.9)
Minimum Age 23 yrs 23 yrs 31 yrs
Maximum Age 77 yrs 80 yrs 84 yrs
Race (White) 92.3% 89.7% 90.5%
Ethnicity (Not Hispanic/Latina) 93.8% 93.5% 97.6%
Obtained College Degree 74.6% 72.3% 71.4%
Employed At Least Part-time 65.1% 71.0% 54.8%
Annual Household Income ( > $100,000) 50.3% 54.2% 73.5%
Health Status
Health Behaviors
Smoke (Current) 2.9% 3.9% 2.4%
Smoke (Lifetime History) 25.6% 29.3% 31.7%
Consume Alcohol (yes) 70.3% 80.0% 75.6%
Drinks per week (M, SD) 4.9 (SD=4.6) 7.0 (SD=6.9) 4.4 (SD=4.4)
Chronic Conditions
Arthritis 29.2% 20.1% 21.4%
High Blood Pressure 21.1% 32.3% 26.2%
Type II Diabetes 5.3% 11.6% 0%
Obesity 16.7% 10.3% 11.9%
Depression 27.3% 14.8% 4.8%
Anxiety 20.1% 11.0% 11.9%
Overall Health Status
Poor/Fair 11.5% 9.6% 11.9%
Good 33.5% 25.8% 28.6%
Very Good/Excellent 55.0% 64.5% 59.5%
Psychosocial Factors
Sleep-related Impairment (M, SD) (0-5 scale) 2.2 (SD=0.75) 2.0 (SD=0.63) 2.1 (SD=0.75)
Fatigue Symptoms (M, SD) (0-5 scale) 2.2 (SD=0.98) 1.7 (SD=0.72) 2.0 (SD=1.00)
Fatigue Interference (M, SD) (0-5 scale) 2.5 (SD= 1.08) 2.0 (SD=0.84) 2.4 (SD=1.10)
Depression Symptoms (M, SD) (0-5 scale) 1.7 (SD=0.81) 1.5 (SD=0.70) 1.4 (SD=0.62)
Anxiety Symptoms (M, SD) (0-5 scale) 1.7 (SD=0.79) 1.5 (SD=0.73) 1.6 (SD=0.83)
Physical Self-Worth (M, SD)(0-4 scale) 2.7 (SD=0.78) 3.1 (SD=0.70) 2.8 (SD=0.82)
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Table 2. Cancer Characteristics (n=251)
Factor Frequency
Age at Diagnosis (M, SD) 46.0 (SD=13.8) yrs
Minimum Age 3 yrs
Maximum Age 73 yrs
Time Since Diagnosis (M, SD) 8.58 (SD=7.7) yrs
Within 5 years 41.9%
Cancer Type (could endorse more than one)
Breast 67.9%
Skin Cancer 10.2%
Ovarian 4.5%
Lymphoma (Hodgkin and Non-Hodgkin) 4.1%
Colon 3.7%
Prostate 3.3%
Treatment Received (could endorse more than one) 97.6%
Chemotherapy 59.0%
Radiation 57.0%
Surgery 86.1%
Hormone Therapy 43.8%
Other 6.4%
Time Since Last Treatment (M, SD) 6.3 (SD=6.2) yrs
Within 1 year 21.3%
Within 5 years 51.7%
Diagnosed with Recurrence 11.5%
Number of Recurrences (M, SD) 1.9 (SD=0.3)
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Table 3. Relationship Factors
Factor Frequency
Survivors (n=209) Partners (n=155) Survivor Couples (n=42)
Participation from both partners (yes) 68.4% 85.7% 92.3%
Relationship Length (M, SD) yrs 23.1 (SD=15.0) 22.2 (SD=13.9) 27.9 (SD=18.2)
Cohabitating 93.3% 94.2% 100%
Less than 10 years 18.5% 20.0% 24.4%
10-19 years 26.7% 28.3% 19.5%
20 or more years 54.9% 51.7% 56.1%
Married 85.1% 86.5% 82.9%
Less than 10 years 17.5% 17.3% 23.5%
10-19 years 27.1% 27.8% 11.8%
20 or more years 55.4% 54.9% 64.7%
Relationship Satisfaction (M, SD) (0-4 scale) 3.3 (SD=0.79) 3.5 (SD=0.69) 3.6 (SD=0.47)
Partner Investment in Health (M, SD) (0-7 scale)
My Partner’s Investment in Me 3.8 (SD=1.09) 4.0 (SD=1.07) 4.2 (SD=1.02)
My Investment in My Partner 4.3 (SD=0.88) 4.3 (SD=0.87) 4.4 (SD=0.89)
Partner Support for Exercise (M, SD) (0-5 scale) 3.1 (SD=1.16) 3.4 (SD=1.10) 3.5 (SD=0.97)
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Table 4. Physical Competency and Current Exercise
Factor Frequency
Survivors (n=209) Partners (n=155) Survivor Couples (n=42)
Physical Competency
Physical Function (M, SD) (0-5 scale) 4.3 (SD=0.83) 4.6 (SD=0.76) 4.2 (SD=1.01)
General Physical Fitness
Poor 13.9% 7.7% 16.7%
Average 22.5% 20.0% 19.0%
Good/Vcrv Good 63.7% 72.3% 64.2%
Cardiorespiratory Fitness
Poor 27.3% 16.1% 31.0%
Average 27.8% 24.5% 31.0%
Good/Vcrv Good 45.0% 59.4% 38.0%
Muscular Strength
Poor 19.6% 3.9% 19.1%
Average 33.5% 32.9% 19.0%
Good/Very Good 46.9% 63.3% 61.9%
Flexibility
Poor 21.1% 24.5% 21.5%
Average 35.9% 32.9% 38.1%
Good/Very Good 43.1% 42.6% 40.5%
Weekly Exercise
MVPA >150 minutes 54.9% 48.4% 66.7%
Exercise with romantic partner (M, SD) 1.2 (SD=1.7) times 1.4 (SD=1.6) times 1.1 (SD=1.5) times
At least 1 time/week with partner 51.2% 56.1% 45.2%
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Table 5. Outcome Variables
Survivors (n=209) Partners (n=155) Survivor Couples (n=42)
Exercise Knowledge and Beliefs
Item 2a: Minutes of Moderate Exercise per Week (Correct) 42.6% 27.7% 45.2%
Item 2b: Minutes of Vigorous Exercise per Week (Correct) 21.1% 10.3% 28.6%
Item 3a-r: Exercise Outcome Expectations (M, SD) (0-5 scale) 4.3 (SD=0.47) 4.3 (SD=0.62) 4.3 (SD=0.52)
Item 4a-j: Dyadic Exercise Expectations & Beliefs (M, SD) (0-6 scale) 4.4 (SD=0.99) 4.7 (SD=0.97) 4.5 (SD=0.93)
Item 5: How important do you think it is that YOU engage in regular physical activity?
Not Important 0.5% 3.9% 0%
Somewhat Important 0% 5.8% 0%
Important 99.5% 90.4% 100%
Item 6: How important do you think it is that YOUR PARTNER engages in regular physical activity?
Not Important 1.9% 0.6% 0%
Somewhat Important 3.8% 7.8% 4.8%
Important 94.3% 91.6% 95.2%
Item 7: How important do you think it is that YOU and YOUR PARTNER engage in regular physical activity TOGETHER?
Not Important 22.4% 18.7% 14.3%
Somewhat Important 26.3% 29.0% 28.6%
Important 51.3% 52.3% 57.2%
Interest in Dyadic Exercise
Item 8: If a couples-based exercise program were offered to you and your partner, how interested would YOU be in participating?
Uninterested 9.1% 18.8% 9.5%
Somewhat Interested 22.5% 26.6% 23.8%
Interested 68.4% 54.6% 66.7%
Item 9: If a couples-based exercise program were offered to you and your partner, how interested would YOUR PARTNER be in participating?
Uninterested 30.3% 17.4% 11.9%
Somewhat Interested 29.3% 20.6% 35.7%
Interested 40.4% 61.9% 52.4%
Item 12: If you were to participate in an exercise program with your partner, would you prefer the program to involve exercising together or the ability for each individual to exercise alone yet share activity data with their partner via an app or website? (Choose one)
Exercise together 37.1% 40.4% 39.5%
Exercise individually and share exercise data on app or website 21.3% 14.0% 15.8%
I like both ideas equally 41.6% 45.6% 44.7%
Intentions for Individual and Dyadic Exercise
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Item 13a-f: Exercise Self-efficacy (\l SD) (0-100% scale) 81.0 (SD=25.0) 76.8 (SD=31.5) 73.3 (SD=32.2)
Item 14a-o: Barriers Self-efficacy (M, SD) (0-100% scale) 54.6 (SD=22.8) 52.6 (SD=25.7) 45.0 (SD=22.2)
Item 16: What is the GREATEST barrier that may keep you from exercising with your partner? (Choose one)
Time or scheduling difficulties 38.2% 44.8% 59.5%
We like different types of exercise 15.9% 19.5% 9.5%
We have different exercise abilities 13.5% 14.3% 19.0%
My partner dislikes exercise 14.0% 1.9% 0%
Item 17: How likely is it that you and your partner will work together to overcome this barrier?
Unlikely 45.1% 33.8% 35.7%
Somewhat Likely 25.5% 26.6% 26.2%
Likely 29.4% 39.6% 38.1%
Item 19a-h: Dyadic Exercise Concerns (M, SD) (0-6 scale) 2.6 (SD=0.93) 2.3 (SD=0.90) 2.4 (SD=0.79)
Item 20: If an exercise program were offered to you ONLY, how likely is it that you would participate?
Unlikely 10.5% 38.3% 14.3%
Somewhat Likely 19.7% 23.4% 14.3%
Likely 70.3% 38.3% 71.5%
Item 21: If a couples-based exercise program were offered to you and your partner, how likely is it that both YOU and YOUR PARTNER would participate?
Unlikely 25.2% 25.3% 19.1%
Somewhat Likely 31.9% 27.3% 23.8%
Likely 43.0% 47.4% 57.1%
Item 22: If you had to sign up for an exercise program to increase or maintain regular exercise, what type of program would you choose?
Couples-based program 26.7% 48.3% 35.0%
A program for cancer survivors ONLY 13.9% 0% 10.0%
A program for partners of cancer survivors ONLY 0% 2.6% 0%
An individual program that is open to anyone 55.4% 33.8% 52.5%
I would never join an exercise program 4.0% 15.2% 2.5%
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Table 6. Correlations Between Predictors and Couples-based Exercise Interest
Outcomes
Item 7: How important do you think it is that Y OU and YOUR PARTNER engage in regular physical activity TOGETHER? Item 8: If a couple s-based exercise program were offered to you and your partner, how interested would Y OU be in participating? Item 9: If a couple s-based exercise program were offered to you and your partner, how interested would Y OUR PARTNER be in participating? Item 21: If a couples-based exercise program were offered to you and your partner, how likely is it that both YOU and YOUR PARTNER would participate?
Predictors Participation from both partners Survivors 0.115 0.087 0.270** 0.206**
Partners 0.037 -0.048 0.091 0.021
Survivor Couples 0.401* 0.199 -0.117 0.252
Gender Survivors 0.036 0.095 0.019 0.082
Partners -0.078 -0.130 -0.222** -0.142
Survivor Couples 0.101 -0.061 -0.455** -0.022
Age Survivors -0.069 -0.047 -0.089 -0.048
Partners -0.073 -0.131 -0.139 -0.109
Survivor Couples -0.193 -0.239 -0.162 -0.260
MVPA Survivors -0.006 -0.069 -0.058 0.050
Partners 0.042 -0.025 -0.088 0.097
Survivor Couples -0.112 -0.409** -0.403** -0.109
Frequency of couple exercise Survivors 0.367** 0.135 0.297** 0.333**
Partners 0.360** 0.107 0.185* 0.270**
Survivor Couples 0.438** 0.035 -0.080 0.077
Relationship Satisfaction Survivors 0.132 0.087 0.269** 0.343**
Partners 0.190* 0.071 0.284** 0.274**
Survivor Couples 0.197 -0.054 0.325 0.290
Partner Support for Exercise Survivors 0.327** 0.207** 0.503** 0.539**
Partners 0.421** 0.185* 0.420** 0.470**
Survivor Couples 0.219 0.041 0.249 0.303
Note: Values in bold indicate factor is statistically significant. * indicates significant at p 0.05. and ** indicates significant at/K0.01. Participation from both partners was coded as yes=l, no=0. Gender was coded male=l, female=0.
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Table 7: Strongest Predictors of Couples-based Exercise Importance and Interest
Item 7: How important do you think it is that YOU and YOUR PARTNER engage in regular physical activity TOGETHER?
Participation from both Gender MVPA Frequency of couple Relationship Satisfaction Partner Support
partners exercise for Exercise
p P R2, p-value
Survivors 0.266** 0.166* 0.152, p<0.001
Partners 0.197* -0.018 0.333** 0.210, p<0.001
Survivor 0.195 0.406** 0.229,
Couples pO.001
Item 8: If a couples-based exercise program were offered to you and your partner, how interested would YOU be in
participating?
Participation from both Gender MVPA Frequency of exercise Relationship Satisfaction Partner Support
partners together for Exercise
P R2, p-value
Survivors 0.207** 0.04, p<0.01
Partners 0.185* 0.034, p<0.05
Survivor -0.409** 0.167,
Couples p=0.128
Item 9: If a couples-based exercise program were offered to you and your partner, how interested would YOUR PARTNER be in participating?
Participation from both Gender MVPA Frequency of exercise Relationship Satisfaction Partner Support
partners together for Exercise
P P P P R2, p-value
Survivors 0.181** -0.022 0.021 0.472** 0.286, p<0.001
Partners -0.173* -0.017 0.063 0.380** 0.211, p<0.001
Survivor Couples -0.275* -0.346** 0.235, p<0.01
Item 21: If a couples-based exercise program were offered to you and your partner, how likely YOU and YOUR PARTNER would participate is it that both
Participation from both Gender MVPA Frequency of exercise Relationship Satisfaction Partner Support
partners together for Exercise
P P P P R2, p-value
Survivors 0.102 0.016 0.102 0.460** 0.309, p<0.001
Partners 0.036 0.061 0.421** 0.224, pO.OOl
Survivor Couples
Note: Non-significant correlations between predictors and outcomes are shaded. Participation from both partners was coded as yes=l, no=0. Gender was coded male=l, female=0. Values in bold indicate statistically significant predictors in the regression equation. * indicates significant at p<0.05, and ** indicates significant at /K0.01.
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Table 8: Couples’ Agreement Regarding Couples-based Exercise (N=161 couples)
Item 7: How important do you think it is that YOU and YOUR PARTNER engage in regular physical activity TOGETHER? Item 8: If a couples-based exercise program were offered to you and your partner, how interested would YOU be in participating? Item 9: If a couples-based exercise program were offered to you and your partner, how interested would YOUR PARTNER be in participating? Item 21: If a couples-based exercise program were offered to you and your partner, how likely is it that both YOU and YOUR PARTNER would participate?
Intraclass correlations ICC=0.34, p<0.001 ICC=0.20, p<0.01 ICC=0.20, p<0.01 ICC=0.26, p<0.001
% of couples that had agreement in their responses 54.0% 52.8% 44.4% 50.0%
% of couples in highest category 36.0% of couples chose important 44.1% of couples chose interested 32.5% of couples chose interested 31.0% of couples chose likely
% of couples in lowest category 8.7% of couples chose unimportant 3.8% of couples chose uninterested 8.9% of couples chose not unlikely
% of couples that had discrepant responses 46.0% 47.2% 55.6% 50.0%
% of couples with extreme mismatch (lowest and highest categories) 10.6% of couples chose unimportant and important 11.8% of couples chose uninterested and interested 18.0% of couples chose uninterested and interested 14.6% of couples chose unlikely and likely
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Table 9: Mean Comparisons Between Education and Control Conditions
Survivors (n=209) Partners (n=153)
Education Mean Control Mean P- value Education Mean Control Mean P- value
Exercise Outcome Expectations (0-5 scale) 4.45 4.25 p<0.01
Exercise will improve the functioning of my cardiovascular system 4.84 4.64 p<0.01
Exercise will increase my acceptance by others 3.25 2.87 p<0.01
Exercise will give me a sense of personal accomplishment 4.64 4.46 p<0.05
Exercise will help prevent cancer recurrence 4.37 3.50 p<0.01 4.10 3.72 p<0.05
Exercise will improve my quality of life 4.72 4.51 p<0.01
Dyadic Exercise Expectations and Beliefs (0-6 scale) 4.60 4.30 p<0.05
I want my significant other to encourage me to exercise 4.87 4.46 p<0.05
I want my significant other to remind me to exercise 4.40 3.95 p<0.05
Ed rather exercise with my significant other than with peers 4.30 3.69 p<0.01
I want my significant other to exercise with me* 5.02 4.56 p<0.01
Ed rather exercise with my significant other than alone* 4.51 3.90 p<0.01
Item 5: How important do you think it is that YOU engage in regular physical activity? 5.10 4.72 p<0.05
Item 20: If an exercise program were offered to you ONLY, how likely is it that you would participate? 5.11 4.69 p<0.05
*These items only became significant when evaluating survivors who watched the entire video; shaded areas were not significant.
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APPENDIX
Below are items that are conceptualized as main outcome measures of the planned study. Cancer-specific Exercise Knowledge
1.) What type of exercise(s) should cancer survivors engage in? (Choose all that apply)
â–¡ Aerobic or cardiovascular exercise (i.e. walkingjogging)
â–¡ Strength training exercises
â–¡ Flexibility/Stretching
â–¡ Other
â–¡ Prefer not to answer
If other is selected: Please specify:________________________________________________
(If you prefer not to answer, please enter -999)
2a.) If a cancer survivor were to engage in MODERATE intensity aerobic activity, at least how many minutes should he/she do per week?
(If you prefer not to answer, please enter -999)
2b.) If a cancer survivor were to engage in VIGOROUS intensity aerobic activity, at least how many minutes should he/she do per week?
(If you prefer not to answer, please enter -999)
2c.) According to the ACSM guidelines, how many days of strength training should cancer survivors do each week?
(If you prefer not to answer, please enter -999)
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The following items reflect your beliefs or expectations about the benefits of regular exercise or physical activity. Please respond to the following statements marking your answer honestly and by indicating the appropriate statement. Remember to read each question carefully.
Items 3a-3r
Strongly Disagree Disagree Neutral Agree Strongly Agree Prefer not to answer
Exercise will improve my ability to perform daily activities â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
Exercise will improve my social standing: â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
Exercise will improve my overall body functioning: â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
Exercise will help manage stress: â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
Exercise will strengthen my bones: â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
Exercise will improve my mood: â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
Exercise will increase my muscle strength: â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
Exercise will make me more at ease with people: â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
Exercise will aid in weight control: â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
Exercise will improve my psychological state: â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
Exercise will provide companionship: â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
Exercise will improve the functioning of my cardiovascular system: â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
Exercise will increase my mental alertness: â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
Exercise will increase my acceptance by others: â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
Exercise will give me a sense of personal accomplishment: â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
Exercise will help prevent cancer recurrence: â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
Exercise will improve my quality of life: â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
Exercise will give me more energy: â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
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Please indicate the extent to which you agree with the following statements:
Items 4a-4j
Strongly Disagree Disagree Somewhat Disagree Somewhat Agree Agree Strongly Agree Prefer not to answer
Exercising with my significant other will strengthen our relationship â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
Exercising with my significant other will increase our attraction for each other â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
Exercising with my significant other will help us adopt healthy habits â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
I want my significant other to encourage me to exercise â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
I want my significant other to remind me to exercise â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
I want my significant other to exercise with me â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
I’d rather exercise with my significant other than alone □ □ □ □ □ □ □
I’d rather exercise with my significant other than with peers (including fellow survivors if applicable) □ □ □ □ □ □ □
My significant other makes me more accountable for exercise â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
My significant other makes exercise more enjoyable â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
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Please indicate your beliefs about exercise:
5. ) How important do you think it is that YOU engage in regular physical activity?
Please rate your response on a scale from 1 to 10 with 1 being not at all important and 10 being extremely important.
1 Not at all Important
2
3
4
5
6
7
8
9
10 Extremely Important Prefer not to answer
6. ) How important do you think it is that YOUR PARTNER engages in regular physical activity? Please rate your response on a scale from 1 to 10 with 1 being not at all important and 10 being extremely important.
1 Not at all Important
2
3
4
5
6
7
8
9
10 Extremely Important Prefer not to answer
7. ) How important do you think it is that YOU and YOUR PARTNER engage in regular physical activity TOGETHER? Please rate your response on a scale from 1 to 10 with 1 being not at all important and 10 being extremely important.
1 Not at all Important
2
3
4
5
6
7
8
63


9
10 Extremely Important Prefer not to answer
8.) If a couples-based exercise program were offered to you and your partner, how interested would YOU be in participating?
â–¡ Very Uninterested
â–¡ Uninterested
â–¡ Somewhat Uninterested
â–¡ Somewhat Interested
â–¡ Interested
â–¡ Very Interested
â–¡ Prefer not to answer
9.) If a couples-based exercise program were offered to you and your partner, how interested would YOUR PARTNER be in participating?
â–¡ Very Uninterested
â–¡ Uninterested
â–¡ Somewhat Uninterested
â–¡ Somewhat Interested
â–¡ Interested
â–¡ Very Interested
â–¡ Prefer not to answer
64


The following questions are about ideas for a couples-based exercise program.
10.) One idea for an exercise program is one in which partners exercise together. They may exercise together by taking an exercise class together, working with a personal trainer together or simply walk outside together. To what extent do you think cancer survivors and their significant others would be interested in exercising together?
â–¡ Very Uninterested
â–¡ Uninterested
â–¡ Somewhat Uninterested
â–¡ Interested
â–¡ Very Interested
â–¡ Prefer not to answer
11.) Another idea for an exercise program is one in which partners exercise separately but work toward shared goals. Partners would set personal goals (e.g,. 150 minutes of activity) and composite goals (e.g., hit more than 300 minutes combined) that they can individually work toward by doing activities of their choice at their convenience. After exercising, each partner would login to an app or website and record his/her progress toward both his/her personal goal and the couple's composite goal. To what extent do you think cancer survivors and their significant others would be interested in exercising individually, yet share exercise data via an app or website?
â–¡ Very Uninterested
â–¡ Uninterested
â–¡ Somewhat Uninterested
â–¡ Interested
â–¡ Very Interested
â–¡ Prefer not to answer
12.) If you were to participate in an exercise program with your partner, would you prefer the program to involve exercising together or the ability for each individual to exercise alone yet share activity data with their partner via an app or website?
â–¡ Exercise together
â–¡ Exercise individually but share exercise data via an app or website
â–¡ I like both ideas equally
â–¡ I don't like either idea
â–¡ No Preference
â–¡ Prefer not to answer
65


The items listed below are designed to assess your beliefs in your ability to exercise three time per week at moderate intensities (e.g. hard enough to increase your heart rate and breathing), for 30+ minutes per session in the future. Using the scales listed below please indicate how confident you are that you will be able to exercise in the future. Please remember to answer honestly and accurately. There are no right or wrong answers.
FOR EXAMPLE:
If you have complete confidence that you could exercise at least three times per week at moderate intensity for 30+ minutes for the next 12 weeks without quitting, you would circle 100%. However, if you had no confidence at all that you could exercise for the next 12 weeks without quitting, (that is, confident you would not exercise), you would choose 0%.
Items 13a-13f
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Prefer not to answer
I am able to continue to exercise at least three times per week at moderate intensity for 30+ minutes without quitting for the NEXT 2 WEEKS â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
I am able to continue to exercise at least three times per week at moderate intensity for 30+ minutes without quitting for the NEXT 4 WEEKS â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
I am able to continue to exercise at least three times per week at moderate intensity for 30+ minutes without quitting for the NEXT 6 WEEKS â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
I am able to continue to exercise at least three times per week at moderate intensity for 30+ minutes without quitting for the NEXT 8 WEEKS â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
I am able to continue to exercise at least three times per week at moderate intensity for 30+ minutes without quitting for the NEXT 10 WEEKS â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
I am able to continue to exercise at least three times per week at moderate intensity for 30+ minutes without quitting for the NEXT 12 WEEKS â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
66


The following items reflect situations that are listed as common reasons for preventing individuals from participating in exercise sessions or, in some cases, dropping out. Using the scales below please indicate how confident you are that you could exercise in the event that any of the following circumstances were to occur.
Please indicate the degree to which you are confident that you could exercise in the event that any of the following circumstances were to occur by circling the appropriate %. Select the response that most closely matches your own, remembering that there are no right or wrong answers.
I believe that I could exercise 3 times per week for the next 3 months if:
Items 14a-14o
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Prefer not to answer
The weather was very bad (hot, humid, rainy, cold). â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
I was bored by the program or activity. â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
I was on vacation. â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
I was not interested in the activity. â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
I felt pain or discomfort when exercising â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
I had to exercise alone. â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
It was not fun or enjoyable. â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
It became difficult to get to the exercise location. â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
I didn't like the particular activity program that I was involved in. â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
My schedule conflicted with my exercise session. â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
I felt self-conscious about my appearance when I exercised. â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
An instructor does not offer me any encouragement. â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
I was under personal stress of some kind. â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
I felt nauseated. â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
I was experiencing fatigue. â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
67


The following items reflect common reasons that prevent couples from exercising together. Please answer the following questions as honestly as possible.
15. ) What are some barriers that may keep you from exercising with your partner? (Choose all that apply)
â–¡ Time or scheduling difficulties
â–¡ We like different types of exercise
â–¡ We have different exercise abilities
â–¡ My partner prefers to exercise without me
â–¡ I prefer to exercise alone
â–¡ I prefer to exercise with friends
â–¡ My partner dislikes exercise
â–¡ I dislike exercise
â–¡ lam satisfied with how much we exercise together
â–¡ Other
â–¡ Prefer not to answer
If other is selected: Please specify:______________________________________________
(If you prefer not to answer, please enter -999)
16. ) What is the GREATEST barrier that may keep you from exercising with your partner? (Choose one)
â–¡ Time or scheduling difficulties
â–¡ We like different types of exercise
â–¡ We have different exercise abilities
â–¡ My partner prefers to exercise without me
â–¡ I prefer to exercise alone
â–¡ I prefer to exercise with friends
â–¡ My partner dislikes exercise
â–¡ I dislike exercise
â–¡ lam satisfied with how much we exercise together
â–¡ Other
â–¡ Prefer not to answer
If other is selected: Please specify:______________________________________________
(If you prefer not to answer, please enter -999)
17. ) How likely is it that you and your partner will work together to overcome this barrier?
â–¡ Very Unlikely
â–¡ Unlikely
â–¡ Somewhat Unlikely
â–¡ Somewhat Likely
â–¡ Likely
â–¡ Very Likely
â–¡ Prefer not to answer
68


18.) What is the GREATEST barrier that may keep OTHER COUPLES from exercising together? (Choose one)
â–¡ Partners may not have time to exercise together
â–¡ Partners may like different types of exercise
â–¡ Partners may have different exercise abilities
â–¡ Partners may prefer to exercise alone
â–¡ Partners may prefer to exercise with peers
â–¡ Both partners may not like exercise
â–¡ Partners may be satisfied with how much they exercise together
â–¡ Other
â–¡ Prefer not to answer
If other is selected: Please specify:_______________________________________________
(If you prefer not to answer, please enter -999)
69


If you were to participate in an exercise program with your significant other, indicate the extent to which you agree with each potential concern
Items 19a-19h
Strongly Agree Agree Somewhat Agree Somewhat Disagree Disagree Strongly Disagree Prefer not to answer
I am concerned my significant other will not stay committed to an exercise program â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
I am concerned my significant other will nag me to exercise â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
I am concerned my significant other will be too competitive with exercise â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
I am concerned my significant other will make excuses not to exercise â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
I am concerned my significant other and I may argue over exercise â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
I am concerned my significant other may not understand my personal barriers to exercise â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
I am concerned my significant other will not want to exercise with me â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
I am concerned my significant other will not want to share his/her exercise data with me â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡
70


The following questions pertain to joining an exercise program.
20.) If an exercise program were offered to you ONLY, how likely is it that you would participate?
â–¡ Very Unlikely
â–¡ Unlikely
â–¡ Somewhat Unlikely
â–¡ Somewhat Likely
â–¡ Likely
â–¡ Very Likely
â–¡ Prefer not to answer
21.) If a couples-based exercise program were offered to you and your partner, how likely is it that both YOU and YOUR PARTNER would participate?
â–¡ Very Unlikely
â–¡ Unlikely
â–¡ Somewhat Unlikely
â–¡ Somewhat Likely
â–¡ Likely
â–¡ Very Likely
â–¡ Prefer not to answer
22.) If you had to sign up for an exercise program to increase or maintain regular exercise, what type of program would you choose?
â–¡ A couples-based program
â–¡ A program for cancer survivors ONLY
â–¡ A program for partners of cancer survivors ONLY
â–¡ An individual program that is open to anyone
â–¡ I would never join an exercise program
â–¡ Prefer not to answer
71


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