We assessed subjective changes in physical activity by asking the question, “Since COVID-19, has your physical activity (a) decreased, (b) increased, or (c) stayed the same?” We assessed changes in sedentary behaviors by asking the question, “Since COVID-19, has your time spent sitting (a) decreased, (b) increased, or (c) stayed the same?”

Anxiety and depression were assessed using the 2-item Generalized Anxiety Disorder scale (GAD-2) [16] and the 2-item Patient Health Questionnaire (PHQ-2) [17], respectively. Both these tools have acceptable sensitivity and specificity [18].

Participants were asked to report all their preferred physical activities during and after COVID-19 from among the following: (1) indoor or outdoor activities with family or friends, (2) indoor or outdoor activities by themselves, (3) physical activity delivered through online platforms, and (4) physical activity delivered through video calls with family, friends, or fitness professionals. They were then asked to respond to an optional open-ended question regarding other preferred means of receiving physical activity programs.

Participants ranked the importance of social support in a physical activity program (scale 0-100). They reported their most preferred means of receiving social support from among the following: (1) in person, (2) video calls, (3) social media, and (4) texting. They then responded to open-ended questions regarding their preferred means of receiving social support.

One participant who was in enrolled in the LIVESTRONG program stated the following when the program was moved to an online platform: “I like the Zoom program better than anything I have ever done.” Three others (10.7%) reported the following regarding remote activities and the use of technology: “Challenges on Fitbit,” “online,” and “videos or DVDs.”

In total, 4 (14.3%) survivors preferred “walking, light hiking,” “walking trails,” and “swimming” at no specified location, 6 (25%) others preferred additional outdoor activities including “outdoor activities - walking, biking,” “bike riding, fishing, gardening,” “yard work,” and “anything outdoors,” and 4 (16.7%) participants preferred indoors “gym,” “senior center,” “LIVESTRONG,” and “market walking.”

In total, 6 (25%) participants preferred social support in addition to their preferred physical activity, such as “phone call with a friend while walking ‘together’” and “walking with friends, family, or other people,” “gym with cancer patients,” and “I need a partner to hold me accountable.”

In total, 5 (33.3%) participants preferred social support to be delivered through a remote or digital platform, such as “phone calls, emails, Zoom, texting, Google, Nest, WhatsApp, and Facebook.” Others (n=2, 13.3%) indicated the involvement of specific individuals, such as “text messages with peers or coaches,” and “video conferencing or phone calls with friends or family.”

In total, 3 (20%) participants preferred in-person support (“I would like to have support in person, but [the Y] is just too far away from my house…” and “to attend senior center,” “Gym or fitness center”).

In total, 5 (33.3%) participants preferred social support but did not specify whether they preferred in-person or remote support (“an advocate to help with the things I struggle with,” “visits with friends or family,” and “small groups”).

Survivors self-reported decreased physical activity levels and greater anxiety and depression levels, similar to those of the general population [2]. In both our quantitative and qualitive analyses, survivors reported their preferences for digital health. Other reported preferences highlighted the importance of social support.

Reductions in the survivors’ physical activity and increases in sedentary behaviors are concerning, as physical activity is critical for their physical and mental health [19-21]. The proportions of our participants who met the diagnostic criteria for depression and anxiety (n=16 [26.2%] and n=15 [24.6%], respectively) were higher than those previously reported for prostate cancer survivors (9.4% and 7.9%, respectively) but lower than those of breast cancer survivors (32.2% and 38.2%, respectively) [22,23]. Overall proportions of survivors are much higher than those of the general US population (3.1% of the general US population adults >18 years have been diagnosed with generalized anxiety disorder and 7.1% with major depressive disorder) [24]. It is critical to develop methods to support the mental health needs of survivors, and our study suggests that the pandemic and social isolation may increase the need for such support.

Survivors expressed their interest in support from digital health platforms for physical activities after COVID-19. While more survivors (n=40, 65.6%) reported their preferences for indoor or outdoor activities by themselves during COVID-19, they may possibly not have had the opportunity to receive support from digital health programs thus far. During and after COVID-19, digital health platforms may serve as a substitute for in-person support for survivors, and they can be tailored to augment the benefits of in-person support, potentially providing long-term support to survivors. COVID-19 has forced practitioners and survivors to embrace digital technology to promote and maintain health care provision and deliver physical activity programs [25]. Some oncological trials assessing physical activity have shifted to digital platforms [26]; however, community-based programs may provide less support and resources to convert in-person programs to virtual ones. A worldwide survey of fitness trends in 2021 reported that online programs ranked 1st in 2021 as opposed to 26th in 2020 [27], indicating that COVID-19 has brought about a paradigm shift in the fitness industry, and practitioners will need to adjust to this trend.

Furthermore, survivors acknowledged the importance of social support, and some expressed preferences for peer support. Telephonically delivered support by trained peer coaches coupled with remote activity monitoring has led to an increase in physical activity in a randomized trial with breast cancer survivors [28]. Although, in this study, 69% (n=42) of survivors preferred in-person social support, peer support for survivors delivered digitally is ideal for those who are unable to attend in-person programs and need additional support [29]. A digital health intervention that includes social support (ie, from family or friends, peer coaches, or other survivors) may address the preferences of survivors for remote programs and their accountability, while potentially improving their physical activity and mental health [30]. However, larger trials are required to examine the causal effects of different types of social support among survivors [31].

This exploratory study had a small cohort size; therefore, the statistical power was not high enough to enable hypothesis testing to assess relationships among variables. Survivors having already participated in the LIVESTRONG at the YMCA program might have been more motivated than those not enrolled in this program; thus, reductions in physical activity reported here may underestimate the prevalence of this issue in the general survivor population. Although this study lacks data on cancer types, previous studies have reported data from a higher proportion of breast cancer survivors [13]. These studies and our study show the homogeneity of the characteristics of participants in the LIVESTRONG to the YMCA program [13], and future trials will need to examine more diverse populations. Program directors had access to email listservs through the YMCA but did not have access to the number of participants registered on them; hence, we could not determine neither the final number of emails sent to eligible participants nor the valid response rate. All responses are self-reported and were obtained in a cross-sectional manner, warranting future assessments of baseline measures to assess longitudinal changes objectively, for example, using activity monitors.

In conclusion, during and after COVID-19, survivors may benefit from support to sustain their physical activity levels and mental health. The survivors in our study voiced various preferences for physical activity and social support, some preferring indoor physical activity by themselves during COVID-19 and others preferring online or remote programs along with social support, including support from family or friends and peer coaches, after COVID-19. Community-based physical activity programs can successfully engage survivors if they provide programs tailored to individual preferences during and after the COVID-19 pandemic.