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Access to exercise therapy for cancer survivors is poor. Professional development to support exercise professionals in delivering these interventions is needed. Few online resources exist for exercise professionals to address this issue.
To develop and evaluate a freely available online toolkit to support exercise professionals working with cancer survivors.
A 2-phase, experience-based co-design approach was used to develop and evaluate the online toolkit. The two phases were as follows: 1) needs identification and co-design of resources and platform and 2) pilot evaluation. Four co-design workshops were conducted, transcribed, and thematically analyzed to identify key elements for the toolkit. For the pilot evaluation, a customized survey (the Determinants of Implementation Behavior Questionnaire) was distributed to exercise professionals at baseline and 3 months after launch of the online toolkit to determine its usability, utility, and effectiveness in improving their knowledge, confidence, and behavior. Results were reported as the median and interquartile range and changes were calculated using non-parametric tests. Website analytics described site usage after the initial evaluation.
Twenty-five exercise professionals participated in co-designing 8 key elements of the online Cancer Exercise Toolkit: the homepage and pages for getting started, screening and safety, assessment, exercise prescription, education, locations, and resources. For the pilot evaluation, 277/320 respondents (87% of whom were physiotherapists) from 26 countries completed the survey at baseline, with 58 exercise professionals completing follow-up surveys at 3 months. Exercise professionals’ knowledge, skills, and confidence in delivering exercise therapy to cancer survivors increased 3 months after baseline (items 1, 6, and 8: median score 5, IQR 3 to 6) to follow-up (items 1 and 6: median score 6, IQR 5 to 6; item 8: median score 5, IQR 5 to 7;
The co-designed online Cancer Exercise Toolkit was a useful resource for exercise professionals that may increase their knowledge, skills, and confidence in providing exercise therapy to cancer survivors.
International guidelines support the integration of exercise into cancer care to improve cancer outcomes [
Skilled exercise professionals are critical for the implementation and delivery of exercise therapy to cancer survivors [
Exercise professionals may be able to develop and consolidate their knowledge through attendance of in-person courses and lectures and passive text-based resources. However, these knowledge sources may be less effective at improving knowledge and skills than active approaches such as e-learning, which provide greater flexibility to cater for individual learning needs [
The primary aim of this study is to develop an online toolkit, based on experience-based co-design [
An online toolkit called the Cancer Exercise Toolkit was developed with an experience-based co-design approach [
Participant recruitment procedure for the creation and evaluation of the Cancer Exercise Toolkit.
Two groups of participants were included in the co-design workshops for toolkit development. Group 1 included “generalist” exercise professionals, defined as physiotherapists and exercise physiologists working in other areas who may have occasional contact with cancer survivors. Group 2 included “expert” or experienced cancer exercise professionals, defined as physiotherapists and exercise physiologists who had worked specifically in cancer for at least 2 years. The workshops did not include patients, as exercise professionals were intended to be the end users of this resource. However, patients who had been diagnosed with cancer and participated in exercise-based cancer rehabilitation were invited to participate in a brief video shown to clinicians in the co-design workshops, setting the scene and direction for the session. Snowball sampling was undertaken to recruit participants over a 2-week period. Exercise professionals were invited to participate in the study through an invitation email distributed by a health service and through local professional networks (eg, the Australian Physiotherapy Association). For workshops 1 and 2, it was estimated that 8 to 10 participants in each group would be sufficient to provide varied experiences and contribute to new knowledge [
For the pilot evaluation phase of the toolkit, a third group of exercise professionals was recruited. We aimed to recruit a convenience sample of at least 100 exercise professionals over a 3-month period. This sample size assumed that 50% of participants would be confident enough to prescribe exercise therapy to cancer survivors and that this would be sufficient for estimating the expected proportion of sufficiently confident participants with 10% absolute precision and 95% CI [
One-hour semi-structured interviews (
Separate workshops (workshops 1 and 2, each 1 hour long) with the generalist and expert exercise professionals were conducted to explore areas for health care improvement and identify therapist learning needs. Learning needs identified from the workshop formed the content outline of the new online toolkit. A combined workshop (workshop 3; 1.5-2 hours long) was then held with all the participating exercise professionals to design key content elements and the overall layout of the online toolkit. A prototype online toolkit was developed based on findings from the combined workshop and key cancer rehabilitation literature [
Following 1 month of access to the prototype, a second joint workshop (workshop 4; 1.5 hours long) was conducted to facilitate feedback. In this workshop, participant perceptions regarding the strengths and limitations of the new resource were explored. Further refinements to the toolkit were made by the research team following this workshop before it was formally evaluated by the broader exercise community (Phase 2).
Workshops were facilitated by a researcher with experience in EBCD (CT). Two members of the study team (AC and AD) generated field notes to assist in triangulation and data trustworthiness. Project team members acted as observers and additional facilitators for the larger joint workshops. Immediately after each workshop, project team members debriefed with the workshop facilitator and discussed their reflections.
Recordings from all workshops were transcribed, stored, and managed using Microsoft Word and NVivo (version 12). Transcripts were coded independently by 2 reviewers (AD and CT), who used an inductive thematic analysis approach to identify touchpoints from the workshops [
The online toolkit was formally piloted and evaluated with a broader, international sample of exercise professionals, including co-design participants (February 2021 to April 2021). An open online survey, Research Electronic Data Capture (RedCap) [
This anonymous online survey (
Survey and website metadata were described using proportions, medians, and interquartile ranges. Content analysis was conducted on open-ended survey questions by 2 researchers (AC and CO) independently. Following recommendations for the analysis of anonymous survey data that cannot be paired [
This study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Studies [
Twenty-five exercise professionals (13 experts and 12 generalists) participated in the co-design workshops. The co-design group included 21 physiotherapists and 4 exercise physiologists. Thirteen co-design participants worked in hospital settings in Australia. On average, the exercise professionals had 15 years of total experience (
Characteristics of co-design participants.
Characteristics, n (%) | All (N=25) | Expert (n=13) | Generalist (n=12) | ||||
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Physiotherapist | 21 (84) | 11 (85) | 10 (83) | |||
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Exercise physiologist | 4 (16) | 2 (15) | 2 (17) | |||
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Hospital | 12 (48) | 10 (77) | 3 (25) | |||
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Community | 9 (36) | 1 (8) | 8 (67) | |||
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Both | 1 (4) | 1 (8) | 0 (0) | |||
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Public | 14 (56) | 8 (62) | 7 (58) | |||
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Private | 2 (8) | 0 (0) | 2 (17) | |||
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Both public and private | 6 (25) | 3 (23) | 3 (23) | |||
Years of total experience, mean (SD) | 14.8 (8.6) | 17.2 (8.0) | 12.3 (8.6) |
Workshops 1 and 2 identified 5 key touchpoints describing successful cancer rehabilitation programs (
Need easy access to latest guidelines for general knowledge...often difficult to keep up to date...
[Need] access [to] article(s), training... [to be] more confident to safely advocate...to other health professionals.
When compared to the generalist group, the experts identified more nuanced, disease-specific knowledge, such as the need for strict infection control procedures and cancer-specific assessments. The importance of practical considerations, understanding the impact of cancer treatment and side effects, and education provision and access were common themes forming the foundational content of the toolkit prototype. These touchpoints informed 8 key sections of the toolkit: the homepage; getting started; screening and safety; assessment; exercise prescription; education; locations; and resources (
In the joint workshop (workshop 3), the exercise professionals agreed the toolkit needed to be simple, practical, and not duplicate existing resources. Participants provided suggestions for existing resources that could be linked or embedded in the toolkit and described a need for templates that could be used in their clinical practice. Website monitoring and updating were identified as critical for the website’s sustained success. At the conclusion of this workshop, the research team drafted the toolkit content. Freely available multimedia resources (videos, infographics, patient handouts, and podcasts) were sourced to supplement information provided on the website rather than creating new multimedia content.
Key touchpoints from workshops 1 and 2.
Elements of cancer rehabilitation | Common themes | Expert only | Generalist only |
Getting started | Setting up the environment, including social support, space, equipment, and group dynamics; communicating with patients how to get started with cancer rehabilitation | Importance of infection control due to work with immunocompromised patients | Whether to deliver therapy one-to-one or in groups; uncertainty as to how to integrate cancer patients with other disease populations; standardized templates and letters |
Screening and safety; assessment | Understanding impact of cancer treatment; precautions and contraindications | Discussion of impairment, performance, and quality of life measures used for assessment, including cancer-specific measures | Emphasis on importance and challenges of goal setting |
Exercise prescription | Individualization; modification and progression/regression; monitoring fatigue | More emphasis on guidelines and optimal dosage | Patient-centered approach to tailor exercise based on needs and symptoms |
Education | Requirement for multidisciplinary input, including psychological and nutritional support and fatigue management; need for resources for both patients and clinicians; inclusion of patient testimonials | N/Aa | N/A |
Access | Poor access to cancer rehabilitation | Acknowledgement of lack of sufficient suitable programs | Difficulty of generating and managing referrals; low confidence of other health professionals to refer patients to cancer rehabilitation |
aN/A: Not applicable. There were no differences in the themes related to education between the 2 groups.
At the second joint workshop (workshop 4), further refinements were made (
The website [
Contact details for follow-up surveys were provided by 160 respondents, of whom 58 completed the follow-up survey (for a response rate of 36%). There were no differences in demographics between those who completed the baseline and follow-up surveys (
Participant characteristics at baseline and in a 3-month follow-up survey.
Characteristics | Baseline (N=320) | 3-month follow-up (n=58) | |||
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Physiotherapy | 277 (87) | 51 (88) | ||
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Exercise physiology | 43 (13) | 7 (12) | ||
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Australia | 249 (78) | 50 (86) | ||
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Europe/United Kingdom | 38 (12) | 3 (5) | ||
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Americas | 15 (5) | 3 (5) | ||
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Asia/Pacific | 8 (3) | 0 (0) | ||
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Africa | 7 (2) | 2 (3) | ||
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Middle East | 1 (0.3) | 0 (0) | ||
City-based, n (%) | 228 (71) | 41 (71) | |||
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Public | 159 (50) | 29 (50) | ||
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Private | 116 (36) | 21 (36) | ||
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Both public and private | 36 (11) | 7 (12) | ||
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Other | 9 (3) | 0 (0) | ||
Years of experience, mean (SD) | 14 (10) | 15 (10) | |||
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<1 | 82 (26) | 9 (16) | ||
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1-2 | 60 (19) | 12 (21) | ||
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3-5 | 60 (19) | 12 (21) | ||
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6-10 | 29 (9) | 9 (15) | ||
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>10 | 25 (8) | 7 (12) | ||
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Cancer/palliative care/lymphedema | 118 (37) | 23 (40) | ||
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Other | 200 (63) | 35 (60) | ||
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76-100% | 61 (19) | 14 (24) | ||
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51-75% | 26 (8) | 5 (9) | ||
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26-50% | 55 (17) | 14 (24) | ||
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≤25% | 174 (54) | 25 (43) | ||
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Undergraduate degree | 138 (43) | 24 (41) | ||
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Post-graduate certificate | 71 (22) | 12 (21) | ||
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Masters by coursework | 73 (23) | 17 (29) | ||
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Masters by research | 13 (4) | 1 (2) | ||
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PhD | 20 (6) | 4 (7) | ||
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Informal training | 175 (55) | 0 (0) | ||
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External courses | 173 (54) | 0 (0) | ||
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Post-graduate education | 42 (13) | 0 (0) | ||
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Other | 23 (7) | 0 (0) | ||
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None | 45 (14) | 0 (0) |
aNo responses were gained at follow-up as this question was not asked at follow-up.
Self-reported motivations for accessing the Cancer Exercise Toolkit website (multiple answers possible).
After the 3-month pilot period, the toolkit received on average 866 views per month. Toolkit usage peaked in June 2021 at 1205 views and declined to 731 views in October 2021.
The most viewed pages were “Locations,” “Patient Education,” and “Precautions and Contraindications” (
Participants found the website useful, easy to understand, and easy to use (items 1 to 4: median score 6, IQR 5-7) (
Great source, filling a gap; like the pulmonary rehab toolkit.
I had difficulties accessing the toolkit and never got around to sorting out the issue.
Participants suggested some minor improvements to the website relating to accessibility (n=3), website function (n=2), increasing website scope (n=2), and dissemination (n=2).
Website usability and utility.
Question | Median rating, IQRa | Rating 6 or 7 (“strongly agree”), n (%) |
Overall, the Oncology Rehabilitation Toolkit website was easy to use (n=44) | 6, 5-7 | 30 (68) |
The content of the Oncology Rehabilitation Toolkit website met my expectations (n=44) | 6, 5-7 | 31 (70) |
Overall, it was easy to understand the organization of the Oncology Rehabilitation Toolkit website screens, especially the menu levels and the flow of the screens (n=42) | 6, 5-7 | 28 (67) |
How useful do you find the Oncology Rehabilitation Toolkit website to be? (n=44) | 6, 5-7 | 29 (66) |
I would recommend the Oncology Rehabilitation Toolkit website to my colleagues (n=44) | 7, 6-7 | 35 (80) |
aNumbers are Likert scales ranging from 1 (“strongly disagree”) to 7 (“strongly agree”)
At baseline, participants rated themselves highest on items relating to their capability to deliver exercise rehabilitation according to guidelines and lowest on items relating to their training and ability to practice delivering exercise rehabilitation (
At the 3-month follow-up, participants self-reported significantly higher scores on items related to knowledge and skills (items 1-7,
Determinants of Implementation Behavior Questionnaire. The significance level was set at
Question | Baseline |
Follow-up |
Between-group difference |
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I know how to deliver Exercise Oncology Rehabilitation following the guidelines. | 5 (3-6) | 6 (5-6) |
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Objectives of Exercise Oncology Rehabilitation and my role in this are clearly defined for me. | 4 (3-6) | 5 (5-6) |
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With regard to Exercise Oncology Rehabilitation, I know what my responsibilities are. | 5 (3-6) | 6 (5-6) |
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In my work with Exercise Oncology Rehabilitation, I know exactly what is expected from me. | 4 (3-5) | 6 (5-6) |
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I have been trained in delivering Exercise Oncology Rehabilitation following the guidelines. | 4 (1-5) | 6 (4-6) |
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I have the skills to deliver Exercise Oncology Rehabilitation following the guidelines. | 5 (3-6) | 6 (5-6) |
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I am practiced to deliver Exercise Oncology Rehabilitation following the guidelines. | 4 (2-5) | 6 (4-6) |
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I am confident that I can deliver Exercise Oncology Rehabilitation following the guidelines. | 5 (3-6) | 5 (5-7) |
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I am confident that I can deliver Exercise Oncology Rehabilitation following the guidelines even when other professionals with whom I deliver Exercise Oncology Rehabilitation do not do this. | 4 (3-6) | 5 (5-6) |
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I am confident that I can deliver Exercise Oncology Rehabilitation following the guidelines even when there is little time. | 4 (3-5) | 5 (4-6) | <.001 |
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I am confident that I can deliver Exercise Oncology Rehabilitation following the guidelines even when participants are not motivated. | 4 (3-5) | 5 (4-6) |
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Differences in Determinants of Implementation Behavior (DIBQ) scores between baseline and 3-month follow-up. Figure legend: Shaded data refer to Likert scales ranging from 1 ("strongly disagree") to 7 ("strongly agree"), numbers refer to absolute number of participants who answered survey question.
Qualitative data obtained from clinician workshops converged with quantitative survey data. Participants expressed a need to access information related to published exercise guidelines and described information related to exercise screening and safety as a priority. Areas of traffic on the toolkit were highest for pages related to safety and education (
This study identified key learning needs of exercise professionals related to cancer care and facilitated development of the co-designed online Cancer Exercise Toolkit. Learning needs included knowledge of practical considerations for starting a cancer rehabilitation program; how to perform assessment, screening, and safety; and how to prescribe exercise, including tailoring and monitoring. Other important elements described by participants were facilitating access to care, clinician and patient education, and inclusion of templates and forms to support practice. The toolkit had international reach and was described as useful and easy to navigate. The pilot evaluation suggests the Cancer Exercise Toolkit may also improve exercise professionals’ knowledge, skills, and confidence to deliver exercise therapy to cancer survivors.
Knowledge, skills, and confidence of exercise professionals to provide exercise therapy according to guidelines were rated higher after access to the Cancer Exercise Toolkit. This finding indicates that online toolkits such as this could be a useful knowledge translation strategy, supporting previous research showing that online platforms can support delivery of evidence-based practice [
Most toolkit users were exercise professionals who did not specialize in cancer but were motivated to obtain professional development and improve patient care. Initial survey respondents and users indicated that we achieved a global reach, with more than 400 health professionals from 26 countries accessing the toolkit. This reach is important considering that recent national [
The toolkit appeared to meet clinician needs, being described as easy and useful, with most survey respondents agreeing they would recommend it to their colleagues. Characteristics of the toolkit informed by the co-design process reflected effective web design, such as easy navigation; inclusion of images, logos, and multimedia content; optimal organization, including a hierarchical structure; and content utility, determined by sufficiency, relevancy, quality, and motivational power of the information [
This is the first study to describe the development of a freely available toolkit to support exercise professionals working with cancer survivors. The co-design approach ensured end user learning needs were met through tailoring the toolkit based on clinician experience [
There were limitations to this study. In the evaluation, only one-third of the original exercise professional participants completed the follow-up survey. Despite multiple attempts to improve engagement with the follow-up survey, including reminder emails and hosting a webinar where survey completion was promoted, the follow-up response rate remained low. This low response rate is consistent with other clinician surveys designed to evaluate physiotherapy professional development initiatives [
This study described the development of the co-designed Cancer Exercise Toolkit. The toolkit was accessed by physiotherapists and exercise physiologists who described the website as valuable and easy to use. Exercise professionals rated their knowledge, skills, and confidence higher after accessing the website, indicating that it may be an effective alternative or complement to traditional professional development. The Cancer Exercise Toolkit may help improve access to exercise therapy and improve the effectiveness of care for cancer survivors through greater capability of the exercise professional workforce.
Experience-based co-design (EBCD) steps.
Patient interview schedule.
Backgrounds of the research team.
Evaluation survey.
Description of website content.
Website changes.
Screenshot example of Cancer Exercise Toolkit.
Cancer Exercise Toolkit Visits.
Full Determinants of Implementation Behavior Questionnaire (DIBQ) outcomes.
Determinants of Implementation Behavior Questionnaire
experience-based co-design
We would like to thank our steering committee, the co-design participants, and the consumers who helped with the development of the Cancer Exercise Toolkit. Thank you to Joshua Stopper for his contribution to web design. This project was funded by a grant from the Pat Cosh Trust.
None declared.