br Current evidence suggests that cancer caregiving is

Current evidence suggests that cancer caregiving is intense, episodic, and has a profound impact on the caregiver's physical well-being and quality of life (QOL) [15,16]. However, FCGs may not participate in phys-ical activity behaviors due to the demands of caregiving and caregiver burden [17,18].
Maintaining physical activity before and after surgery is challenging for older adults with cancer and their family caregivers (FCGs). Few studies have investigated factors that promote and hinder perioperative physical activity adherence in older adults with cancer and their FCGs. Understanding the barriers and facilitators to physical activity is essen-tial in designing feasible and effective interventions to improve dyadic functional capacity and QOL. The goal of this Aprotinin study was to explore barriers and facilitators of adherence to a perioperative physical activity intervention for older adults with lung and gastrointestinal (GI) cancers and their FCGs, in order to gain better insight into factors that may pre-dict intervention engagement.
2. Methods
2.1. Intervention, Sample, and Setting
The parent intervention study was reviewed and approved by the Institutional Review Board (IRB). All participants provided written in-formed consent prior to enrolling in the study. Briefly, the perioperative physical activity intervention provided one-on-one coaching to opti-mize physical and psychological functioning before and after surgery. It was delivered by a trained physical therapist (PT) and occupational therapist (OT), and involved five videoconference and telephone ses-sions. The sessions were delivered before surgery and continued through hospitalization and up to two to four weeks post-discharge. Pa-tients/FCGs were enrolled as dyads, using the following eligibility criteria: 1) diagnosis of lung or GI (colorectal, gastric, pancreas, liver) cancers; 2) scheduled to undergo surgery; 3) patient age ≥65 years;
4) family member/friend identified by the patient as the primary care-giver before and after surgery; 5) FCGs age ≥21 years; and 6) ability to read and understand English. Following baseline comprehensive assess-ment (geriatric assessment, six minute walking distance, short physical performance battery), a personalized walking and lower extremity exercise (sit to stand, step up and down-front, step up and down-sideways, standing wall push away) program was developed for patients. Classic behavioral change strategies were integrated, which in-cluded goal setting, identifying challenges/barriers to physical activity, problem solving to overcome the challenges/barriers, and skills building related to functional recovery. Throughout the study period, patients/ FCGs wore wristband pedometers (Vivofit 3; Garmin Ltd) on the non-dominant hand for self-monitoring purposes. FCGs were trained to serve as “coaches,” and were encouraged to participate in the walking program with patients.
All eligible participants who met the parent intervention study in-clusion criteria were identified and recruited from one National Cancer Institute-designated comprehensive cancer center in Southern Califor-nia over a seven month period. A total of 34 dyads (sixteen GI, eighteen lung) were enrolled. Median age for lung surgery patients was 74; for lung surgery FCGs, median age was 71. GI surgery patients and FCGs were younger, with median age of 68 and 67 respectively. Forty one per-cent of patients were female, 82% were of white race, and 94% were married. Fifty-nine percent of the caregivers were female, 82% were of white race, and approximately 53% were employed.
Baseline comprehensive assessments were completed during a rou-tine clinic visit, while the intervention sessions were delivered via Zoom videoconferencing before surgery and during inpatient hospitalization following surgical procedures. The length of intervention sessions
ranged from 30 to 70 min. Baseline comprehensive assessment encoun-ters and intervention sessions were noted by PT/OT.
We focused our analysis on PT/OT notes from the following encoun-ters: 1) baseline comprehensive assessment, 2) intervention session #1 before surgery (Zoom videoconferencing), and 3) intervention session #2 during postoperative hospitalization (inpatient encounter). PT and OT provided separate notes at each of the three encounters. For each of the 34 dyads, a total of six independent notes were available for anal-ysis. Free-text data were transcribed into a spreadsheet for coding pur-poses. Data interpretation was guided by the direct qualitative content analysis approach, which allowed for the identification of initial key concepts by expanding on existing behavior change adherence theories and research [19]. All written comments were read, individually coded, and categorized into themes by investigators experienced in qualitative analysis. One investigator (VS) read all notes and independently coded all data and categorized the content themes. Two investigators who did not participate in the initial review and selection process (SH, GV) conducted a final validation of themes and content. Data deoxyribonucleic acid (DNA) were dis-cordantly coded were discussed for refinement and consensus.