Motivation of patients with chronic cancer during COVID-19: A qualitative analysis

doi:10.21203/rs.3.rs-2324880/v1

Purpose

Motivation to treat cancer and prevent its negative impact has been largely explored in a non-pandemic context. However, little is known about the motivation to comply with the treatment, especially during a pandemic. To fill this gap we have explored the individual and contextual factors impacting patients’ motivation during the COVID-19 period using the integrated model.

Methods

We have conducted two qualitative studies before (study 1) and during the COVID-19 (study 2) period in a cancer centre. We respectively interviewed 30 and 22 patients with various chronic cancers in study 1 and also with COVID-19 in study 2. Data analysis was based on content analysis and grounded theory approach identifying the factors affecting patient motivations during both periods, and then comparing them.

Results

Our results show the mechanisms that allow patients to maintain their motivation despite the threats related to COVID-19. They underline the importance of respecting the rules and laws for patients’ motivation.

Conclusion

Compliance with legislation fuels the psychological need of protection in patients, which is a key determinant of motivation in the context of the pandemic. Considering patients’ self-regulatory activities to assess motivational factors, going beyond clinical aspects, to include organisational and quality-of-life-related aspects throughout their care pathway is crucial.

Chronic cancer

COVID-19

external factors

integrated model

motivation

organisation

Motivations in patients with cancer have been largely explored in a non-pandemic context in terms of compliance with treatment management or maintaining physical and professional activities[1–4]. With the COVID-19 pandemic, many studies have warned about its negative psychological impact on patients with cancer[5–13]. In addition, the role of personality traits for maintaining adherence to cancer treatment during the pandemic has been demonstrated[14].

Although the negative impact of mental distress of patients with cancer has been documented, little is known about their motivation during the COVID-19 period. To address this gap, this research studies the individual and contextual factors impacting motivations of patients with chronic cancer for their treatment before and during the COVID-19 pandemic.

For identifying these factors, we used an integrated model that combines the self-determination theory (SDT) [15]¹⁵ and the theory of planned behaviour (TPB) [16]. According to the SDT, when social environments are supportive of patients’ basic psychological needs (i.e. autonomy, competence, and relatedness), individuals are more likely to endorse self-motivation (i.e. acting towards an inherent interest, satisfaction, personal goals, and values) than controlled motivation (i.e. acting due to external contingencies and internal pressure). In addition, the TPB explains how the link between SDT-related motivation and a given target behaviour is mediated by social cognitive beliefs and intention. According to this theory, individuals are more likely to demonstrate adherence to health behaviours[17, 18] when cognitive beliefs (i.e. attitude, subjective norms, and perceived behavioural control) and intentions are well-oriented. Based on these principles, the integrated model has been widely applied to various health contexts, providing empirical evidence of the power of explanation and the ability to predict healthy behaviours[19–21].

Applied to our context, law and enforcement rules, such as social distancing measures, quarantine and lockdown/travel bans may represent external factors supporting the development of controlled motivation while individual and contextual factors that promote the needs of autonomy, competencies, and social relatedness may represent factors supporting intrinsic motivation[22]. According to the SDT, individuals who are motivated by such controlled motivation can adhere to advisory behaviour when external factors are present, but may be more vulnerable in the long-term than those who develop intrinsic motivation. Some social circumstances may also impact different motivational and social cognition factors. For instance, the shortage of personal protective equipment might impair an individual’s sense of competence and perceived behavioural control [23]. Due to social isolation, the COVID-19 context can also alter existing relationships, limiting the expression of patients’ needs for relatedness vis-à-vis their environment. Cancellation of some services and lockdown can also negatively impact their need for autonomy. Fears associated with COVID-19 can negatively impact their attitude as well as their perceived behavioural control. In addition, some factors may mediate the level of motivation by affecting cognitive beliefs, according to the TBP.

The current qualitative study, based on two studies conducted in a cancer centre, aimed to identify the individual and contextual factors impacting patients’ motivation and cognitive beliefs before and during the COVID-19 period.

2.1. Study participants

The participants in the first study were selected from among those who followed up as part of a remote monitoring system for patients with cancer undergoing oral therapy (i.e. the Capri program in Gustave Roussy, Villejuif, France)[24]. Faced with the COVID-19 pandemic, the system was adapted accordingly for patients with cancer who tested positive for COVID-19. The participants for the second study were selected between 2020 and 2021 among those following this program. During the pandemic, patients had to follow the rules applied in the Ile-de-France (Paris) region where they lived: strict lockdown during mid-March and April 2020 coupled with potential rescheduling of their hospital appointments over the same period; rescheduling of their appointments from June 2020 onwards; and delivery of lower-grade treatment throughout the year. Lockdown was in place from October 2020 to February 2021, except for the Christmas period, alongside a gradual return to rescheduling appointments (June 2021).

2.2. Data collection

Two researchers (EM, IG) interviewed patients via video or phone call. The first study cohort (July 2019 to February 2020) comprised 30 patients, and the second study cohort during the pandemic (September 2020 to June 2021) involved 22 patients. Three patients declined to be interviewed during the second study and did not offer any explanation. The semi-structured interviews (interview guide in Appendix 1) lasted 1 hour 15 minutes on average with the first part dedicated to the patient experience, and the second one more focused on different facets of their motivation. All interviews were recorded and transcribed (except for two patients who declined to be recorded). The study was approved by the French Data Protection Agency (CNIL) and an ethics committee (CPP Paris-Ile-de-France IV no. 2016/20SC, US Department of Health and Human Services approved IRB no. 00003835). Informed consent was obtained from all participants prior to the interview.

2.3 Data analysis

Throughout the study, we met on a monthly basis to continuously compare data and theories as new evidences emerged, to acquire greater understanding of the observed phenomena[25–26]. We initially coded our data for pre-COVID-19 episodes. Axial coding was used to translate responses based on six categories of the integrated model, with vertical coding defining the contents of each factor. The original coding scheme reflected factors for patients with cancer. This stable approach to identify motivation became the baseline to which motivational and socio-cognitive factors during the COVID-19 pandemic were compared. We replicated our coding approach during the COVID-19 period to compare the ways in which motivational and socio-cognitive factors evolved. In addition, we coded the impact of COVID-19 on various factors representing threats with a potentially negative impact. Questions or discrepancies were resolved through regular discussion. Discussions on saturation led to the decision to end the analysis after interviewing 22 patients with cancer who tested positive for COVID-19.

3.1. Study Sample

Gender, type of cancer and type of treatment were similar between the participants of the qualitative study and those of the Capri program (Table 1).

Table 1

Characteristics of interviewees according to the Capri programme
Capri Programme (2020–2021)* (n = 272 )		Interviewed Pre-COVID-19 (n = 30)	Interviewed During COVID-19 (n = 22)	p-value**
Male	37.2	30.0	33.0	0.414
Female	62.8	70.0	67.0	0.414
Treatment
Oral chemotherapy	40.4	34.0	29.0	0.248
Targeted molecular therapies	59.6	66.0	71.0	0.248
Age (years)
< 45 45–54 55–64 65–74 > 75	15.4 16.5 25.7 27.9 14.5	22.0 19.9 16.0 27.5 14.6	19.0 12.0 24.0 20.0 25.0	0.339 0.991 0.333 0.596 0.407
* Patients receiving less than 28 days of treatment were excluded from the programme.
**The p-value was calculated between the overall sample of interviewees (N = 52) and the Capri programme participants

Insert around here Table 1

3.2. Motivational factors before and during the COVID-19 period

3.2.1. Autonomy

First, some patients expected to be involved in all treatment-related decisions while others accepted not to be involved in medical decisions. The lack of participation threatened the autonomy for some patients:

‘They do not let us participate in the decision-making process. We are treated a bit like children. It is depressing’.

Second, dysfunctions, such as rescheduling of appointments, lack of coherence in appointments, discrepancies in prescriptions, or a lack of information, experienced during the care pathway undermined the patients’ need for autonomy.

Third, different conditions in everyday life (as administrative procedures) affected patients’ requirements of autonomy. For instance, a patient said:

‘But I have my salary…that definitely makes daily living more comfortable. I do not have to worry about material constraints; I stay focused on my cancer treatment’.

When the pandemic emerged, several threats challenged the motivating factors of the patients. The rescheduling of certain procedures due to becoming COVID-19 positive and the difficulty in getting an appointment was not accepted by some patients, who questioned their ability to be treated on the required dates or their freedom of movement between home and the hospital, limiting the opportunity to make choices in the way their treatment was organised:

‘The scan should have been done in March, but as I got COVID-19, I was stuck ... I lost six months which demo’.

Faced with these threats, factors emerged to support autonomy. The opportunity to discuss with the doctor, the choice of dates to go to the hospital when required, and the independence to travel between home and hospital, were identified. The context of isolation also led patients to adjust to certain acts of daily living. Several highlighted the satisfaction of receiving financial assistance from their insurance fund or public aid to have their shopping delivered to them at home.

3.2.2. Competencies

The clarity of the messages conveyed by Health Care Professionals (HCP) helped the patients. Some patients highlighted the importance of expert knowledge, which validated the information conveyed by the professionals. Some patients collected information on the Internet.

‘When they carry out a fasting blood glucose test, there are numbers. ...You are not a doctor. We do not know what it means. So, we go on the Internet to find out’.

However, other patients were wary of how reliable this information actually was:

‘Unfortunately, you know what it is like on the Internet. It is a collection of information, each element being as questionable as the other... I find it demoralising to see all of this information and yet not know whether it is reliable’.

Second, support and guidance from professionals in response to patients’ questions played a key role in the patients’ need to be competent in getting themselves treated

for cancer:

‘The nurse spoke to me about the doctor in these terms: “he was the best

in the world and was going to operate on me’.

The COVID-19 period impacted competency needs in both respects. Various patients reported having a lack of information about the virus. The amount of media-generated information about COVID-19 and the differing viewpoints of professionals kept the patients guessing. Discussions with physicians was difficult during COVID-19 period:

‘With COVID-19, it is even harder to see my general physician. I want him to explain the impact of COVID-19 on my immune system..and I do not know what to do’.

Several strategies were implemented in response. The patients initially focused on selecting what appeared to be reliable information in this context. Internet sites considered reliable and the trust placed on a doctor interviewed on a radio station were elements deemed essential by various patients to clarify their understanding of their clinical situation. These strategies also involved remote follow-up. Direct dialogue with the professionals was essential during the hospital stay:

‘My oncologist reassured me when I had COVID-19. He came into my room and said, ‘My job is to cure you’.

However, in most cases, the patients’ need for competence was mainly addressed by remote follow-up. The latter facilitated more frequent discussions with the hospital teams during this period:

‘Every day I had a call or the option to exchange e-mails…They advised me on how to deal with symptoms…I feel much more confident ’.

3.2.3. Relatedness

Support from family and friends was often reported to cater to the patient’s need for social proximity:

‘I was with the father of my children. We go to all of the appointments together’.

However, proximity had a negative impact. In the case of having a partner who expressed negative views about the treatment given, or having regular discussions about their health status affected the patients in a negative way.

Mr. X (husband of a patient interviewed): ‘Which doctor? (laughs). He is never around’.

‘I keep everyone up to date on my Facebook page ... it saves me from repeating’.

Support was also provided through remote follow-up. It was a source of regular contact, which enabled the coordinating nurses to support the patient in moments of anxiety, as testified by a patient during social isolation:

‘I had a call every day, or if there was a problem, I put it on the app. All of this reassured me’.

During COVID-19, lockdown was perceived negatively by patients as it isolated them from friends or family:

‘We are isolated with COVID-19…I miss everyone’.

Since the COVID-19 context was marked by uncertainty and lack of knowledge, HCP tended to keep their distance from patients:

‘Everyone who came into the room wore a double mask…plus gowns, mob-caps, overshoes, and gloves. We felt like abnormal beings’.

Despite the context, continuous and remote dialogue was organized with family, friends or colleagues. There were displays of solidarity as the life situations led to unexpected closeness and leading patients in using new means of communication:

‘My daughter, whom I do not see very often, visited regularly at this time, my neighbours always ask about me…my two children called me regularly .. My son even introduced me to WhatsApp’.

HCP support was seen as essential by many patients. However, feelings differed, with a patient reporting anxiety about remote follow-up during COVID-19:

‘All the symptoms are described and the nurses call us every day. However, it is a double-edged sword, because at first it is very reassuring..And yet, at the same time, the nurses were saying, “Are you okay? Are you breathing properly?” That made me anxious and I had panic attacks’.

The results are summarized in Table 2

Table 2

Factors and threats vis-a-vis patients’ needs
INDIVIDUALS’ NEEDS	Identified Factors before covid-19	Threats perceived during Covid-19	Identified factors to maintain motivation during Covid-19
Autonomy	Relationships between patients and health care professionals (e.g. sharing treatment-related decision making with doctors)	Relationships between patients and health care professionals (e.g. general practitioner not available)	Relationships between patients and health care professionals (e.g. opportunity to resume contact with health care professionals to share treatment-related decisions)
	Care pathway (e.g. rescheduling, a lack of consistency in appointments)	Care pathway (e.g. difficulties getting to the hospital and accessing treatment, treatment rescheduling)	Care pathway (e.g. travelling to the hospital with third-party assistance)
	Everyday life (e.g. the lack of financial resources, bureaucratic burden)	Everyday life (e.g. food provision, impossible to come and go freely)	Everyday life (e.g. the use of home assistance service, obtaining additional financial resources, support from neighbours)
Competencies	Quality of Information on treatment and its effects (e.g. from professionals, patient experts, or the Internet)	Quality of information (e.g. lack of reliable media information on the effects of COVID-19)	Quality of information (e.g. checking the quality of Internet information, confidence in certain doctors perceived as reliable in advising on the approach to adopt) Feedback (e.g. personalised feedback with remote follow-up)
Competencies	Feedback and encouragement from health care professionals	Feedback (e.g. difficulty in accessing professionals)
Relatedness	Close environment (e.g. family and friends, burden relatedness) Professional environment (e.g. colleagues and management) Health care professionals’ environment (e.g. attention paid by the health care professionals to the patients’ social conditions)	Close environment (e.g. isolation, which makes it impossible to see relatives) Health care professionals’ environment (e.g. stigmatisation of the patient with COVID-19)	Close environment (e.g. developing relationships with neighbours, colleagues, suitability of new methods of communication) Health care professionals’ environment (e.g. dialogue maintained through remote follow-up, which can cause patients to become anxious)

(Insert Table 2)

3.3. Social cognitive factors before and during the COVID-19 period

3.3.1. Attitude

First, patients assessed their health status in many ways. Depending on the clinical context, the lack of perspective could have a negative impact:

‘Actually, not knowing what will happen to me after the sixth chemotherapy session casts a cloud over everything’.

Second, personality traits of being positive, pessimistic, or anxious influenced attitude:

‘When I know I am going to be hospitalised, I start crying, I do not know if I am going to come back ’.

Third, religious beliefs helped some patients see the perceived constraints of cancer in perspective:

‘I was a staunch Buddhist. Thus, I was in the moment. It helped me avoid additional stress’.

The COVID-19 period generated anxiety. It equated to a fear of the unknown in the face of this new disease, or a more negative attitude towards the distressing symptoms experienced once the disease had taken hold:

‘I was demoralised because I was very tired; I could not do anything’.

In this context, patients minimised the impact of the virus compared to that of cancer. For instance, a patient thought they would die and was surprised to have beaten COVID-19:

‘I was more worried about my cancer recurrence than I was about COVID-19. When you have cancer, you know that contracting COVID-19 is not the same thing’.

In addition, positive attitude was strengthened by their treatment going well and their evaluation of the cancer treatment. The patient realised that they could continue their treatment in this context:

‘I am optimistic, I saw that my appointments were still being scheduled, albeit without someone coming with me, but we continued to take care of the situation... by being careful and rigorous, we manage things’.

3.3.2. Subjective norms

Different patients sought support by comparing themselves to people with similar conditions. Patient associations played an important role in connecting patients with similar conditions:

‘I knew two people with pancreatic cancer—they were gone in six months. It is very serious and I know that I will not be cured .... but everyone is different’.

Additionally, HCP provided indications showing that the patient’s situation was no less curable compared to others:

‘He had the same therapy as me. He had surgery in the same hospital, too. He did not have the same doctor. I had the boss…that made me feel really good’.

The COVID-19 pandemic transferred these factors to a new context. It was a doctor friend with a similar case, or a family case. In this new context, the search for these points of comparison also varied depending on the patients. While some remained interested in understanding what was happening to patients in similar conditions, others expressed no interest in this type of approach, believing their case to be unique.

3.3.3. Perceived behavioural control

First, the ability to follow the treatment affected patients’ perception of control of the situation. The patient was able to express that a lack of coordination between professionals may have led to confusion in terms of what to do and which professionals to meet:

‘I was lost for my home-based chemotherapy. For one week, I didn't understand whether I had the right equipment…I didn’t understand anything, and that had an impact on me’.

Second, the reputation of the professional and the establishment generated the feeling of being in the right place at the right time:

‘I am treated at Gustave Roussy. Everyone knows that it is the best possible cancer centre... It gave me a boost’.

Some services were also interpreted as comfort factors such as the quality of the meals during a hospital stay:

‘The meals are quite good … We feel that everything is well thought-out to create the right scenario’.

Third, the ability to enjoy leisure activities appeared to help people control their daily life despite cancer. It allowed people to ‘distance themselves from’ or ‘get a grip on’ the disease, to coin familiar terms.

The COVID-19 period created uncertainty on the access to HCP. For example, a patient’s chemotherapy session was cancelled due to a drop in their immune system due to the virus, while another patient’s enrolment in a clinical trial protocol was challenged.

These levels of uncertainty could nevertheless be controlled by various means. For example, the patient who had lost his sense of taste and smell was able to regain control of the situation through remote follow-up:

I had difficulty with meals, because I had no taste, no sense of smell, and was tired; the nurses who manage remote follow-up called a pharmacy across the street from me and faxed them a prescription to deliver food supplements

The delay in scheduling treatment due to COVID-19 was an opportunity for some patients. This encouraged individuals to better prepare themselves for the ordeal, which in turn, was seen as a condition in treating themselves more efficiently:

‘I went from: “Damn, I might have to have chemotherapy" to “when all is said and done, if it allows me to be calm afterwards, why not?” Thus, the fact that there was a reflection period, had advantages’.

Finally, despite the lockdown, patients continued to enjoy leisure activities such as reading, cooking, or music, which served as diversions.

The results are summarized in Table 3

Table 3

Factors and threats regarding socio-cognitive constructs
Socio- cognitive constructs	Factors identified before covid-19	Threats perceived during Covid-19	factors identified to maintain intention during Covid-19
Attitude	Patient’s assessment of their condition and outlook (e.g. role of the clinical context)	Patient’s assessment of their condition and outlook (e.g. fear of the unknown and effects of COVID-19 on health)	Patient’s assessment of their condition and outlook (e.g. the patient minimises the effect of COVID-19, alongside the continuity of care during the COVID-19 period)
Attitude	Patient self-assessment depending on personality traits (e.g. optimistic, anxious) Religious and spiritual practices (e.g. Buddhism)
Subjective norms	Patients’ comparison of their clinical status with that of other patients (e.g. identification of referral patients)	Patients’ comparison of their clinical status with that of other patients (e.g. difficulty finding patients in a similar situation regarding Cancer and COVID-19)	Patients’ comparison of their clinical status with that of other patients (e.g. a more nuanced assessment) Relationships between patients and health care professionals (e.g. taking into consideration the opinions of doctors who predict a positive outcome for the patient)
Subjective norms	Relationships between patients and health care professionals (e.g. taking into consideration the opinions of doctors who support a positive outcome based on similar cases)
Perceived behaviour control	Ability to have follow-up treatments (e.g. actions to be taken during treatment, adequate equipment for care administered at home) Reputation (e.g. of the health care professional, institution, and quality of service provision—meals	Ability to have follow-up treatments (e.g. rescheduling of tests and discontinuation of treatment if the patient tests positive for COVID-19)	Ability to have follow-up treatments (e.g. role of remote follow-up, role of time in accepting treatment)
Perceived behaviour control	Ability to enjoy leisure activities (e.g. cooking, reading, music)		Ability to enjoy leisure activities in isolation (e.g. cooking, reading, music)

(Insert Table 3)

3.4. The positive role of the law enforcement rules

Most patients confirmed that they adhered to barrier measures:

‘I clean my key ring, I clean my door handle. Protecting myself is the best way to stay focused on my cancer and keep all the options open’.

This compliance with barrier measures may have led some to cancel procedures to avoid contaminating others. When they were isolated, this need for protection was in direct competition with the need for social proximity, but it nevertheless remained a priority for many:

‘I shut myself away in a room. I separated myself from my wife and children. I did not want them to catch COVID-19 at all, but I also had to protect myself’.

The failure of others to comply with barrier measures might also have restricted patients’ movements. In this case, it was the need for autonomy that was challenged, leading to anger:

‘But for me, it was the others, because people, in my opinion, were not careful enough. It was so stressful going shopping’!

Individual and collective compliance with barrier measures was therefore often put forward as a necessity, both to protect oneself and prevent future constraints in terms of autonomy linked to an increasingly worsening situation.

This study investigated the factors that affect the motivation of patients with chronic cancer before and during the COVID-19 pandemic when they get infected with the virus.

First, our results show that the health regulations introduced during the pandemic have played an important role. The integrated model emphasizes the need to promote factors that support intrinsic motivation. Law enforcement is perceived as constraints affecting controlled motivation with limited effects on time[22]. Paradoxically, we showed that health regulations were seen positively by patients with cancer as they protected them from others. To explain the acceptance by the patients with cancer, we assume that it may express a new type of psychological need that supports motivation, a need for protection, as the conditions that facilitate rather than undermine intrinsic motivation are not the same during a pandemic period. The need for protection can be contextual and support integrated regulation which ‘occurs when identified regulations are fully assimilated to the self’[17]. Therefore, it may be in competition with social relatedness.

Second, contemporary research on motivation has accentuated intervention programs based on the integrated model to predict long-term motivational change in patients, in terms of improving their clinical condition. Based on the integrated model theory, we identified external factors which positively or negatively affected patients before and during COVID-19. They are: (1) patient and HCP relationship, (2) care pathway (i.e. the different organisational steps occurring during their treatment), (3) situations of daily life, (4) clear and comprehensive information about cancer and COVID-19, (5) support from family and friends, (6) patient’s assessment of their condition, (7) their own perception of personality, (8) their spiritual practices, (9) the ability to follow one’s treatment, (10) the reputation of professionals and the institution, and (11) the ability to still enjoy leisure activities. These results highlight the need to approach the patients’ pathway in a broader perspective including more daily life needs and cognitive beliefs of patients. Furthermore, the factors can be mobilised in a specific and unexpected way by each patient. For instance, the use of media in terms of understanding cancer or COVID-19 was used at varying degrees to meet competence needs. Some saw it as useful, while others rejected it for the fear of fake news. Positive expressions of relatedness might also have a negative impact on individuals who tried to limit social interactions. Different factors motivated individual patients and changed over time, thereby confirming that motivation was more complex than a singular construct[17] .

4.1. Study Limitations

Firstly, we focused on patients with cancer in extremely vulnerable situations as they contracted COVID-19, and no homogeneous cohort could have been designed in this respect. Same patients were not interviewed before and during the COVID-19 pandemic, therefore, we could not analyse the evolution of motivation for each person.

Secondly, at this stage, our work identified the specific role of factors during the COVID-19 pandemic leading to the need for personal and collective protection for vulnerable populations, including patients with chronic cancer. Further research should investigate this aspect.

Finally, semi-structured interviews provide more accurate and reliable assessments of behaviour than do self-reporting measures²⁷; however, those can be subject to social desirability.

4.2. Clinical implications

Some studies suggest including the motivational self-regulation activity performed by each person involved, in a motivational change programme[28]. Our results confirm such an approach highlighting the role of non-clinical activities such as social prescribing[29]. Also, the study highlights the positive perception of law reinforcement rules and compliance by patients with cancer. Moreover, this study recognises the importance of patients’ idiosyncratic and dynamic motivational activity.

4.3. Conclusion

Motivation to treat cancer and prevent its negative impact has been largely explored in a non-pandemic context. However, little is known about the motivation to comply with the treatment, especially during a pandemic. To fill this gap, we have conducted two qualitative studies before and during the COVID-19 period in a cancer centre. Our results show the mechanisms that allow patients to maintain their motivation despite the threats related to COVID-19. They underline the importance of respecting the rules and laws for patients’ motivation. These findings promote an understanding of evolving psychological mechanisms to better maintain one’s motivation under threatening situations.

- Ethical Approval

The study was approved by the French Data Protection Agency (CNIL) and an ethics committee (CPP Paris-Ile-de-France IV no. 2016/20SC, US Department of Health and Human Services approved IRB no. 00003835).

Informed consent was obtained from all individual participants included in the study.

- Competing interests

None conflict of interests, authors declare they have no financial interests.

- Authors' contributions

Two co-authors (EM and IG) contributed to the different steps of the study : conception and design ; material preparation, data collection and analysis. They wrote the different versions of the manuscript. The third co-author (FS) validated the final version

- Funding

No funding were received for this study

Acknowledgements

We thank all participants of the study for their availibility. We also thank Delphine Mathivon, Adeline Duflot-Boukobza, Marie Ferrua and Aude Fourcade for their assistance.

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No competing interests reported.

Motivation of patients with chronic cancer during COVID-19: A qualitative analysis

Status:

Journal Publication

Version 1

Abstract

1. Background

2. Methods