Factors associated with physical activity among Thai women with breast cancer postmastectomy at a University Hospital, Thailand

doi:10.21203/rs.3.rs-4854096/v1

The primary treatment for breast cancer patients is surgery and it often impacts physical activity (PA). This study aimed to investigate factors associated with the PA level of Thai women with breast cancer after surgical mastectomy at Siriraj Hospital, Thailand. Ninety-three participants were completed the questionnaires included personal information, the Global Physical Activity Questionnaire, perceived benefits, perceived barriers, perceived self-efficacy, interpersonal influence and situational influence, the Thai Body Image Index score, and the Thai Hospital Anxiety and Depression Scale. Data was analyzed using descriptive statistics and Chi-square statistics (Odds-Ratio and 95% Confidence Interval). The study found that after post-mastectomy Thai women had sufficient PA (2.8 metabolic equivalent of tasks (METs)). It was also found that PA at work was associated with occupation, higher incomes, moderate satisfaction as assessed by the Thai Body Image Index score, and higher levels of anxiety and depression. Additionally, participation in recreational activities was associated with older age, higher perceived self-efficacy, and greater interpersonal influence. By exploring these association, we can tailor supportive care strategies that address the PA needs of individuals affected by breast cancer and it is essential for developing comprehensive interventions that optimize patient health and well-being throughout the cancer journey.

Biological sciences/Cancer

Health sciences/Health care

Breast cancer

Physical activity

Body Image Index

Perceived self-efficacy

Anxiety

Depression

Breast cancer is the major female cancer globally, accounting for 11.7% of all new cancers¹. When compared to Asian populations, Western populations, including those in Australia and New Zealand, North America, and Western Europe, have a significantly higher incidence of breast cancer¹. However, due to the early detection and advancements in treatment, the fatality rate for breast cancer has significantly decreased in Western populations. However, the prevalence of breast cancer in Thailand is increasing at an alarming rate. In Thailand the annual incidence of breast cancer is showing an increasing trend, from 17.8 per 100,000 in 1998 to 26.6 per 100,000 in 2012 to 31.4 per 100,000 in 2015. The condition is most prevalent in the 40 to 60-year age group^2–3.

Cancer diagnosis and treatment have a significant impact on the psychological health of patients, especially when surgery is involved^4–6. There are several types of mastectomy procedures involved in the treatment of breast cancer specifically: total (simple) mastectomy, modified radical mastectomy, radical mastectomy, skin-sparing mastectomy, and nipple-sparing mastectomy^{5, 6}. The choice of mastectomy type depends on a range of factors, the reason for the procedure, the size and location of any tumors, and the overall health of the patient^{5, 6}. After a mastectomy, breast reconstruction surgery can be performed to restore the appearance of the breast^{5, 6}. Every year, more than 10,000 women in Thailand undergo a mastectomy⁷; the psychological impact on patients, affecting various aspects of quality of life including self-image, self-esteem, and sexual relationships. The procedure is also associated with high rates of depression⁸.

Physical activity (PA) has been well-documented for its substantial health benefits^{9, 10}. PA is “any bodily movement produced by skeletal muscles that requires energy expenditure”¹⁰. It includes all forms of movement, from light activities like walking and gardening to vigorous activities like running and swimming. According to epidemiological studies inactivity and the underlying diseases which presence of cardiovascular risk factors including hypertension, insulin resistance, non-insulin dependent diabetes, dyslipidemia, and obesity are strongly linked^{9, 11}. It has also been suggested that consistent PA is effective for the prevention and treatment of the aforementioned illnesses as well as chronic conditions like osteoporosis, also helping to reduce stress and improve self-esteem^{12, 13}. PA has been shown to be effective in ensuring the reduction in sequelae of the complication from mastectomy, decreased need for both hospitalization and use of drugs, lowering hospital medical expenses. It has been suggested that PA is a possible intervention to enhance the quality of life of women with breast cancer both pre- and post- diagnosis, and after surgery¹⁴. Furthermore, exercise is “a subset of physical activity that is planned, structured, and repetitive”¹⁰. Exercise has been shown to help women with breast cancer and survivors improve their quality of life, cardiorespiratory fitness, physical functioning, and reduce tiredness^{10, 14}. It may also increase overall and disease-free recovery in women with breast cancer, reduce breast cancer recurrence and improve quality of life in women with breast cancer postmastectomy^{14, 15}. Women who have undergone mastectomy to treat breast cancer may have barriers to exercise in terms of biological mechanisms such as inflammation, immune function, and insulin sensitivity, body weight changes, other comorbidities, treatment effects, mental health, and quality of life¹⁶. In addition, given the nature of the breast cancer and the associated decline in physical function, women with breast cancer postmastectomy may not expect to derive benefit from exercise programs and struggle with outcome expectations despite exercise being routinely recommended for these women^{16, 17}. Social support from family, friends, and healthcare professionals can encourage individuals to engage in regular PA by providing motivation and companionship^{18, 19}. Cultural norms and values also play a critical role, with certain cultures placing a higher emphasis on PA than others^{18, 19}. Additionally, studies in modern lifestyles, characterized by sedentary behaviour and increased screen time, underscore the importance of promoting PA to counteract these trends²⁰. A lack of a patient-centred approach to prescribing PA may further limit motivation and outcome expectations in this population in Thailand.

Understanding the adequate and appropriate level of PA and the factors that influence PA participation in women postmastectomy is essential for developing targeted interventions and support strategies to promote an active lifestyle in this population²¹. There are some key factors that are often associated with PA in post mastectomy women. First, personal motivation: women who are personally motivated and have a positive attitude towards PA are more likely to engage in regular exercise after mastectomy^{8, 22}. Motivation could stem from a desire to regain strength, maintain a healthy lifestyle, or improve overall quality of life. Second, social support: having a strong support system, including friends, family, and healthcare professionals, can greatly influence a woman's decision to engage in PA after mastectomy²². Support from others can provide encouragement, guidance, and accountability. Third, body image and self-esteem: body image concerns and self-esteem can impact a woman's willingness to engage in PA after mastectomy⁴. Positive body image and high self-esteem are associated with a higher likelihood of participating in exercise and PA⁸. Fourth, physical limitations and side effects: physical limitations and side effects resulting from the mastectomy, such as pain, fatigue, lymphedema, and range of motion issues, can affect a woman's ability and willingness to engage in PA^{8, 21}. These factors need to be considered and managed appropriately to ensure safe and effective participation in exercise. Finally, access to resources and programs: availability and accessibility of resources, such as exercise facilities, specialized programs, and knowledgeable, patient centred, healthcare professionals, can greatly influence a woman's ability to engage in PA postmastectomy^{23, 24}. Access to suitable exercise options and guidance is crucial for a successful recovery. It is important to note that each woman's experience and circumstances may vary, so it is essential to consult with healthcare professionals who can provide personalized guidance based on the needs and preferences of individuals.

This study sought to explore the level of PA most suited to women with breast cancer postmastectomy in Siriraj Hospital, which is the largest university hospital in Thailand. On the basis of the review of pertinent literature, we investigated the idea that perceived factors are more predictive of PA and exercise behaviour than perceived motivators in women with breast cancer postmastectomy. We also aimed to determine factors which are important to consider in women with breast cancer postmastectomy in Siriraj Hospital. We hypothesised that the results achieved, including the knowledge of modifiable, perceived factors influencing the PA could help physiotherapists develop strategies to promote both short-term and long-term adherence to increase PA and exercise in Thai women with breast cancer postmastectomy. The focus of this study was on a previously underexplored group, Thai women with breast cancer postmastectomy aged over 30—thereby addressing a significant gap in the literature and proposing new theoretical frameworks for understanding PA in this population.

Study design and setting of the study

This study was cross-sectional in design with an aim of exploring the level of PA of women with breast cancer postmastectomy in outpatients from Siriraj Breast Clinic, Division of Head-Neck and Breast Surgery, Siriraj Hospital, Thailand from September 2023 to March 2024. Data collection was performed at a single session during patients' follow-up period with the doctor (DS and VL).

Participants

Previous studies have suggested that for exploratory factor analysis, a minimum of 50 samples is necessary, with around 100 samples being typically recommended^{25, 26}. Therefore, we have provided a sample size of about 100 participants to the Ethical committee. However, there were only 93 participants who met the criteria. The inclusion criteria were: 1) women age ≥ 30 years with a diagnosis of breast cancer and had undergone surgery due to the statistics from the previous study that the incidence rate among Thai women was diagnosed aged between 40 to 60 years old³. However, we have decreased the age from 30 due to the medical expert of breast cancer suggestion (DS and VL), 2) all types of mastectomy e.g. total mastectomy with sentinel node biopsy, modified radical mastectomy, and total mastectomy; 3) both with and without reconstruction carried out more than 1 year prior, and 4) able to follow commands and instructions. The exclusion criteria were: 1) a cognitive impairment score ≤ 24/30 assessed using the Thai Mental State Examination²⁷, 2) any use of medication for anxiety and/or dizziness; 3) self-reported neurological, musculoskeletal, or other problem which could influence the questionnaires, and, 4) any problems involving completion of the questionnaire resulted in stopping the interviews and exclusion from the study. Medical records relating to the primary diagnosis were used to provide details regarding tumor characteristics and treatment. Baseline questionnaires included information regarding adjuvant therapies. The Ethical Committee of Mahidol University Institutional Review Board, Mahidol University, Thailand gave approval for the study and written informed consent was obtained from each participant (COA No. MU-MOU 2023/127.2808) which was carried out fully in accordance with International Guidelines for Human Research Protection and the ethical standard guidelines of the Declaration of Helsinki.

Procedure and outcome measures

All participants self-administered the questionnaires on the same occasion. The questionnaires included:

1. Physical activity (PA) levels were assessed using the original English “Global Physical Activity Questionnaire”^{28, 29} which was translated into Thai³⁰. Participants indicated how often and for how long they engaged in moderate and vigorous physical activities as part of their work, transportation, or recreational activities during a typical week. This questionnaire was selected due to its satisfactory level of convergent validity (Spearman’s rho = 0.33, p < 0.01) when compared with physical activity measurements obtained from accelerometers, and its strong seven-day test-retest reliability (Spearman’s rho = 0.77, p < 0.01) among adults in Thailand [30]. In addition, a previous study considered perceptions regarding benefits and barriers to regular exercise behaviorus, which demonstrated good test-retest reliability (0.97, p < 0.0001) and internal consistency (Cronbach's alpha = 0.88), and had been confirmed as appropriate Thai working age people³¹ for providing comprehensive insights into PA behaviour. The questionnaire consists of mixed types of questions, including both open-ended and closed-ended formats. The details of the questionnaires are:

Part 1: Collection of demographic data including gender, age, education level and occupation. The history of breast cancer was recorded from medical records.

Part 2: Assessment of PA, specifically 4 main sections: activities at work, transport, recreational activities and sedentary behaviour, 16 questions in total. The total PA and sub-domains of PA from moderate to vigorous PA and the sufficient level of PA were calculated in accordance with the World Health Organization's recommendations (WHO)²⁹, 600 metabolic equivalent (MET)-minutes/week, including the following steps:

Calculation of the energy from PA in each activity group (MET-minutes/week) = Intensity of PA (MET) x Duration used each day (minutes) x Number of days per week.

Calculation of the total energy from all PA groups (work group + travel group + recreational group).

Determination of the sufficient level of PA by dividing the total energy from all PA groups by 600 MET-minutes/week (according to the recommended sufficient level of PA by the WHO).

If the value obtained was greater than or equal to 1, the participant is considered to have a sufficient level of PA.

Part 3: Assessment of each domain of PA by the perceived benefits, specifically 12 items, perceived barriers 10 items, perceived self-efficacy 8 items, interpersonal influence 10 items and situational influence 8 items. The scores were used to calculate each domain with scoring criteria as follows³¹:

Score 3.1-4 = High, indicating a strong feeling of each domain

Score 2.1-3 = Moderately high, indicating a moderate feeling of each domain

Score 1.1-2 = Low, indicating a slight feeling of each domain

Score 0–1 = Very low, indicating a very slight feeling of each domain

2. The Body Image Index score was used, by permission³², and translated into Thai to evaluate a self-perception about physical appearance³³. The Body Image Index score shows high internal consistency (Cronbach's alpha = 0.93) and has demonstrated good clinical validity based on the prevalence of responses, discriminant validity (p < 0.0001, Mann–Whitney test), sensitivity to change (p < 0.001, Wilcoxon signed ranks test), and consistency of scores across different breast cancer treatment centres³². The Body Image Index questionnaire consists of 10 questions about satisfaction with body parts and overall appearance, often using a Likert scale. Responses can evaluate body image concerns and self-perception. These tools are commonly used in psychological and medical research to understand body image issues, in this case in women with breast cancer postmastectomy³².

3. The Thai Hospital Anxiety and Depression Scale (Thai HADS) was used to assess depression or anxiety in participants. Thai HADS included a 7-item anxiety sub-scale (HADS-A) and a 7-item depression sub-scale (HADS-D). Thai HADS has been translated into Thai³⁴. The sensitivity for the anxiety and depression subscales of Thai HADS is 100% and 85.71%, respectively, while specificity is 86.0% for anxiety and 91.3% for depression³⁴. Thai HADS also shows a good internal consistency, with Cronbach’s alpha for the anxiety subscale and 0.8259 for the depression subscale, indicating it is a dependable and valid tool for screening anxiety and depression in Thai patients, especially those who are patients with cancer³⁴.

All questionnaires in this study were used after being granted permission by the relevant authors and organisations.

Statistical Analysis

SPSS version 29.0 (IBM Corporation, Armonk, NY) was used for statistical analysis. Descriptive statistics were used to describe the characteristics of the participants. The Chi-square test using Odds-Ratio (OR) and 95% Confidence Interval (CI) was applied to investigate the association between the factors, including demographic data (e.g., age, gender, education level, occupation, income, and underlying disease), and aspects of medical records pertinent to breast cancer and mastectomy, Thai Body Image Index, Thai HADS, perceived benefits, perceived barriers, perceived self-efficacy, interpersonal influence, situational influence, and PA characteristics (activities at work, transportations, recreational activities, and total physical activities). An OR exceeding 1 indicates a higher probability of the factor being associated among the independent variables, while an OR below 1 indicates a reduced likelihood of such an association. The statistical significance was set at p < 0.05.

Demographic data and medical records of women with breast cancer postmastectomy

The average age of participants was 60.5 ± 10.5 years and time from mastectomy surgery was 6.0 ± 5.1 years. Most patients presented as breast cancer stage 1 (n = 38, 40.9%), had undergone the total mastectomy (n = 48, 51.6%), and had breast cancer on the left side (n = 54, 58%). All had received adjuvant therapies and were independently ambulant without using an assistive device (n = 93, 100%). The majority reported no lymphedema (n =79, 84.9%) and no complications after mastectomy (n = 52, 55.9%). The most common comorbidities were hypertension (n = 38; 40.9%). Most of the participants graduated at Bachelor degree level (n = 36; 37.8%) and continued working in their usual employment (n = 54, 58.1%) with a salary income of more than 30,000 Thai baht per month (about $857). Other demographic data and details of medical records of participants are shown in Table 1.

[Table 1 Here]

Reporting of engagement in physical activity (PA) of women with breast cancer postmastectomy

Seventy-two percent of participants travelled to and from activities either on foot or by using a bicycle (pedal cycle), 64% were engaged in recreational activities, and 51% performed work-based activities (Table 2). With regards subgroup domains of PA, 54.8% of participants performed moderate activity at work over 7 days for 55 minutes per day, whereas only 10.8% of participants performed vigorous activity at work in 1 day for 74 minutes per day. In the recreational domain 14% of participants performed vigorous-intensity recreational activities and 62% of participants performed moderate-intensity recreational activities. For those that travelled to and from places, the activity on foot or using a bicycle (pedal cycle), 73.1% walked for at least 10 minutes continuously. Finally, sedentary behaviour was reported as an average of 224.9 minutes a day. Total PA averaged 1680 MET-minutes/week, and an adequate PA level of 2.8 METs.

[Table 2 Here]

Reporting of Body Image Index and Thai Hospital Anxiety and Depression Scale of women with breast cancer postmastectomy

Seventy-six percent of participants were very satisfied with the Body Image Index, 15% were moderately satisfied, and 2% were slightly satisfied with the Thai Body Image Index (Table 3). With regards to Thai HAD, no one was reported to have depression or anxiety, considering the scores of our results and the previous reports [34] (Table 3).

[Table 3 Here]

Perceived benefits, perceived barriers, perceived self-efficacy, interpersonal influence, and situational influence with the physical activity (PA) of women with mastectomy

Figure 1 demonstrates the outcomes regarding the impact of perceived benefits, perceived barriers, perceived self-efficacy, interpersonal influence, and situational influence on the PA of women with mastectomy for the 93 participants. The perceived benefits were notably high, indicating a strong belief in the benefits and capabilities (mean ± SD = 3.54 ± 0.46). Perceived self-efficacy, interpersonal influence, and situational influence scored relatively high (mean ± SD = 2.82 ± 0.72, 2.33 ± 0.76 and 2.68 ± 0.8, respectively), while perceived barriers were low (mean ± SD = 1.57 ± 0.44), indicating minimal barriers for Thai women with mastectomy in this study.

Factors association with physical activity (PA) in Thai women with breast cancer after mastectomy

In this cohort of 93 women with breast cancer postmastectomy (Table 4), the factors associated with an appropriate level of PA included recreational and overall PA levels specifically: those engaging in activity at work (OR = 3.2, 95% CI = 1.357 - 7.548), an income of more than 30,000 Thai baht (OR = 4.5, 95% CI = 4.500 (1.549 - 13.070), moderate satisfaction on Body Image Index score (OR = 4, 95% CI = 1.045 - 15.317) and a higher score of Thai Hospital Anxiety and Depression Scale (OR = 2.969, 95% CI = 1.103 - 7.992). In addition, the findings indicate that individuals engaging in recreational activities recorded older age (OR = 0.245, 95% CI = 0.088 - 0.682), significantly high scores of perceived self-efficacies (OR = 3.284, 95% CI = 11.110 - 9.719), and significantly high scores of interpersonal influences (OR = 3.382, 95% CI = 1.215 - 9.416). However, no significant associations were found between the factors and travelling to and from the activity on foot or using a bicycle (pedal cycle) (Table 4).

[Table 4 Here]

Our study aimed to investigate the adequate physical activity (PA) level and the factors associated with PA among Thai women who had undergone mastectomy due to breast cancer at Siriraj Hospital, Thailand. The findings provide valuable insights into the levels of PA engagement and the influences affecting participation in PA in this population.

The demographic data shows that most participants in this study were pre-elderly to elderly with a mean age of 60.5 ± 10.5 years, 37.8% graduated at Bachelor degree level and 58.1% had high salary income for Thailand (more than 30,000 Thai baht). Data pertinent to the breast cancer and surgery shows that participants had a mean duration post-mastectomy of 6.0 ± 5.1 years, covering all stages of breast cancer (the majority being at stage 1 of breast cancer). Just over half, 51.6%, of participants had received total mastectomy, removal of the whole breast, including the nipple, areola, and the majority of the overlying skin. Previous research by Mason et al. in 2013 studied 631 women for a decade, examining their PA levels before and after a diagnosis of breast cancer³⁵. They discovered that only a minority consistently met PA guidelines over the 10-year period, with participation declining over time. The meeting of guidelines initially was linked to continued adherence at 5- and 10-years post-diagnosis. However, no demographic factors predicted long-term changes in PA levels³⁵. A notable observation from our study that is the level of engagement of PA and the adequate PA level among 93 participants were similar, despite the challenges posed by mastectomy. Seventy-two percent of participants reported engaging in walking or cycling for transportation, while 64% participated in recreational activities, and 51% were active in their work setting. Importantly, in this cohort average total PA = 1680 MET-minutes/week and PA level of 2.8 METs, indicating an adequate level of PA according to the WHO guidelines^{28, 29}. These findings suggest a willingness among Thai women with breast cancer postmastectomy to engage in various forms of PA, highlighting the importance of promoting and supporting such behaviours in this population. In contrast to our findings, a previous study using tools such as the International Physical Activity Questionnaire (IPAQ), Stanford Health Assessment Questionnaire (HAQ-20), and Medical Outcomes Study 36-item Short-Form Health Survey (SF-36), reported postmastectomy women or those who had undergone breast-saving surgery exhibited lower levels of PA and quality of life compared to those who underwent breast reconstruction³⁶. In addition, De Groef et al. in 2018 found that a 2-year follow-up study of 267 consecutive breast cancer patients in Belgium into PA levels showed that they remained significantly lower two years after breast cancer surgery compared to preoperative levels³⁷. There are several possible reasons that Thai women who have undergone mastectomy maintain their PA levels. Firstly, the perceived benefits of PA, Thai women may perceive numerous benefits associated with PA, such as improved physical fitness, mental well-being, and overall quality of life. These perceived benefits may motivate them to continue engaging in PA¹⁴. Secondly, engaging in PA and health benefits postmastectomy can instill a sense of empowerment and control over one's health. It allows women to regain a sense of agency and resilience, demonstrating their ability to overcome physical challenges and maintain an active lifestyle³⁸. It was evident that highly intelligent, high-earning women and the majority of those employed, are more likely to engage with the positive aspects of PA compared to lower-earning, potentially less well-educated women with lower expectations. Our findings also indicate that the majority of participants graduated with a Bachelor's degree and work as a government employee. Higher educational attainment with a good job may be associated with greater health awareness, which could encourage these individuals to pursue physical activity outside of work hours to balance their typically sedentary jobs³⁹. Thirdly, social support from family, friends, healthcare professionals, and support groups can play a crucial role in encouraging women to remain physically active after mastectomy. Positive social interactions and encouragement from peers can provide motivation and accountability for maintaining PA levels⁴⁰. Finally, the perceived benefits of PA among participants were notably high, indicating a strong belief in the positive outcomes associated with PA. Similarly, perceived self-efficacy, interpersonal influence, and situational influence were relatively high, suggesting that participants felt confident in their ability to engage in PA and were influenced by social and environmental factors. These findings are supported by Mishra and colleagues in 2023 who reported that the underscoring of the importance of addressing psychosocial factors in promoting PA among women with breast cancer postmastectomy⁴¹.

Our analysis of factors associated with PA revealed several noteworthy findings. Engagement in PA at work was associated with occupation, higher income, moderate satisfaction with Thai Body Image Index score, and higher levels of anxiety and depression. Additionally, participation in recreational activities was associated with older age, higher perceived self-efficacy, and greater interpersonal influence. These findings highlight the complex interplay of individual, social, and environmental factors influencing PA engagement among women postmastectomy. However, the findings are summarized and discussed in each point below.

The significant association between PA at work and occupation, and higher incomes among Thai women with breast cancer postmastectomy breast cancer is significant. No study has directly investigated these association. One possible explanation for this association is the impact of PA on productivity, job performance, and financial status in older adults⁴², which may be relevant to our sample. Before a diagnosis of breast cancer, individuals who engage in regular PA may experience improvements in energy levels, concentration, and overall well-being, which can positively influence their work performance and career advancement opportunities. Further research should explore these associations and evaluate interventions to promote PA in the workplace for this population.

An association was found between engagement in PA at work and moderate satisfaction with the Body Image Index score which highlights the potential psychological affects in Thai women with breast cancer postmastectomy. This idea is supported by the findings of Türk & Yılmaz in 2018, when they reported that this association suggests that incorporating PA into the workday may contribute positively to body image perceptions, particularly in the moderate satisfaction range⁴³. PA can enhance self-esteem, promote a sense of accomplishment, and foster body appreciation, which may contribute to improved body image. Janowski and colleagues in 2020 suggested that the workplace environment, with its opportunities for social support and positive reinforcement, may serve as a conducive setting for individuals to develop a more positive perception of their bodies [40]. However, it's important to acknowledge that individual differences and contextual factors can influence the relationship between PA at work and body image satisfaction. Further research is needed to explore these dynamics and to develop targeted interventions that promote positive body image through workplace PA initiatives.

The research indicated a link between engagement in PA at work and higher levels of anxiety and depression which raises important considerations. While PA is typically associated with improved mental health, this association suggests a more complex relationship in the workplace⁴⁴. Several factors may contribute to this finding, including individuals using PA as a coping mechanism for anxiety or depression, workplace-related stressors influencing both PA engagement and mental health, and variations in exercise intensity and preferences in Thai women with breast cancer postmastectomy⁴¹. Further research is needed to better understand these dynamics and develop strategies to support the mental well-being of employees alongside workplace PA initiatives.

The significant association between individuals aged over 60 and recreational activity is increasingly recognized for its positive impact on overall well-being in Thai women with breast cancer postmastectomy. Studies consistently reveal a notable correlation between increasing age and heightened engagement in leisure pursuits^{45, 46}. In 2023, Tripathi & Samanta found that such activities, ranging from social gatherings to outdoor excursions, serve as avenues for maintaining physical health, cognitive function, and emotional resilience among older adults⁴⁶. Moreover, recreational endeavors provide opportunities for meaningful social interactions, contributing to a sense of purpose and belonging in later life⁴⁶. Recognition of this association underscores the importance of promoting and facilitating recreational activities tailored to the needs and interests of older individuals. Ultimately, fostering an active lifestyle in this demographic may enhance the quality of life and promote healthy aging.

Higher perceived self-efficacy and greater interpersonal influence are significantly associated with recreational activities in Thai women with breast cancer post- mastectomy. Through the setting and achieving of goals in activities like sports or fitness classes, individuals build confidence in their abilities, creating a positive feedback loop of increased engagement and self-belief. These findings are supported by previous studies which demonstrated that social interactions inherent in these activities provide opportunities for social learning, where observing and learning from others enhances skills and confidence after those who have been diagnosed with breast cancer and undergone a mastectomy^{16, 21}. As early as 2006 McNeely et al. reported that social support networks in recreational settings offer encouragement and motivation, reinforcing one's belief in their abilities¹⁴. These experiences can transfer to other areas of life, improving overall well-being and resilience. Understanding these connections can inform interventions and programs aimed at promoting personal development and well-being through recreational engagement in this population.

Contrary to expectations, our study found no significant association between breast cancer stages and mastectomy, and PA levels. Despite the well-established benefits of PA for overall health, other factors beyond exercise may predominantly influence cancer progression¹⁴. The findings between mastectomy and PA suggests that the psychological and emotional impact of surgery may outweigh its physical effects on activity levels³⁰. Individuals may find motivation in PA as a coping mechanism, or they may adjust their routines to accommodate post-surgical changes. In addition, our study has shown that Thai women with breast cancer postmastectomy had a reliance on self-reported data and potential oversight of other influential variables including socioeconomic status and access to healthcare which was data collected at the biggest medical school at Siriraj Hospital.

Our research has several limitations. Firstly, the sample size is relatively small compared to the previous studies^{13, 21}. Due to practical constraints, including limited access to participants and resource restrictions, we were unable to increase the sample size. This limitation may affect the generalizability of our findings, as a larger sample would provide more robust data and potentially reveal additional trends and correlations. We acknowledge that the small sample size could introduce a degree of bias and reduce the statistical power of the study. Future research should aim to include a larger, more diverse cohort to validate our results and enhance the reliability of the conclusions drawn. Secondly, the sample may not be representative; participants were recruited from a single breast cancer clinic at Siriraj Hospital. However, this study is a good beginning with several avenues opened for exploration in the future as regards PA levels in this field. The high levels of motivation of this cohort facilitated extensive completion of the questionnaires, offering a unique opportunity to explore various aspects of Thai women with breast cancer postmastectomy and the level of PA within the group. However, a third limitation, or rather showing a potential extension for the future, our study included only women who had undergone a surgical mastectomy, limiting the exploration of an association between PA and multidimensional surgical techniques. Finally, our data did not show significant results when multiple regression was applied, therefore, we have excluded of multiple regression analysis, which could have provided a more comprehensive understanding of the interactions between various factors influencing physical activity. Future research could address this by employing multiple regression to capture the combined effects and potential interactions of multiple predictors.

This study provides valuable insights into the perceptions around an adequate level of PA among Thai women who have undergone mastectomy. Our study into the factors associated to PA revealed several notable findings, specifically that participation in PA at work was associated with occupation, higher incomes, moderate satisfaction with the Thai Body Image Index, and elevated levels of anxiety and depression. Furthermore, engagement in recreational activities was associated with older age, increased perceived self-efficacy, and greater interpersonal influence. Promotion and supporting PA engagement in this population is essential for enhancing overall health and well-being. Future research should focus on developing tailored interventions to address barriers to PA and promote a more active lifestyle among Thai women with breast cancer postmastectomy.

Competing interests

The authors declare no competing interests.

Author Contribution

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by F.K, P.W., D.S, S.P., S.P., V.L. and W.K.. The first draft of the manuscript was written by F.K and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Acknowledgement

The authors would like to thank all members from Faculty of Physical Therapy, Mahidol University and Siriraj Breast Clinic, Division of Head-Neck and Breast Surgery, Siriraj Hospital. The authors would also like to thank to all participants who participated in this study.

Data Availability

The data presented in this study are available from the corresponding author upon reasonable request.

Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA. Cancer. J. Clin. 71,209 – 49. doi: 10.3322/caac.21660 (2021)
Bray F, Colombet M, Aitken JF, Bardot A, Eser S, Galceran J, Hagenimana M, Matsuda T, Mery L, Piñeros M, Soerjomataram I, de Vries E, Wiggins C, Won YJ, Znaor A, Ferlay J, editors Cancer Incidence in Five Continents, Vol. XII (IARC CancerBase No. 19).
Ditsatham C, Sripan P, Chaiwun B, Klunklin P, Tharavichitkul E, Chakrabandhu S, et al. Breast Cancer Subtypes in Northern Thailand and Barriers to satisfactory survival outcomes. BMC. Cancer, 22, 1147. doi: 10.1186/s12885-022-10196-0 (2022)
Frierson GM, Thiel DL, Andersen BL. Body change stress for women with breast cancer: the Breast-Impact of Treatment Scale. Ann. Behav. Med. 32, 77–81. doi: 10.1207/s15324796abm3201_9 (2006)
Scott-Conner CEH. Mastectomy: Simple (Total), Modified, and Classical Radical. In: Scott-Conner CEH, Kaiser AM, Nguyen NT, Sarpel U, Sugg SL, editors. Chassin's Operative Strategy in General Surgery: An Expositive Atlas. Cham: Springer International Publishing. p. 937–46 (2011)
Ching-Wei D, Howard H, Bland K, Scott-Conner CJBst, Springer imNY. Chapter 35. Mastectomy. 409 – 22 (2011)
Lohsiriwat V, Peccatori FA, Martella S, Azim HA, Jr., Sarno MA, Galimberti V, et al. Immediate breast reconstruction with expander in pregnant breast cancer patients. Breast 22, 657–60. doi: 10.1016/j.breast.2013.06.005 (2013)
Lasry JC, Margolese RG, Poisson R, Shibata H, Fleischer D, Lafleur D, et al. Depression and body image following mastectomy and lumpectomy. J. Chronic. Dis. 40,529 – 34. doi: 10.1016/0021-9681(87)90010-5 (1987)
Lakka TA, Laaksonen DE, Lakka HM, Männikkö N, Niskanen LK, Rauramaa R, et al. Sedentary lifestyle, poor cardiorespiratory fitness, and the metabolic syndrome. Med. Sci. Sports. Exerc. 35, 1279–86. doi: 10.1249/01.MSS.0000079076.74931.9A (2003)
Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public. Health. Rep. 100,126 – 31 (1985)
Rennie KL, McCarthy N, Yazdgerdi S, Marmot M, Brunner E. Association of the metabolic syndrome with both vigorous and moderate physical activity. Int. J. Epidemiol. 32,600–6. doi: 10.1093/ije/dyg179 (2003)
Physical activity and cardiovascular health. NIH Consensus Development Panel on Physical Activity and Cardiovascular Health. JAMA. 276, 241–6 (1996)
Borch KB, Braaten T, Lund E, Weiderpass E. Physical activity before and after breast cancer diagnosis and survival - the Norwegian women and cancer cohort study. BMC Cancer. 15,967. doi: 10.1186/s12885-015-1971-9 (2015)
McNeely ML, Campbell KL, Rowe BH, Klassen TP, Mackey JR, Courneya KS. Effects of exercise on breast cancer patients and survivors: a systematic review and meta-analysis. CMAJ. 175, 34–41. doi: 10.1503/cmaj.051073 (2006)
Zhou HJ, Wang T, Xu YZ, Chen YN, Deng LJ, Wang C, et al. Effects of exercise interventions on cancer-related fatigue in breast cancer patients: an overview of systematic reviews. Support. Care. Cancer. 30, 10421–40. doi: 10.1007/s00520-022-07389-5 (2022)
Friedenreich CM, Gregory J, Kopciuk KA, Mackey JR, Courneya KS. Prospective cohort study of lifetime physical activity and breast cancer survival. Int. J. Cancer. 124, 1954–62. doi: 10.1002/ijc.24155 (2009)
Chevray PM. Timing of breast reconstruction: immediate versus delayed. Cancer. J. 14, 223–9. doi: 10.1097/PPO.0b013e3181824e37 (2008)
Mathew Joseph N, Ramaswamy P, Wang J. Cultural factors associated with physical activity among U.S. adults: An integrative review. Appl. Nurs. Res. 42, 98–110. doi: 10.1016/j.apnr.2018.06.006. doi: 10.2165/00007256-200232030-00001 (2018)
Seefeldt V, Malina RM, Clark MA. Factors affecting levels of physical activity in adults. Sports. Med. 32, 143–68. doi: 10.15280/jlm.2022.12.1.9 (2002)
Kapoor G, Chauhan P, Singh G, Malhotra N, Chahal A. Physical activity for health and fitness: past, present and future. J. Lifestyle. Med. 12, 9–14 (2022)
Marell PS, Vierkant RA, Olson JE, Herrmann J, Larson N, LeBrasseur NK, et al. Factors Associated with Physical Activity Levels in Patients With Breast Cancer. Oncologist. 27, e811-e4. doi: 10.1093/oncolo/oyac159 (2022)
Hailey V, Rojas-Garcia A, Kassianos AP. A systematic review of behaviour change techniques used in interventions to increase physical activity among breast cancer survivors. Breast. Cancer. 29, 193–208. doi: 10.1007/s12282-021-01323-z (2022)
Joaquim A, Leão I, Antunes P, Capela A, Viamonte S, Alves AJ, et al. Impact of physical exercise programs in breast cancer survivors on health-related quality of life, physical fitness, and body composition: Evidence from systematic reviews and meta-analyses. Front Oncol. 12:955505. doi: 10.3389/fonc.2022.955505 (2022)
Cormie P, Zopf EM, Zhang X, Schmitz KH. The impact of exercise on cancer mortality, recurrence, and treatment-related adverse effects. Epidemiologic reviews. 39, 71–92 (2017)
Hair JF, Black WC, Babin BJ, Anderson RE. Multivariate Data Analysis: Pearson Education Limited; (2013)
Memon MA, Ting H, Cheah JH, Thurasamy R, Chuah F, Cham TH, editors. Sample size for survey research: review and recommendations (2020)
Muangpaisan W, Assantachai P, Sitthichai K, Richardson K, Brayne CJJMAT. The distribution of Thai Mental State Examination Scores among non-demented elderly in suburban Bangkok metropolitan and associated factors. J. Med. Assoc. Thai. 98, 916–24 (2015)
Organization. WH. Global Physical Activity Questionnaire (GPAQ) Geneva: World Health Organization. [Accessed September 12, 2023]. https://www.who.int/publications/m/item/global-physical-activity-questionnaire
Organization WH. Global Physical Activity Questionnaire (GPAQ) Analysis Guide. World Health Organization. [Accessed March 28, 2024]. https://www.who.int/docs/default-source/ncds/ncd-surveillance/gpaq-analysis-guide.pdf
Visuthipanich V. Psychometric testing of GPAQ among the Thai population. Thai. Pharmaceut. Health. Sci. J. 11(4):144–52. https://ejournals.swu.ac.th/index.php /pharm/ article/view/8792 (2016)
Montien Thongnopakul, Yuwadee Leelukkanavera, Junprasert S. Factors related to physical activity of working age people in Maptaphut municipality in Rayong province. J. Public. Health. Nursing. Thai. 33,1–19 (2019)
Hopwood P, Fletcher I, Lee A, Al Ghazal S. A body image scale for use with cancer patients. Eur. J. Cancer. 37, 189–97. doi: 10.1016/s0959-8049(00)00353-1 (2001)
Cheewapoonpol B, Thanasilp S. Relationships between personal factors, fear of reactions of significant persons, stress coping strategics, social support and body image of post mastectomy patients. Bangkok: Chulalongkorn University; (2004)
Nilchaikovit T, Lotrakul M, Phisansuthideth U. Development of Thai version of hospital anxiety and depression scale in cancer patients. J. Psychiatr. Assoc. Thai. 41, 18–30 (1996)
Mason C, Alfano CM, Smith AW, Wang CY, Neuhouser ML, Duggan C, et al. Long-term physical activity trends in breast cancer survivors. Cancer epidemiology, biomarkers & prevention. Cancer. Epidemiol. Biomarkers. Prev. 22, 1153–61. doi: 10.1158/1055-9965.EPI-13-0141 (2013)
Fontes KP, Veiga DF, Naldoni AC, Sabino-Neto M, Ferreira LM. Physical activity, functional ability, and quality of life after breast cancer surgery. J. Plast. Reconstr. Aesthet. Surg. 72, 394–400. doi: 10.1016/j.bjps.2018.10.029 (2019)
De Groef A, Geraerts I, Demeyer H, Van der Gucht E, Dams L, de Kinkelder C, et al. Physical activity levels after treatment for breast cancer: Two-year follow-up. Breast. 40, 23–8. doi: 10.1016/j.breast.2018.04.009 (2018)
Del-Rosal-Jurado A, Romero-Galisteo R, Trinidad-Fernández M, González-Sánchez M, Cuesta-Vargas A, Ruiz-Muñoz M. Therapeutic physical exercise post-treatment in breast cancer: A systematic review of clinical practice guidelines. J. Clin. Med. 9, 1239. doi: 10.3390/jcm9041239 (2020)
Mäkinen TE, Sippola R, Borodulin K, Rahkonen O, Kunst A, Klumbiene J, et al. Explaining educational differences in leisure-time physical activity in Europe: the contribution of work-related factors. Scand. J. Med. Sci. Sports. 22, 439–47 (2012)
Janowski K, Tatala M, Jedynak T, Wałachowska K. Social support and psychosocial functioning in women after mastectomy. Palliat. Support. Care. 18, 314–21. doi: 10.1017/S1478951519000774 (2020)
Mishra A, Nair J, Sharan AM. Coping in post-mastectomy breast cancer survivors and need for intervention: systematic review. Breast. Cancer., 17 doi: 10.1177/11782234231209126 (2023)
Luong MN, Hall M, Bennell KL, Kasza J, Harris A, Hinman RS. The impact of financial incentives on physical activity: a systematic review and meta-analysis. Am. J. Health. Promot. 35, 236–49. doi: 10.1177/0890117120940133 (2021)
Türk KE, Yılmaz M. The effect on quality of life and body image of mastectomy among breast cancer survivors. Eur. J. Breast. Health. 14, 205–10. doi: 10.5152/ejbh.2018.3875 (2018)
Jones TL, Edbrooke L, Rawstorn JC, Hayes SC, Maddison R, Denehy L, et al. Self-efficacy, motivation, and habits: psychological correlates of exercise among women with breast cancer. Support. Care. Cancer. 31, 584. doi: 10.1007/s00520-023-08040-7 (2023)
Bone JK, Bu F, Sonke JK, Fancourt D. Leisure engagement in older age is related to objective and subjective experiences of aging. Nat. Commun. 15, 1499. doi: 10.1038/s41467-024-45877-w (2024)
Tripathi A, Samanta T. Leisure as social engagement: does it moderate the association between subjective wellbeing and depression in later life? Front. Sociol. 8, 1185794. doi: 10.3389/fsoc.2023.1185794 (2023)

Table 1. Demographic data of women with breast cancer postmastectomy.

Characteristics

n = 93

Age (years): mean ± SD (range)

60.5 ± 10.5 (38, 85)

Thai Mental State Examination: mean ± SD (range)

27.9 ± 3.82 (26, 30)

Time from mastectomy surgery (years): mean ± SD (range)

6.0 ± 5.1 (1, 31.6)

Stage of breast cancer

- 0 (n, %)

- 1 (n, %)

- 2 (n, %)

- 3 (n, %)

- 4 (n, %)

8 (8.6%)

38 (40.9%)

27 (29.0%)

19 (20.4%)

1 (1.1%)

Side of breast cancer

- Right (n, %)

- Left (n, %)

- Both (n, %)

30 (32.3%)

54 (58.0%)

9 (9.7%)

Type of mastectomy

- Total mastectomy (n, %)

- Modified radical mastectomy (n, %)

- Nipple sparing mastectomy (n, %)

48 (51.6%)

38 (40.9%)

7 (7.5%)

Adjuvant therapies

Yes

93 (100%)

Lymphedema phenomenon

- Yes

- No

14 (15.1%)

79 (84.9%)

Complication of mastectomy

- Yes

- No

41 (44.1%)

52 (55.9%)

Ambulation (n, %)

- Independent without assistive device

93 (100%)

Number of comorbidities (n, %)

- Hypertension

- Diabetes mellitus

- Dyslipidemia

- Heart disease

- Others

38 (40.9%)

17 (18.3%)

25 (26.9%)

11 (11.8%)

9 (9.7%)

Marital status (n, %)

- Single

- Married

- Divorce/Widow

25 (26.9%)

53 (57.0%)

15 (16.1%)

Education levels (n, %)

- Uneducated

- Primary school

- Secondary school

- Diploma degree

- Bachelor degree

- Master/Doctoral degree

-

18 (19.4%)

15 (16.1%)

11 (11.8%)

36 (38.7%)

13 (14.0%)

Occupation (n, %)

- Unemployed

- Employed

· Government employee

· Self-employed

· Employees of the company

· Farmers

39 (41.9%)

54 (58.1%)

26 (48.1%)

15 (27.7%)

7 (12.9%)

4 (7.4%)

Income per month (n, %)

- None

- ≤ 10,000

- >10,000 – 20,000

- >20,000 - 30,000

- >30,000

- No data

1 (1.1%)

25 (26.9%)

16 (17.2%)

8 (8.6%)

39 (41.9%)

4 (4.3%)

n – number of participants, % - percent, SD – standard deviation

Table 2. Physical activity characteristics of women with breast cancer postmastectomy.

Physical activity characteristics			n = 93
Physical activity (n, %) - Activity at work - Transportation - Recreational			51 (54.8%) 67 (72.0%) 64 (68.8%)
Sub-domain of Physical activity (n, %) - Vigorous work (n, %) - Moderate work (n, %) - Transportation (n, %) - Vigorous recreation (n, %) - Moderate recreation (n, %) - Sitting (mean ± SD (range))			12 (10.8%) 51 (54.8%) 68 (73.1%) 13 (14.0%) 62 (66.7%) 224.9 ± 171.9 (10, 840)
Total Physical Activity MET-minutes/week: median (range)			1680 (80, 13440)
The adequate physical activity level (MET)			2.8 (0.13, 22.40)

MET: metabolic equivalent of task

n – number of participants, % - percent

Table 3. Body Image Index score and Thai Hospital Anxiety and Depression Scale of women with breast cancer postmastectomy.

Score

n = 93

Body Image Index score: mean ± SD (range)

Very satisfied

Moderate satisfied

Little satisfied

14.0 ± 5.8 (10, 36)

76 (81.7%)

15 (16.1%)

2 (2.2%)

Thai Hospital Anxiety and Depression Scale

Total: mean ± SD (range)

Score 0-7

Score 8-10

Score 11-21

Anxiety: mean ± SD (range)

Depression: mean ± SD (range)

5.6 ± 4.8 (0, 19)

67 (72.1%)

11 (11.8%)

15 (16.1%)

3.4 ± 2.9 (0, 10)

2.2 ± 2.3 (0, 9)

n – number of participants, % - percent, SD – standard deviation

Table 4. Factors associated with physical activity of women with breast cancer postmastectomy.

Factors

Activity at work

Transportation

Recreational

activities

Total

Odds ratio (95% CI)

Age (years)

- <60

- ≥60

1.000

0.431 (0.183, 1.013)

1.00

2.443 (0.969, 6.158)

1.000

0.245 (0.088, 0.682)^*

1.000

0.676 (0.117, 3.887)

Status

- Single/widowed/divorced/separate

- Married

1.000

1.180 (0.517, 2.692)

1.000

0.615 (0.240, 1.574)

1.000

1.113 (0.460, 2.695)

1.000

0.645 (0.112, 3.708)

Education

- Non-Primary school

- Secondary school – Vocational

- Bachelor-higher than bachelor

1.000

0.781 (0.231, 2.646)

2.578 (0.854, 7.783)

1.000

2.171 (0.609, 7.739)

02.764 (0.878, 8.698)

1.000

1.091 (0.325, 3.667)

3.120 (0.977, 9.958)

1.000

0.958 (0.143, 6.404)

6.000 (0.509, 70.668)

Occupation

- No

- Yes

1.000

3.200 (1.357, 7.548)^*

1.000

0.403 (0.150, 1.085)

1.000

2.194 (0.899, 5.355)

1.000

2.971 (0.516, 17.110)

Incomes

- ≤10,000

- >10,000 – 30,000

- >30,000

1.000

3.750 (1.160, 12.122)

4.500 (1.549, 13.070)^*

1.000

0.476 (0.131, 1.735)

0.536 (0.163, 1.759)

1.000

1.875 (0.556, 6.324)

1.591 (0.555, 4.564)

1.000

0.200 (0.021, 1.934)

1.520 (0.091, 25.434)

Body Image Index score

- Very satisfied

- Moderate satisfied

- Little satisfied

1.000

4.000 (1.045, 15.317)^*

1.000 (0.060, 16.577)

1.000

0.381 (0.122, 1.191)

N/A

1.000

0.923 (0.284, 2.996)

N/A

1.000

0.361 (0.060, 2.178)

N/A

Thai Hospital Anxiety and Depression Scale

- No (<8)

- Yes (≥8)

1.000

2.969 (1.103, 7.992)

1.000

1.418 (0.496, 4.060)

1.000

1.742 (0.614, 4.942)

1.000

N/A

Underlying disease

- Hypertension

- Diabetes mellitus

- Dyslipidemia

- Heart disease

0.600 (0.260, 1.382)

0.376 (0.126, 1.123)

0.686 (0.274, 1.723)

0.652 (0.184, 2.309)

1.149 (0.454, 2.904)

1.324 (0.389, 4.509)

1.319 (0.459, 3.792)

1.040 (0.253, 4.265)

0.426 (0.174, 1.042)

0.582 (0.197, 1.724)

0.741 (0.281, 1.952)

1.238 (0.303, 5.051)

0.673 (0.128, 3.528)

N/A

0.338 (0.064, 1.801)

0.649 (0.069, 6.135)

Duration since surgery (years)

0.963 (0.886, 1.047)

1.025 (0.929, 1.130)

1.098 (0.969, 1.243)

1.031 (0.848, 1.253)

Stage of breast cancer

- 0

- 1

- 2

- 3

1.000

2.292 (0.477, 11.010)

2.424 (0.478, 12.302)

1.667 (0.311, 8.928)

1.000

2.455 (0.519, 11.601)

3.500 (0.668, 18.343)

3.000 (0.539, 16.689)

1.000

1.473 (0.299, 7.250)

1.425 (0.273, 7.439)

1.114 (0.203, 6.105)

N/A

Side of breast cancer

- Right

- Left

- Both

0.613 (0.148, 2.544)

2.300 (0.492, 10.743)

1.000

0.605 (0.113, 3.227)

0.980 (0.165, 5.825)

1.000

1.267 (0.280, 5.730)

0.909 (0.189, 4.366)

1.000

1.200 (0.124, 11.659)

N/A

1.000

Type of mastectomy

- Total mastectomy

- Modified radical mastectomy

- Nipple sparing mastectomy

1.000

1.451 (0.608, 3.462)

0.141 (0.016, 1.262)

1.000

1.040 (0.397, 2.723)

0.495 (0.097, 2.519)

1.000

0.714 (0.283, 1.800)

0.495 (0.097, 2.519)

1.000

3.364 (0.360, 31.422)

0.545 (0.052, 5.728)

Complications

- No

- Yes

1.000

1.872 (0.811, 4.321)

1.000

1.379 (0.547, 3.473)

1.000

0.424 (0.173, 1.037)

1.000

1.625 (0.283, 9.344)

Perceived benefits

Low (1.00 – 3.46)

High (3.47 – 4.00)

1.000

0.811 (0.352, 1.867)

1.000

1.086 (0.434, 2.722)

1.000

1.032 (0.423, 2.516)

1.000

0.708 (0.123, 4.077)

Perceived barriers

Low (1.00 – 1.45)

High (1.46 – 4.00)

1.000

0.625 (0.271, 1.444)

1.000

0.819 (0.324, 2.068)

1.000

0.635 (0.256, 1.578)

1.000

1.417 (0.270, 7.422)

Perceived self-efficacy

Low (1.00 – 3.12)

High (3.13 – 4.00)

1.000

1.818 (0.748, 4.420)

1.000

0.923 (0.355, 2.401)

1.000

3.284 (1.110, 9.719)^*

1.000

N/A

Interpersonal influence

Low (1.00 – 2.78)

High (2.79 – 4.00)

1.000

1.832 (0.779, 4.312)

1.000

2.071 (0.768, 5.587)

1.000

3.382 (1.215, 9.416)^*

1.000

N/A

Situational influence

Low (1.00 – 3.00)

High (3.01 – 4.00)

1.000

1.069 (0.457, 2.498)

1.000

1.427 (0.543, 3.753)

1.000

1.425 (0.560, 3.622)

1.000

3.056 (0.342, 27.309)

* statistical significantp<0.05

N/A – Not applicable

CI – Confident interval

No competing interests reported.

Factors associated with physical activity among Thai women with breast cancer postmastectomy at a University Hospital, Thailand

Status:

Version 1

Abstract

Figures

Introduction

Methods

Study design and setting of the study

Participants

Procedure and outcome measures

Statistical Analysis

Results

Discussion

Conclusion

Declarations

Competing interests

Author Contribution

Acknowledgement

Data Availability

References

Tables

Additional Declarations

Status:

Version 1