Social Support and Physical Activity in the Perioperative Period and Six Months After Colorectal Cancer Surgery.

Background: According to the recommendations of the ERAS protocol, physical activity is a key behavior for pre-surgical preparation of patients. The research aimed at determining the relationship between physical activity and social support, self-ecacy, cancer symptoms in preparation for colorectal cancer resection and half a year after surgery. Methods: The research was carried out among patients with colorectal cancer. The assessment was performed in a longitudinal study, a week before the surgery (T1) (N=151) and six months after the surgery (T2) (N=105). The data was collected through the following research tools: physical activity, social support (OSS-3), self-ecacy (GSES) and the experienced cancer symptoms (Brief IPQ). Results: In a week before the surgery, social support facilitated in the time of physical activity (β=.18), whereas half a year after the surgery social support had a negative impact on the time of physical activity (β=-.20). The variable of symptoms is related to the negative effect of physical activity, and this is particularly evident in the six-month period after surgery (a week before the surgery: β=-.16; six months after the surgery: β=-.34). Conclusions: It has been shown that social support, symptoms are important for shaping physical activity in the period before colorectal cancer surgery and six months after surgery. Patients with colorectal cancer living alone have had higher levels of physical activity than patients with colorectal cancer living in a partnership. In the period after colorectal cancer surgery social support may lead patients to believe that they do not need to make any physical effort because caregivers take care of their daily responsibilities.


Background
Social support connected with health is de ned as a sum of all efforts of the members of a support network centered on providing help and positive feedback in order to promote behaviors which are bene cial for health [1]. In healthcare, social support has long been regarded as a factor protecting against life stress and negative health conditions. Social support is an important factor for changing health-related behaviors among cancer patients [2]. Nevertheless, the results of previous studies have not veri ed the role of social support in shaping health-related behaviors among colorectal cancer patients at particular stages of treatment -before the surgery and half one year later. The treatment of colorectal cancer mainly requires a surgical excision of a part or the whole of the rectum along with the tumor and mesorectum which contains adipose tissue and the regional lymph basin with a margin of healthy tissues [3].
Patients awaiting surgery are expected to cut down on smoking tobacco and alcohol intake, as well as introduce regular physical activity (PA) adjusted to their abilities in order to improve their physical e ciency [4]. Studies prove that such behavior contributes to lowering the amount of postsurgical complications and increases the pace of returning to full activity following the surgery [5]. According to the recommendations of the Enhanced Recovery After Surgery (ERAS) protocol the key factor for pre-and postsurgical care is motivating patients to self-activity in order to facilitate convalescence. Introducing systematic PA in the form of 30-minute walks or cycling every day over a 4-week period prior to the surgery increases the preoperative physiological reserves of the patient and decreases the risk of acquiring postsurgical complications [6]. The studies showed a relationship between the symptoms of cancer and physical activity. For instance Beckman et al. showed that physical activity reduces the symptoms of cancer [7].
Studies on the relationship between PA and received social support among oncological patients provide unambiguous conclusions. In 2009, Stephenson et al., demonstrated that there is no relationship between PA and perceived social support among colorectal cancer patients [8] On the other hand, Lee et al. (2018) pointed out that family support is signi cant for undertaking PA [9]. The ambiguity of the previous reports and contemporary recommendations concerning the introduction of pre-surgery PA prompts carrying out further scienti c studies in this area. Seeking the predictors of health behaviors, scientists should also consider the sense of self-e cacy. This factor is regarded as the best predictor of behavioral change and its in uence on making health-related decisions has been documented in numerous studies [10]. Cognitive psychology sees the sense of self-e cacy as the strength of conviction that a person is able to ful l particular activities or achieve their intended aims.
The present study aimed to determine the relationship between PA and social support, self-e cacy, disease symptoms in the course of disease with two different time intervals: preparation for colorectal cancer resection and six months after the surgery. The main hypothesis is: social support increases PA in the preoperative period and six months after surgery. Self-e cacy and cancer symptoms are predictors of this relationship.

Methods
The participants of the study were quali ed from patients sent to the Clinical Department of Surgical Oncology at the Oncology Centre for colorectal cancer resection (laparoscopic hemicolectomy, lower anterior resection of the rectum, abdominoperineal resection of the rectum). They were treated for one the following types of cancer: colorectal (C18), rectosigmoid junction (C19), rectum (C20), anal canal (C21).
The exclusion criteria concerned patients who revealed previous cancer diagnosis, decline of cognitive functions, a risk of undernourishment based on the BMI<18.5kg/m 2 in the period before the CRC surgery.
The assessment was performed in a longitudinal study, a week before the surgery (T1) and six months after the surgery (T2). One month before the rst assessment during a visit to the anesthesiologist, patients were given a lea et designed on the basis of the recommendations of the ERAS protocol, which suggested undertaking moderate, at least 30-minute PA (a walk, Nordic walking, cycling). The assumption of a six-month interval between the measurements was based on the results of clinical observations indicating that it is the period when supplementary chemotherapy is completed and a relative improvement in the patients' physical functioning occurs. Each patient was handed an information lea et based on the ERAS protocol one month before the rst measurement. At T1, patients were asked to determine their health-related behaviors during the last month before the surgery. At T2, patients were asked about any increase in health-related behaviors in the last month before the study. The obtained results were analyzed through both descriptive statistics and analyses for statistical inferencing (Statistica 13).
The project received a positive opinion of the Independent Ethics Committee (the name of the institute, decision and number are concealed to ensure the authors' anonymity). The project was carried out as part of a grant nanced by the National Centre of Science (the no. and title hidden to make sure the authors remain unidenti ed).
The rst assessment before the surgery involved 151 participants (M age =64.89, SD age =10.14) while the second assessment was carried out six months after the surgery -105 (M age =64.39, SD age =10.51). The majority of the participants were men (about 65%). The most popular type of surgery was lower anterior resection of the rectum (44%) whereas the other surgeries included sigmoid tumor resection or Transanal Endoscopic Microsurgery. Preoperative (neoadjuvant) treatment in the form of chemotherapy, radiotherapy or chemo-radiotherapy was applied in 40% of the patients. Adjuvant therapy was applied in 45% of the patients (T2). The sociodemographic variables and percentage of people in particular sample groups before the surgery (N=151) and six months later (N=105) are shown in table 1. In the T1 and T2 similar percentage shares were obtained for the variables of gender, place of residence, marital status, education, type of cancer, therapy and surgery and extent of spread of cancer. Dropout analyses were performed for social support and PA. For example social support in T1 (M=10.21, SD=2.77) among people who have not participated in T2 was not a signi cant difference (p=.362) with all participants of T1. It allowed us to compare the results in T1 and T2. There was a statistically signi cant difference (p=.046) between PA in T1 (M=388.61, SD=308.28) and PA in T2 (M=319.43, SD=206.71). It means that patients show lower PA six month after surgery than before tumor resection.

Social support
Social support is understood as a perceived resource which an individual refers to encountering personal problems or seeking particular instrumental help (advice, money). The researchers applied The Oslo Social Support Scale-3-items (OSS-3), by Dalgard, 1996 [11] recommended by WHO [12]. OSS-3 has been used in numerous studies which con rmed its predictiveness with regards to psychical and physical functioning of healthy and ill people. The reliability of the tool obtained in our own study was satisfactory (Cronbach α=.60).
Self-e cacy The Generalized Self-E cacy Scale (GSES) [13] measures the strength of the general conviction of an individual about their effectiveness in coping with di cult situations and obstacles. It is designed for measuring healthy and ill adults. The sense of self-e cacy determines the intentions and activities in various areas of health-related behavior. The reliability of the tool obtained in our own study was satisfactory (Cronbach α=.89).

The experienced symptoms of cancer
Symptoms -a cognitive component which indicates the degree of the experienced symptoms (ranging from "lack of symptoms" to "numerous severe symptoms"). This position was operationalized on the basis of The Illness Perception Questionnaire developed by Broadbent, Petrie, Main and Weinmann (2006) (Brief IPQ) [14]. The tool is designed to appraise these representations and, additionally, factors which may cause the illness. Reliability measured by test-retest =.75 after six weeks. The questionnaire was constructed from a semantic scale which consists of bipolar descriptions e.g. "does not in uence at all"-"in uences completely."

Discussion
Recommendations in the ERAS protocol advise to undertake deliberate activities such as walking or cycling for at least 30 minutes a day before the surgery. Before the surgery it was reported that 58.28% of patients followed these recommendations, while six months after the surgery this statistic was 47.62%. A small percentage of active patients, limitations of PA after diagnosis and during the course of treatment are a common problem con rmed by other researchers [15,16].
It is generally assumed that social support has a positive impact on shaping health behaviors [9,17,18], psychical health [19,20]. Similarly, this study showed that social support facilitates the PA before the surgery. Nevertheless, six months after the surgery, an important role of social support for this type of health behavior was observed: the higher the perceived social support, the lower PA. It may be explained by the phenomenon which we may call "the role of a patient" [21]. Basically, following cancer surgery, people who receive more social support could more often be relieved of most of their daily duties by close relatives, which would result in decreasing their PA. We have shown that the signi cance of social support for PA changes depending on the period of measurement. Therefore, a systemic approach to health-related behaviors is needed that aims to improve self-managing behavior [16]. It may be claimed that social support should include a speci ed type of health-related behavior (e.g. social support for undertaking PA, social support for cutting down on alcohol intake) and the period over which the study is carried out (before the surgery, after the surgery).
In the period before the diagnosis and before the surgery, those patients who lived alone showed a lower time of PA than patients lived in partnership. This tendency corresponds to the ndings of Hawkins et al., (2010), who proved that the fact of becoming widowed, divorced or separated contributes to decreasing the time of PA. However, a reversed relationship was seen half a year after the surgery -PA of people who lived alone was higher than people in partnership. It may be explained by the fact that people who live alone are forced to undertake more PA in everyday life than people who are assisted by a partner.
This dependence con rms the discussed relationship between social support and the increase in PA [22].
The success of cancer treatment depends on external factors (e.g. the selection of an appropriate method of treatment, selection and care of medical staff) and on the patient (e.g. health behaviors, social support). Although the patient's role in self-determination and self-management in illness is crucial, there are various factors that determine the extent to which patients are aware of this. Entering the "role of a patient" involves in some way the need to modify one's own identity, internalizing in oneself those aspects of life that were previously unknown. Illness is a situation that affects not only the patient, but often requires a reformulation of the life of the entire family system. The role of social support in disease discussed in this article is complex, so it is worth looking at theories that can explain the obtained relationships.
According to Seligman's learned helplessness theory (1974), an organism that has come to terms with its inability to control the situation will react in three ways: motivational de cit, cognitive de cit and emotional de cit. The motivational de cit appears secondary to the belief that there is no control over the situation, and its effect is to refrain from attempting to change. Cognitive de cit is synonymous with the belief that nothing can be done to prevent unpleasant situations. The consequence of such thinking is developing a passive or indifferent attitude in the patient, which may lead to an attempt to take over some of the duties by the closest relatives to help relieve the patient of their daily duties [23]. As mentioned earlier, people who are facing the disease on their own would be more active. Presumably, people without social support in a crisis situation may want to seek such support. Such an inference would explain the time of PA, because leaving home, among others for a walk, a bike ride or a trip to the store, may give the patient a greater chance of meeting someone with whom they might share their concerns. People who are provided with support in their immediate surroundings would not see the need to acquire new contacts, bene tting from a safe and familiar social environment. On the other hand, a patient's family members and relatives might enter "the role of the protector" to make them feel appreciated, important and responsible for the patient's life and health . A similar situation applies to medical staff, who might feel the need to ful ll their professional duties.
We have con rmed the positive role of self-e cacy for PA in the period before the surgery. It con rms with the studies by Morey and associates (2015) [24] and Dennis and associates (2013) [25]. It has been shown that self-e cacy had not related with PA six months after surgery. The experienced cancer symptoms proved to be of key importance for changing this behavior six months after the surgery. The patients' appraisal of their symptoms as nagging did not favor undertaking PA (symptoms explain the 13% variability in PA). It is noteworthy that such medical variables as the type of surgery, using stoma, and adjuvant treatment were not signi cant predictors of PA.
The study results could contribute to the development of education programs for medical staff who work with patients as well as for patients and their families. It seems important to educate them about the necessity patients' own activity in disease. In the lights of these studies it is reasonable to monitor health behaviors not only in the hospital, but also outside the medical facility. Conclusions 1. It has been shown that social support and cancer symptoms are important for shaping PA in the period before colorectal cancer surgery and six months after surgery.
2. Patients with colorectal cancer living alone have had higher levels of PA than patients with colorectal cancer living in a partnership.
3. In the period after colorectal cancer surgery social support may lead patients to believe that they do not need to make any physical effort because caregivers take care of their daily responsibilities. This situation will not be conducive to proper time of PA, necessary for the course of postoperative recovery.
4. Six month after colorectal cancer surgery the variable concerning the patient's somatic statesymptoms -has been shown as the largest part of the variance in PA. Therefore, postoperative quality of medical care is important to eliminate pain symptoms.

Limitations And Practical Implementation
The present paper relied on the patients' self-reported assessment of PA, and therefore, subjective representations of health behaviors was obtained. In replicating the study, it would be worthwhile to apply objective methods e.g. the use of an accelerometer [26]. Study were conducted in only one institution and other variables such as mood, pain and quality of life were not controlled. In this study, social support was understood as instrumental support and interest in the patient's situation. It is advisable that in future research the support should be operationalized as an aid in shaping PA.
Despite these limitations, the results of our study may have practical implications. The most signi cantin the authors' opinion -is to inform deliberations on the in uence of social support on the time of PA among colorectal cancer patients with empirically documented input. The results may contribute to designing education programs for medical staff members who remain in direct contact with patients and may have direct in uence on their health-related behaviors, as well as for the patients themselves and their families.

Consent for publication:
All patients signed the following declaration: "I consent to the processing of my personal data regarding the implementation of the research topic, except for the publication of personal data. Only authorized persons will have access to medical data for research purposes. I give my voluntary consent to participate in this study and I am aware of the fact that I can withdraw my consent to participate in the further part of the study at any time, without giving a reason and without any consequences." Availability of data and materials: The details include age, sex, place of residence, marital status, type of cancer and type of surgery. The authors only obtained permission to publish general results. There is a probability of identifying people on the basis of detailed data because the research was conducted in one institution.