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... Title: The Role of Occupational Therapy in the Care of Children with Cortical/Cerebral Visual Impairment; a Narrative Review Daria Seccurro May, 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Beth Ann Walker, PhD, MS, OTR, QIDP Abstract Objective: This paper describes functional impairments experienced by children with Cortical/Cerebral Visual Impairment (CVI) and how occupational therapists (OTs) play an important role in the evaluation of functional vision and intervention guided by the PersonEnvironment-Occupation (PEO) model. Background: Prevalence of CVI in children is increasing; however, there is lack of consensus on diagnostic practices and few studies evaluating interventions for children with CVI. Some papers discuss the difficulties children with CVI experience in areas such as self-care, play, education, and mobility, but there is minimal evidence to support OT efforts. Methods: A narrative literature review was conducted to identify relevant research. A comprehensive search was performed across multiple databases. Studies that met the inclusion criteria were synthesized for key findings. Discussion: Findings supported that children with CVI face challenges with functional vision impacting daily living skills. These daily skills fall within the OT scope of practice. Although evidence-based interventions specific to OT are limited for CVI, existing literature reports deficits in ADLs, IADLs, play, education, and social participation, emphasizing the need for OT specific interventions for children with CVI. Conclusion: Due to OTs focus on daily activities (occupations), environmental and activity modification, and emphasis on client-specific care, they have a distinct role in caring for this population. Key Words: Cortical Visual Impairment; Cerebral Visual Impairment; children; occupational therapy; rehabilitation Introduction Cortical/Cerebral Visual Impairment (CVI) is the leading cause of visual impairment among children in developed countries (McConnell et al., 2021). CVI is a brain-based visual disorder associated with damage to the posterior portion of the brain, causing the inability to process visual information (Lueck et al., 2019). More than 40% of the brain plays a role in vision and is responsible for visual processing (Dutton et al., 2006). As a result, the brain is unable to process the information coming in from the eyes causing impairments in visual functioning. The impairments associated with CVI vary and span a broad range of severities (Orbitus et al., 2011). The location and extent of the brain insult often plays a factor in the level of impairment (McConnell et al., 2021; Sakki et al., 2022). Vision is a vital sense used in daily activities to interpret the environment. Although most children impacted by CVI often have some level of visual functioning, visual dysfunction plays a significant role in a child's development, learning, mobility, and overall quality of life (Merabet et al., 2017). In addition, CVI profoundly impacts one's ability to complete daily activities which constitute a large portion of life. The daily activities and skills that makeup life are known by occupational therapists as occupations (American Occupational Therapy Association [AOTA], 2020). Within the occupational therapy profession, active engagement in occupations is what supports, facilitates, and promotes participation in life (AOTA, 2020). Occupational therapists have distinct knowledge, skills, and qualities that enhance the occupational process (AOTA, 2020). Contributors in this profession exhibit qualities to complement cornerstones of practice which include but are not limited to client-centered practice, occupation-based practice, evidence-informed practice, theory-based practice, and leadership and professionalism (AOTA, 2020). Occupations are core components to a clients health, identity and sense of competence that are meaningful and viable to that client (AOTA, 2020). Occupations are meaningful everyday activities and include things people need to, want to, and are expected to do (AOTA, 2020). However, a persons context, made up of both personal and environmental factors, largely influences engagement in occupations. Occupational therapists accept the idea that people who achieve full participation must function and engage comfortably in their own contexts (AOTA, 2020). As a person enters different stages of life, their occupations may shift depending on their roles and responsibilities. Occupations commence in infancy and develop throughout life. Although a childs occupations may look vastly different from those later in life, occupations are present across the entire lifespan. A child's daily activities and occupations involve learning, playing, exploring, eating, crawling, among many others. Unfortunately, CVI impacts a child's ability to perform these occupations. However, adapting the activity and/or environment can make it easier for children with CVI to visually process, and increase participation in the activity. The unique needs of children with CVI are often affected by their environment, impacting their ability to function; however even small changes in ones environment positively impact a child (Tsirka et al., 2020) The principle of recognizing the environment's impact on participation in occupation provides a holistic perspective and distinguishes occupational therapists from other professionals trained to care for children with CVI. According to the Person-Environment-Occupation (PEO) Model, occupational performance is the outcome of the interaction between a person, their environment, and an occupation or task (Law et al., 1996). Assumptions from this model presume that the three components continuously overlap to enhance or impede ones ability to achieve occupational performance throughout life. In this model, the person is defined as a unique individual made up of various qualities, experiences, and skills that influence the capacity to engage in occupations and interact with the environment (Law et al., 1996). The person is viewed as an ever-developing individual made up of characteristics that can, in some cases, be responsive to change with intervention (Law et al., 1996). The environment is the context in which occupational performance occurs and can positively or negatively impact a person or an occupation (Law et al., 1996). An environment can affect occupational performance but is said to be more easily modified than the person. Last, occupations include the tasks and activities a person engages in across various environments to meet their needs (Law et al., 1996). In regard to the PEO model, the term occupation is described as a complex task or activity that a person engages in throughout the entire lifespan. These three components continuously overlap and adjust as the person, environment, and occupations change. In order to achieve optimal occupational performance in life, one must balance all three components to maximize the personenvironment-occupation fit (Law et al., 1996). The relevance of the PEO model and occupational therapy poses an avenue to help connect the dots to improve the lives of children with CVI and their families. Occupational therapists use the PEO model as a foundation in practice to encourage individualized, patientcentered care (Law et al., 1996). The needs of this population vary depending on the person, the environments they interact, and the occupations meaningful to them. The number of children diagnosed with CVI is increasing due to advances in medical care. Therefore, there is a need to better understand and gain consensus on the methods of diagnosis and increase evidence supporting interventions for this unique population. However, there is a lack of knowledge across the medical field about CVI and even less evidence on the role of occupational therapy practitioners in treating children with CVI. In order to understand the unique role of occupational therapy in children with CVI, one must first understand the needs of this population and the abilities of OT practitioners to meet those needs. This narrative review focuses on the challenges children with CVI face impacting their occupational performance and explores the specific role of occupational therapy in this unique population. Specifically, this narrative review aims to identify the needs of children with CVI that fall under the OT scope of practice which have been documented in previous literature, and explore how these deficits impact the person, environment, and occupation/task indicating an important role for OT in children with CVI. Background Visual processing is different in children with CVI compared to a child with typical vision. Due to the unique characteristics of CVI, this condition can be hard to diagnose and commonly unintentionally missed (Dutton et al., 2017; Williams et al., 2021). Traditionally, the diagnosis of CVI is given by ophthalmologists due to the impact on visual impairment, but neurological components may require involvement of neurologists (Pehere & Jacobs, 2019; Jackel, 2019). A comprehensive evaluation used to diagnose CVI consists of structured history taking to determine factors of predisposal, parent/caregiver reported observations and insights through interview, a functional vision assessment, eye examination, neurological assessment, and may include neuroimaging (Chang & Borchert, 2020; Itzhak et al., 2021). Children with CVI often present with abnormalities in visual processing that are not explained by the eye exam. Children affected by CVI commonly have a variety of comorbid medical conditions that take precedence early on. As a result, children with CVI demonstrate behaviors and characteristics attributed to their co-occurring medical conditions and are not further evaluated or assessed as disruptions in vision (McConnell et al., 2021; Tsirka et al., 2020). The uncertainties and lack of formal diagnostic protocol can sometimes cause a significant gap in receiving a diagnosis and ongoing care for children with CVI (Sakki et al., 2021). The most crucial time for intervention early in life to optimize brain plasticity (Chang & Borchert, 2020; Chokron & Dutton, 2016; McConnell et al., 2021). Therefore, children with CVI should be offered early intervention for the best outcome in visual processing (Roman-Lantzy, 2007). Martn et al. (2016) expressed that now, more than ever, there is a great need for improved accuracy in diagnosing, assessing, and developing compelling education and rehabilitation programs for individuals with CVI. CVI is a dynamic diagnosis that impacts all areas of life making interdisciplinary care important to maximize support for this population (Jayaraman et al., 2021; Pehere & Jacob, 2019). Beyond receiving a diagnosis, interventions and treatments for CVI have been explored in pharmacology and neurology-based approaches but researchers feel evidence-based assessment and intervention strategies are still lacking (Tsirka et al., 2020). Children with CVIs care is managed by various professionals including ophthalmologists, optometrists, pediatricians, occupational therapists, and nurses (Philip & Dutton, 2014). Other medical and educational professionals who commonly provide support for children with CVI include speech-language pathologists, physical therapists, teachers of students with visual impairments (TVIs), assistive technology specialists and orientation and mobility specialists (Blackstone et al., 2020; Jayaraman et al., 2021; Kran et al., 2019). Initial literature searches revealed two studies that involve occupational therapists' caring for children with CVI. Therefore, the present review comprises literature that is not occupational therapy specific but will reflect on impairments and areas of occupation in which OT intervention could be impactful. Additionally, this review will compile previous researchers' findings on the challenges this population faces and explain how occupational therapy practitioners have the unique skill set to address the needs of this population through the lens of the PEO model. Since children with CVI experience complex challenges in many areas of life, greater attention must be brought to the complexity and extent CVI plays on childrens development. As a result, a comprehensive analysis of the functional challenges that commonly occur in children with CVI is needed to identify the methods which lead to acquisition and/or preservation of everyday skills. Finally, this narrative is intended to raise awareness and better inform healthcare professionals across all settings about the unmet needs of children with CVI and their families to inform quality care better. Method A narrative review methodology was used to conduct and report the research findings regarding the role of occupational therapy in children with cortical/cerebral visual impairment. A narrative review is a comprehensive synthesis of literature that has been previously published and aims to present the broad perspectives of a topic and serve as thought-provoking pieces of literature (Green, 2006). According to Ferrari (2015), narrative reviews do not present new data but intend to assess what is already published; therefore, this style is appropriate for the specific aims of this paper. There is relevant literature regarding children with CVI, but few OT-specific publications. However, discuss issues that could be improved by including OT intervention for children with CVI. Narrative reviews have been popular among authors and readers, making up the largest share of all medical text types and impacting doctors in their clinical practice and research, deeming them a staple of medical literature (Baethge et al., 2019). A structured and in-depth literature search focused on the role of occupational therapy in CVI. Due to the limited literature on this topic, no databases were excluded when searching for relevant literature. Similarly, since the current body of evidence on OT for children with CVI is limited and the objectives of this paper are broad, the inclusion and exclusion criteria for this review were flexible. The authors primary search terms included Cortical visual impairment OR cerebral visual impairment, OR brain based visual impairment, OR CVI, AND children, functional vision impairment, functional vision in children, pediatric, childhood. Articles were excluded if the target population included adults because the challenges, presentation, and prognosis for CVI in children are vastly different. Since research relevant to daily life skills and/or functional challenges is sparse in this population, foundational articles from the late 1980s and 1990s were included. Articles that reported on children with low vision or other visual impairments and CVI were included if an accurate definition of CVI was given. Similarly, articles that discussed exclusively children with low vision, ocular visual impairments, or visual acuity were excluded. Line-by-line examination was utilized during full-text review to identify articles with information that could be related to the role of OT in this population or the CVIspecific characteristics and/or challenges related to the OT scope of practice. Person Visual Characteristics in Children with CVI One of the most significant components in children with CVI are their functional vision deficits, noted in literature as early as 1987. Children with CVI have unique visual traits and behaviors that help them function and/or compensate for decreased visual abilities. One of the most considerable challenges associated with children with CVI is the variable visual abilities that can change from one day to the next (Jan et al., 1987). This concept was reported in 1987 by Jan et al. and has since been verified by many of CVIs top researchers (Chang & Borchert, 2020). However, in recent years, researchers have gained an understanding as to why performance of children with CVI appears to vary frequently and have associated reasoning for this phenomenon. In short, it is now understood that the childs ability to use vision depends greatly on their physical environment, biobehavioral state, performance demands of the task, motivation, and their familiarity with the objects and people in which they are interacting (Lueck et al., 2019). The article by Jan et al. (1987) is one of the earliest works of literature that describes the behavioral characteristics seen in children with CVI. Notable findings documented in this article include improved vision in a familiar environment, impaired visual attention and visual curiosity, and signs of fatigue with visual learning (Jan et al., 1987). More than half of children in this study were reported to use touch to supplement vision during exploration and bring items close to eyes to use vision. Other behaviors noted by the researchers include inaccurate depth perception, need for movement of objects, looking away when reaching, light gazing, and restricted visual fields (Jan et al., 1987). Orbitus et al. (2011) echoes similar findings also indicating the child may fatigue easily when using vision, struggles to maintain focus during tasks, and rely on other perceptions to implement for vision. Various studies have been published over the last 30 years reporting similar behaviors and characteristics in children with CVI. In a study by van Genderen et al. (2012) researchers found that more than 40% of the children with CVI in their sample had challenges using vision in complex visual scenes, 53% had impaired visual fields, and 30% had nystagmus. A Delphi study by Pilling (2022) obtained expert input on various skills and behaviors common in children with CVI. Among this list are behaviors such as the child positioning their head in distinct ways to use vision, looking out of the corner of the eye, avoiding visual input by looking away, and commonly bumping into things when walking (Pilling, 2022). Children with CVI often experience high level visual processing issues such as difficulty with visual discrimination, orientation and need for additional visual processing time (Philip & Dutton, 2014). Similarly, children with CVI often display challenges with delayed visual latency, difficulty with facial recognition, navigation challenges, and inability to process moving objects (Good et al., 2001). Philip and Dutton (2014) summarize the varying abilities of children with CVI fall into three categories including children with profound visual impairments, children with impaired functional vision combined with cognitive and sometimes motor challenges, and children who have impaired functional vision but are capable of working at or close to the expected level for their age (Philip & Dutton, 2014). The CVI Range (Roman-Lantzy, 2007) is an assessment tool as well as a method to understand the varying characteristics and abilities of children with CVI by describing functional vision through scores organized into levels. Children with a score 1-2 have minimal visual response, score 3-4 exhibit more consistent visual response, score 5-6 use vision for functional tasks, score 7-8 demonstrate visual curiosity, and score 9-10 spontaneously use their vision functionally during most activities (Roman-Lantzy, 2007). Co-occurring medical conditions and other visual impairments Along with the brain based visual challenges children with CVI face, researchers have revealed most children with CVI have additional diagnoses and/or comorbidities that challenge development. The most common cause of CVI is an injury to the brain due to a lack of oxygen during the birthing process or shortly after birth (Parajuli et al., 2020). Other associated medical conditions include Periventricular Leukomalacia (PVL), Hypoxic Ischemic Encephalopathy, Cerebral Vascular Accident (CVA), Traumatic Brain Injury (TBI), structural malformations, infection, and metabolic disorders (Chang & Borchert, 2020). CVI is also associated with children born premature, and those who have other neurodevelopmental disorders such as cerebral palsy and seizures disorders (Chang & Borchert, 2020). There have also been findings of children with autism spectrum disorder (ASD) (Chokron et al., 2020), hearing impairments (Matsuba & Jan, 2006) and developmental coordination disorder with CVI (Chokron & Dutton, 2016). Vision plays a significant role in learning motor skills. For children with CVI that have co-occurring motor diagnoses like cerebral palsy, physical performance may be impaired. Children with CVI may have difficulties with motor activities such as walking (Jayaraman et al., 2021) and reaching due to the demands of functional vision use (Baker-Nobles & Rutherford, 1995). Lack of motivation to interact with people and objects may be a direct result of visual dysfunction (Fazzi et al., 2015). Many children with CVI are often delayed with fine motor skills such as reaching, grasping, and pointing because of the inability to process stimuli in the environment, limiting their ability to interact with objects though these skills (Fazzi et al., 2015; Chokron & Dutton, 2016). Similarly, researchers have reported how vision plays a large role in learning postural control and stability important for motor tasks in development (Chokron et al., 2021; Guzzetta et al., 2001). Children with CVI also have co-occurring diagnoses impacting cognition. Chokron and Dutton (2016) explain the impact vision has on all areas of development and how failure to address the visual needs of CVI leads to decreased learning and presents as an intellectual deficit. Matsuba and Jan (2006) reported in their study of 423 children, 86.7% also had cognitive impairments classified as moderate to severe. The researchers report that of the remaining children with high cognition had underlying learning difficulties (Matsuba & Jan, 2006). Finally, co-occurring visual impairments may be present in addition to CVI. Pehere et al. (2018) describe the most common disorders of eye movement control in children with CVI include: strabismus, nystagmus, unstable fixation, inaccurate fast eye movements (dysmetric saccades), deficient smooth pursuit movements, and paroxysmal deviations, in which the eyes intermittently deviate upward. The researchers in this study believe that due to the difficulty in examining childrens vision, many visual issues are often missed (Pehere et al., 2018). Sensory, Behavioral, Psychological Challenges When thinking about CVIs impact on a childs sensory system, vision is the most apparent sense associated. Since vision is impacted for these children, their other senses such as touch and sound are often heightened, and the children use them to compensate for their visual deficits and weak vision (Pehere & Jacob, 2019). Therefore, when the other senses are more easily stimulated children can experience sensory processing difficulties requiring minimizing sensory input in order to focus on use of vision (McKillop & Dutton, 2008). For example, some children with CVI may be sensitive to auditory stimuli, and face additional struggles in environments with a lot of auditory stimulation (Morse, 1999). Similarly, many children early on implement the use of other senses or multiple senses to compensate for a lack of vision to explore their environment (Pehere & Jacob, 2019). Adverse behaviors are another area that can be challenging for children with CVI. This is often attributed to external causes such as complex sensory environments, difficulties with communication, and mental health challenges such as frustration, anxiety, and issues with selfesteem (Goodenough et al., 2021; Lueck et al., 2019). Chokron et al. (2021) indicates how humans naturally adapt to the environment they are in, however if a person cannot see their environment, then they are unable to respond to it. Further, they describe how individuals react emotionally when faced with frightening or stressful events, requiring one to adapt behavior appropriately to overcome the circumstance (Chokron et al., 2021). Researchers connecting this scenario back to children with CVI explain that they are similar in the way they react; however it may be viewed as a behavior disorder or concern (Chokron et al., 2021). The difference between other children that display similar behaviors and children with CVI is that their impacted vision is causing these emotions and behaviors. For example, many children with CVI might be easily frustrated due to the constant visual challenges encountered and have been reported to become fearful when certain visual landmarks are removed that they use to help them identify the environment (Lueck & Dutton, 2015). This may lead to misinterpretation of their environment leading to confusion, fear, and being overwhelmed. There is also evidence that due to decreased ability to identify objects/people in public, children with CVI may also have heightened anxiety or fear of getting lost or injured (Lueck et al., 2019). Parents from Goodenough et al. (2021) indicated how anxiety regarding accessibility at school and in the community affected their child. As children with CVI age, many often struggle with self-concept and self-image challenges due to their experiences socially comparing themselves to other children and/or the expectations (Goodenough et al., 2021). Environment A child with CVIs ability to visually process is dependent on the set up and familiarity of their environment. In particular, children with CVI have more difficulty processing in environments that are new, complex, and stimulating. Physical Ones environment plays an important role in how they interact. Children with CVI are no different, except that environmental challenges and barriers are often more influential to their functioning and much harder to overcome. Physical environments most often associated with children are their homes, school, playground, or stores. However, even these frequently visited places can propose environmental barriers based on external factors. For example, crowding and complexity in the environment can have a negative impact on children with CVI (Philip & Dutton, 2014; Roman-Lantzy, 2007). Environmental complexity proposes too many visual stimuli to process at once for the child and complicates use of functional vision. This frequently leads to visual shutdown in children with CVI or other adverse behaviors. For example, a busy playroom with toys all over the floor is very hard for children with CVI to function (Pehere & Jacob, 2019; Philip & Dutton, 2014). Challenges in an environment like this are hard for children with CVI to focus and are overwhelming to visually process. They often experience additional challenges in unfamiliar environments especially during navigation and often prefer familiar toys and faces (Good et al., 2001; Roman-Lantzy, 2007). Other environmental barriers that can create challenges for children with CVI to use their vision are the level of lighting (too low or bright), low contrasting of colors, and noisy environments (Roman-Lantzy, 2007). Children with CVI often need objects and stimuli brought close to them and struggle to function with stimuli at a distance (Baker-Nobles & Rutherford, 1995; Swift et al., 2008). This especially creates challenges in environments like school and stores. Social, Cultural, and Institutional Researchers from an article by Goodenough et al. (2021) facilitated interviews of parents of children with CVI. In this study parents expressed that many medical professionals do not recognize CVI as an actual condition, nor do they understand challenges associated with CVI (Goodenough et al., 2021). This same sentiment was echoed by Pehere et al. (2018) indicating that awareness about CVI needs to increase in the ophthalmic community and also in general society. The same concept was echoed later in the study when a parent explained that within the childs institutional environment at school, there was lack of training and support from staff and professionals causing more challenges for the child (Goodenough et al., 2021). Further, parents from this study go on to reflect the large amount of time they spent communicating and educating others about their childs needs, as well as taking time off work to create and supply learning materials and resources for their child to use in school (Goodenough et al., 2021). In a follow up study, it was reported that children with CVI can also be greatly affected by their social and cultural environment. Socially, the lack of awareness and understanding of CVI can create barriers for this population, as well as unmet expectations from parents and/or teachers (Lueck & Dutton, 2015). Occupations Our daily activities and tasks change throughout life and continue to develop and change. Children with CVI face barriers in various aspects of life affecting their ability to participate in tasks, activities, and occupations. Occupational therapy practice categorizes occupations as activities of daily living (ADLs), instrumental activities of daily living (IADLs), health management, rest and sleep, education, work, play, leisure, and social participation (AOTA, 2020). ADLs The challenges associated with CVI impact daily activities that prevent children from interaction and participation in various tasks. Commonly, children with CVI face more challenges with everyday activities such as dressing, grooming, toileting, bathing, and eating. Challenges associated with dressing include orientating garments correctly while putting them on, locating and/or fastening buttons, finding clothing in a pile or closet, locating and putting on shoes and socks, and localizing the position of lower body dressing to put legs in the correct holes (Philip & Dutton, 2014; Salavati et al., 2015). Other tasks associated with dressing such as tying shoes have also been reported as challenging in this population (Orbitus et al., 2011). Other self-care activities that may be problematic include brushing teeth, due to struggles during application of toothpaste, orienting toothbrush correctly, and locating toothbrush on similar colored surfaces (Salavati et al., 2015). Additionally, challenges with brushing hair might also occur if they cannot locate all areas needing brushing or struggle to position brush correctly in relation to their body (Salavati et al., 2015). Toileting is another skill that occurs daily and can be troublesome for children with CVI. Most commonly, navigation to the bathroom, correct orientation of body in relation to toilet (sitting and/or standing), and challenges with adequately performing toileting tasks (Salavati et al., 2015). Functional skills related to bathing may cause obstacles for children with CVI. For example, navigating placement of bath time materials (soap, washcloth, towel, etc.), not being able to determine the height of the bathtub/shower, need for additional lighting, and failing to rinse soap adequately can all cause disturbances during bathing (Philip & Dutton, 2014; Salavati et al., 2015). Children with CVI may also experience adverse challenges associated with feeding and eating due to the inability to see food on plate, using utensils and vision together to obtain food, or seeing a spoon or bottle as it approaches when being fed (Lam et al., 2010; Philip & Dutton, 2014). Other challenges are drinking from a cup with a straw, and frequently spilling food and drinks (Philip & Dutton, 2014; Salavati et al., 2015). Good et al. (2001) reports that another element of feeding that may be impacted in this population is chewing. Due to chewing being partially learned through vision during early development, this can cause challenges with feeding that may lead to other medical issues such as aspiration (Good et al., 2001). Proper positioning during mealtime is also important and may be challenging for children with CVI due to having to focus intensively on vision use, especially when paired with co-occurring motor challenges (Lam et al., 2010). IADLs When performing IADLs, safety is one of the largest areas of concern in children with CVI. Children with CVI may experience problems that could hinder safety such as not seeing traffic because of impaired movement perception, experience difficulty identify the family car in a parking lot, and getting easily lost in crowds or malls due to too much visual input (Philip & Dutton, 2014; Salavati et al., 2015). Similarly, grocery shopping can cause distress from the overwhelming visual and auditory environment combined, inaccurately navigating locations due to inability to interpret signs (Lam et al., 2010; Pehere & Jacobs, 2019; Philip & Dutton, 2014). Education Research also indicates children with CVI struggle with education activities. Some studies that are specific to children with CVI in the school system have shown children experience issues with school related tasks such as reading depending on complexity of books, writing, viewing materials on a board, loud sensory environment of a room, among others (Philip & Dutton, 2014; Swift et al., 2008). Chokron et al. (2021) reviews the common obstacles children with CVI face and the impact they have on issues with reading. Issues in the classroom may also include slower processing time, struggling to see worksheets, trouble staying in the lines, and difficulty copying items from the board (Philip & Dutton, 2014; Swift et al., 2008). Literature indicates most children with diagnosed CVI have an IEP (Jayaraman et al., 2021) and often receive services from a TVI within the school system. Jackel (2019) conducted a survey on parents of children with CVI and found that parents felt their TVI was competent in treating CVI but other school professionals and staff were not. The same study reports that most parents indicated receiving appropriate accommodations for their child within the school system to be very challenging (Jackel, 2019). Researchers from Goodenough et al. (2021) reiterates similar experiences in their study and reports the importance of the parent in the childs success at school. Also not indicated in literature but an issue to think about is the challenges kids have at school with eating, toileting, navigation, and play which also take place at school every day. Some children with CVI need technological accommodations and work better on tablet/ipad/computer (Baker-Nobles & Rutherford, 1995; Swift et al., 2008). It is important to consider that if accommodations are not made at school and in classrooms, children have a decreased chance to learn and gain knowledge (Goodenough et al., 2021; Jackel, 2019). Social Participation Although occupational struggles are not well studied in children with CVI, an occupation that is often mentioned in professional level works is the challenge this population faces with social participation. Pehere and Jacob (2019) explain how most people identify and recognize people through use of vision, as well as gain information about their emotions from body language and facial expression paired with tone of voice. Children with CVI often have difficulty making eye contact and often miss social cues or fast facial expressions impacting social functioning (Morse, 1999; Philip & Dutton, 2014). They may also struggle to look at someone or something while listening at the same time, leading to either looking away or inability to divide attention (Philip & Dutton, 2014). Literature also shows children with CVI often frequently position themselves in unique ways to use their vision best and may not see a hand presented for a handshake if placed in a non-preferred visual field, further leading to embarrassment and/or appearing rude (Philip & Dutton, 2014). Children with CVI struggle to recognize faces, which is one of the largest documented factors associated with their social struggles; therefore, sometimes even recognizing family members or friends can be challenging (Fazzi et al., 2009; Orbitus et al., 2011; Philip & Dutton, 2014). Socially, parents have reported children with CVI have anxiety surrounding unfamiliar social environments due to fear of getting lost or not being able to find their friends (Philip & Dutton, 2014). Functional Mobility Another large area that impacts children with CVI is functional mobility and navigation. Children with CVI often struggle with navigation for many reasons. Most commonly, lower field deficits make navigating different surfaces more challenging and lead to safety concerns. Children with CVI have also been documented to have challenges with mobility on stairs and uneven surfaces (Lam et al., 2010; Orbitus et al., 2011). Additionally, when in an unfamiliar environment, navigation is more challenging, as well as distance vision impacting ability to see signs or familiar landmarks (Lueck & Dutton, 2015). Functional mobility is often impacted in children with CVI with reports of them commonly falling over clearly visual objects and commonly running into things during mobility (Pilling, 2022). Another challenge is transferring most commonly in the bathroom. Children with CVI often run into things and struggle with depth perception making navigation increasingly challenging (Philip & Dutton, 2014). Another aspect of CVI is the inability to realize movement of an object. This is most likely relevant for safety during navigation especially when crossing the street or walking in public due to the inability to recognize moving structures such as a car (Philip & Dutton, 2014) Play The most important occupation for a child is play. Play is not only how children enjoy life and spend their leisure time but is also a huge element connected to cognitive development early on in life. For some children with CVI, play can be difficult. They have issues with structured play like games due to complications following directions (Salavati et al., 2015). Kids may also have challenges with sports due to the environmental factors (Lam et al., 2010). Similarly, children with CVI often struggle to discriminate between 2-D imagery and prefer 3-D items. This is a barrier in tasks such as puzzles, games, and matching activities, due to it being hard for them to process (Orbitus et al., 2011). Other activities that children often enjoy such as riding a bike or kicking a ball can also be hard due to decreased coordination and balance, and difficulty with safe navigation. Philip and Dutton (2014) list similar activities as challenging such as jumping into a swimming pool due to not being able to judge the height of the water and going down a slide from inability to see the slide when seated. Some children with CVI also have delayed/impacted reflexes which may impact tasks like throwing and catching a ball (Philip & Dutton, 2014). Numerous studies have also mentioned challenges of children when finding a toy in a complex environment such as toy box (Bennett et al., 2019; Philip & Dutton, 2014). Occupational Therapys Role A key role in OT intervention planning includes conducting a detailed occupational profile to help understand specifics to improve both visual and functional outcomes (Harpster, in press). Additionally, in order to better understand ways that occupational therapists can adapt environments to better meet the needs of the child and the occupation, they must be informed on appropriate modifications. Use of the CVI Range can be helpful when implementing interventions due to breakdown of phases in the tool (Roman-Lantzy, 2007). The basis for this functional vision assessment examines the 10 key characteristics of CVI including color preference, need for movement, visual latency, visual field preferences, challenges with complexity, need for light, difficulties with distance viewing, atypical visual reflexes, limited visual novelty, and absence of visual motor skills (Roman Lantzy, 2007). Based on assessment of these components, children are placed into a phase to better understand their current level. The three phases are grouped by scores from 0 (no functional vision use) to 10 (typical functional vision for age and no CVI) into five levels, further classified into three phases to target intervention methods (Roman-Lantzy, 2007). Phase I intervention aims to build consistent visual behavior, phase II targets integrating vision with function, and phase III works on refining CVI characteristics (Roman-Lantzy, 2007). Researchers from Salavati et al. (2015) emphasize that due to the high number of children with CP and CVI together, both occupational and physical therapists need assessment tools available that are adapted for children with CVI in order to gain accurate performance results to inform treatment. Similarly, an intervention study focused on telemedicine for children with CVI involved the Canadian Occupational Performance Measure (COPM) as a primary outcome measure (Schwartz et al., 2021). The results of this study indicate occupational therapy interventions via telemedicine can lead to functional improvements and an increase in satisfaction of goal performance through use of the COPM (Schwartz et al., 2021). As previously discussed, OT are skilled in adapting environments to better suit functioning through task and environment modification. Morse (1999) emphasizes how intervention should analyze the environment the child is in, the activities they participate in, the sensory-motor demands, and time pressure and other variables. Similarly, since OT are skilled to treat children with co-occurring diagnosis of CVI (Chang & Borchert, 2020), therefore, they need to know how to incorporate functional vision use during treatments in order to facilitate visual progress while working on other challenges. Another large element that could be beneficial in treatment of children with CVI is parent education. Parents are very important in teaching their challenge and need the knowledge to modify environments and materials correctly to better support the childs functional vision use and improve daily living (Pehere & Jacob, 2019). The engagement of caregivers/parents is essential, and OT can advocate and teach them how to better understand their child and help meet their needs. Discussion Many of these children experience impacts from CVI in all aspects of daily living, creating functional and developmental challenges. Because occupational therapy provides services exclusively for the persons tasks and occupations, the role of occupational therapist in caring for children with CVI is crucial. CVI affects children in a variety of ways and is a diagnosis that varies from person to person requiring client specific care to individualize treatment to best fit their skills and abilities. A key element important in relation to intervention is that visual functioning in CVI has been proven to improve if the child receives specialized care (Roman-Lantzy, 2010). This reiterates that children with CVI can make improvements overtime. Occupational therapy intervention may focus on specific occupations, context, and environments, and/or performance patterns and skills (AOTA, 2020). Common interventions in OT scope include therapeutic use of occupations and activities, interventions to support occupations, education, training, and advocacy (AOTA, 2020). However, OTs expect that due to the dynamic involvement of a person, environment, and the occupation the ability to adapt, change or develop in certain areas will impact other areas (AOTA, 2020). Because occupational therapy practitioners are taught to analyze the physical and environmental demands of an occupation, they can provide a unique insight into appropriate adaptations and modifications needed in children with CVI during engagement in occupations. Through the use of activity analysis, occupational therapy practitioners can assess the physical and contextual demands of an occupation, specific to the client and their abilities (AOTA, 2020). For children with CVI, their ability to engage in an occupation is variable depending on the context and environment they are in. Therefore, intervention for children with CVI cannot solely disassociate the person from the environment or occupation. Instead, intervention for this population must be inclusive of all three components and provide constant reassessment to determine optimal balance to gain occupational performance. However, modification and intervention can be implemented at the person, environment, and occupational level. The next three sections include general recommendations for OT to use at the person, environment, and occupation level, but do not fully capture all recommendations. For the person, some methods might include allowing extra time for visual processing, adequately address cooccurring challenges such as taking sensory breaks to help maintain focus, being aware of the impact of visual fatigue associated with CVI so planning harder activities earlier in sessions, practicing social participation situation with a child to help increase confidence, implementing emotional regulation strategies for the child to use when overwhelmed or frustrated, and provide the child with skills to advocate for themself and their needs, among many others (Baker-Nobles & Rutherford, 1995; Philip & Dutton, 2014; Swift et al., 2008). Environmental modifications can include but are not limited to adapting the light to be more or less stimulating with a light box, decreasing visual clutter by presenting items one at a time, use of contrasting colored backgrounds such as presenting toys in front of black sheet, adding shiny materials that can be eye catching such as holographic tape on the stairs, placing stimuli at close viewing distances, elevating material with slant board, and avoiding patterned tables or flooring (Baker-Nobles & Rutherford, 1995; Pehere & Jacob, 2019; Philip & Dutton, 2014). Occupational and task adaptation during intervention may involve choosing occupations/tasks meaningful to the child, implementing verbal guidance and cueing during activity, using visual attracting elements during activities, ensuring food on a plate is a contrasting color during eating, placing a mirror in front of the child for dressing to help with fastening buttons, giving verbal directions before games to ensure the child understands rules, and implementing consistent routines (Good et al., 2001; Pehere & Jacob, 2019; Swift et al., 2008). Other characteristics important for occupational therapists to consider when providing interventions is that treatment and intervention methods for children with low vision or other visual impairments will not suffice for children with CVI due to the impairments in CVI being at the brain level (Gorrie et al., 2019). Pehere and Jacob (2019) emphasize that whoever is leading intervention for these children should choose stimuli specific to the childs interests and continually make adjustments to facilitate ongoing engagement. They also suggest that intervention for children with CVI should be carried out through regular childhood development tasks including play, learning, communication, and movement. This specific suggestion further validates the role of OT in caring for this population due to centering all treatment around regular tasks and activities, known to them as occupations. OTs are skilled in environmental modification and task adaptation, which are evident as the forefront of CVI functioning. Because OT professionals are trained in adapt environments to better meet the needs of the individual and optimize their independence. Since children with CVI often exhibit many visual challenges, one of the most important intervention methods is environmental adaptation. Although limited evidence has been proven to examine the difference in how these environmental modifications help children with CVI, there are a few works of literature that have explored parent reports about caring for children with CVI. Many of the unique modifications can be recommended by therapists and applied in the childs natural environment. As a profession, occupational therapists pride themselves on implementing evidencebased care for all clients. However, the evidence and literature for tested intervention is minimal, causing the inability to implement evidence-based care for this population (Harpster, In press). Researchers in Williams' (2021) article mention the growing concern about unmet needs, failure to achieve potential, and avoidable mental health problems like anxiety and poor self-esteem that may be seen in children with CVI whose difficulties go unrecognized over time. Due to OT's broad scope of practice, occupational therapists could be the key to bridging these caps and maximizing care. In order for occupational therapy practitioners to obtain competence in caring for this unique population, they must first have evidence-based literature to guide them in care. Conclusion Due to OTs focus on daily activities (occupations), environmental and activity modification, and emphasis on client-specific care, occupational therapists can provide a unique skill set to help this population. The role of OT as part of the interdisciplinary care team for children with CVI is imperative. In order for healthcare providers to ensure children with CVI are receiving quality care, evidence-based interventions need to be explored in the literature. As the increase in CVI continues to rise, the need for research to support treatment for this population should follow. Occupational therapist can be vital assets in the interdisciplinary team that cares for children with CVI to help increase overall quality of life and independence during daily functioning. References Baethge, C., Goldbeck-Wood, S., & Mertens, S. (2019). SANRA-a scale for the quality assessment of narrative review articles. Research Integrity and Peer Review, 4, 5. https://doi.org/10.1186/s41073-019-0064-8 Baker-Nobles, L., & Rutherford, A. (1995). Understanding cortical visual impairment in children. The American Journal of Occupational Therapy: Official Publication of the American Occupational Therapy Association, 49(9), 899903. https://doi.org/10.5014/ajot.49.9.899 Bennett, C. R., Bex, P. J., Bauer, C. M., & Merabet, L. B. (2019). The assessment of visual function and functional vision. Seminars in Pediatric Neurology, 31, 3040. https://doi.org/10.1016/j.spen.2019.05.006 Blackstone, S. W., Luo, F., Canchola, J., Wilkinson, K. M., & Roman-Lantzy, C. (2021). 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... Building the Screen of Cancer Survivorship - Occupational Therapy Services (SOCS-OTS): A Delphi Study Taylor Henson, Jordan Romero, Kenzie Salzbrenner, Daria Seccurro, Shanele Tyler, and Michael Wroblewski December 2, 2021 A research project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the research advisor: Dr. Katie M. Polo, DHS, OTR, CLT-LANA Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 1 of 61 A Research Project Entitled Building the Screen of Cancer Survivorship - Occupational Therapy Services (SOCS-OTS): A Delphi Study Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By: Taylor Henson, Jordan Romero, Kenzie Salzbrenner, Daria Seccurro, Shanele Tyler, and Michael Wroblewski Doctor of Occupational Therapy Students Approved by: 2021-12-15 Research Advisor Date Accepted on this date by the Chair of the School of Occupational Therapy: 2021-12-15 Kate E. DeCleene Huber, OTR, MS, OTD Chair, School of Occupational Therapy Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Date Page 2 of 61 TABLE OF CONTENTS Page ACKNOWLEDGEMENTS 3 CONTRIBUTORS 4 PLAN FOR DISSEMINATION 4 LITERATURE REVIEW 5 ABSTRACT 29 RESEARCH PAPER 31 CHAPTER I. INTRODUCTION 31 II. METHOD 32 III. RESULTS 37 IV. DISCUSSION 41 V. CONCLUSION 45 APPENDIX A 58 APPENDIX B 59 APPENDIX C 60 APPENDIX D 61 Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 3 of 61 Acknowledgements Beth Ann Walker, Cancer survivor panelists from Round 1 of Delphi study Contributors Student Contributors: Cassidy Stinson, Moriam Olorunoje, Kayla Mitchell, Tara Nastoff, Isabel Mazanowski & Ally Delks Expert Panelists: Kathleen Lyons, Sheila Longpr, Francie Baxter, Naomi Anderson, Heidi Spyridakis, Jennifer Hayter, Donna Kelly, Molly Sleigh, Karen Smith, Asfia Mohammed, Alix Sleight, Megan Turner, Lauro Antioco Munoz, Leslyn Keith, Jennifer Wahowski, Theresa Smith, Jennifer Cook, Rose Duffy, Ann Marie Potter, Nicole Scheuman, Karen A Enlow, Jennie Marti Plan for Dissemination Our research team has been accepted to present this information at the AOTA Inspire conference in San Antonio, Texas in April of 2022. Our team also plans to disseminate this information at the Scholars Showcase in April of 2022 for those members who were unable to attend the conference. Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 4 of 61 Literature Review As of 2016, researchers estimated that there were 15.5 million cancer survivors in the United States and that by the year 2026, that number will rise to 20.3 million (National Cancer Institute, 2018). Researchers define a cancer survivor as anyone with or who had cancer from diagnosis to the end of life (National Cancer Institute, 2019). As the number of cancer survivors increases, it is essential to consider what factors may impact their quality of life following cancer treatment. Researchers indicated that quality of life was inversely related to occupational performance deficits, which can occur due to side effects of cancer treatment such as fatigue, pain, sensory loss, and cognitive impairments (Brekke et al., 2019). Occupational performance is the accomplishment of an occupation, a purposeful activity that has meaning to the individual (American Occupational Therapy Association, 2014). In 2006, the Institute of Medicine (IOM) called for the implementation of cancer survivorship recommendations to improve care coordination, facilitate follow-up care, and assure patient outcomes (Stricker et al., 2011). The American Society of Clinical Oncology (ASCO) Survivorship Care Plan (SCP) is a document that includes a treatment summary and follow-up care plan to improve communication and coordination of care for cancer survivors. The ASCO SCP assists patients in tracking check-up appointments, reviewing follow-up tests, mapping out possible late side effects of treatment, and providing ideas for staying healthy (Centers for Disease Control and Prevention, 2018). The ASCO SCP addresses concerns related to emotional and mental health, physical functioning, memory or concentration loss, fatigue, parenting, school/work, and sexual functioning. However, the SCP in care coordination does not include various life activities (occupations) that researchers found cancer survivorship impacts (American Society of Clinical Oncology, 2019). Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 5 of 61 Despite the implementation of the ASCO SCP, researchers have indicated that a lack of coordination in survivorship care can contribute to poor care delivery and adverse patient outcomes (Klabunde et al., 2013). Researchers have recommended an occupational participation approach to address gaps in cancer survivorship care (Yim Loh & Jonsson, 2016). Although survivors face performance deficits resulting from cancer treatment, there is a lack of referral to occupational therapy services. Survivorship care requires an occupational participation approach which includes regular screening for occupational therapy services. Currently, no validated screening tools indicate the need for referral to occupational therapy in survivorship care. However, the Screening of Cancer Survivorship - Occupational Therapy Services (SOCS-OTS) tool is available but requires a true consensus from experts in the field to indicate which items researchers should include in its final rendition. The purpose of this study was to formally validate The Screening of Cancer Survivorship-Occupational Therapy Services (SOCS-OTS), which researchers developed for oncology team members to identify those that need occupational therapy services due to occupational performance limitations in survivorship care. Side Effects of Cancer Treatment Although there is currently no developed screening tool indicating the need for referral to occupational therapy in survivorship care, there are many side effects of cancer treatment that may impact survivors occupational performance. Larkey et al. (2015) performed a quantitative randomized control trial for breast cancer survivors with cancer-related fatigue (CRF). Researchers selected 87 female breast cancer survivors for this study, of which 49 participated in the tai-chi intervention group. Researchers then administered the exercises for a total of 24 weeks for 90-minute supervised periods twice a week for 12 weeks, followed by 30-minute unsupervised periods five times a week for an additional 12 weeks. Researchers utilized the Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 6 of 61 Fatigue Symptom Inventory (FSI), in which participants rated fatigue on a scale of zero to ten, with a three or higher score considered a meaningful level of fatigue. The intervention group showed a moderate decrease in CRF after the supervised activities. The scores during the individual intervention were consistent with those reported at the end of the supervised portion of the intervention, suggesting a lasting effect for decreased CRF due to tai-chi exercise in cancer survivors (Larkey et al., 2015). Johansson et al. (2013) similarly performed a quantitative, randomized control trial that utilized water-based intervention measuring shoulder range of motion for breast cancer survivors with chronic lymphedema. Researchers recruited 29 female survivors for participation in the study, with 15 participating in the intervention group and 14 participating in the control group. The intervention group completed water-based exercise three times a week for eight weeks. The participants either swam or performed specific shoulder exercises shown to them by an instructor during the allotted time. The control group received no intervention treatment. Median changes for flexion and external rotation were significantly larger in the intervention group. Flexion median change increased by seven degrees, and external rotation median change increased by thirteen degrees. Researchers did not observe significant increases in the control group (Johansson et al., 2013). Salerno et al. (2019) performed a randomized crossover trial study to measure the effects of cancer-related cognitive impairment (CRCI) in breast cancer survivors after aerobic exercise training. Researchers recruited 29 participants for this study and conducted three sessions. The first session consisted of determining the max heart rate of participants. In the second session, participants completed a cognitive battery test followed by either 30 minutes of exercise on a treadmill or 30 minutes of sitting. They then completed a second cognitive battery test following Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 7 of 61 the intervention. Out of the recruited participants, 15 performed walking during the second session, while 14 performed sitting during the second session. Researchers reversed the groups for the third and final session. Participants showed a significant improvement in spatial working memory and processing speed upon the conclusion of the exercise intervention (Salerno et al., 2019). Similarly, Baumann et al. (2011) used physical activity to explore the effects of CRCI in breast cancer survivors. Researchers found significant improvements in intelligence and memory in the exercise intervention group (Baumann et al., 2011). Kneis et al. (2019) incorporated balance and endurance training in a quantitative randomized control designed to study the effect on neuropathic symptoms. The intervention group performed both balance and endurance training, while the control group performed only endurance training. Researchers selected 50 cancer survivors, with 25 participating in one-onone interventions lasting 60 minutes in length. Participants completed endurance training for 30 minutes on a stationary bicycle and 30 minutes for balance training. The control group included 25 survivors. Modules in the European Organization for Research and Treatment of Cancer Quality of Life (EORTC QLQ-C30) measured chemotherapy-induced peripheral neuropathy (CIPN) severity in sensory, motor, autonomic, and upper and lower extremity categories. Upon conclusion of the study, the intervention group had significantly better scores in the EORTC QLQ-C30 in all categories measured for CIPN purposes, indicating a significant reduction in reporting the symptoms of CIPN reported (Kneis et al., 2019). These common side effects of cancer treatment, including CIPN, CRF, CRCI, and lymphedema, can impact the occupational performance of cancer survivors. Jung et al. (2017) used the Brief Fatigue Inventory (BFI) to measure the severity of fatigue, the Hospital Anxiety and Depression Scale (HADS) to measure levels of anxiety and Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 8 of 61 depression, and the EORTC QLQ-C30 to target the patients emotional, cognitive, social and role functionalities of lung cancer survivors. Researchers reported that approximately 332 individuals of their initial outreach of 830 survivors agreed to complete the questionnaires (Jung et al., 2017). Researchers utilized a univariate analysis of sociodemographic factors to record the impacts on fatigue and anxiety, such as comorbidities, age, and educational level. The researchers concluded that fatigue and depression had the most significant effect on lung cancer survivors (Jung et al., 2017). Fitch et al. (2020) surveyed a total of 13,258 Canadian respondents in a transitional study asking about unmet needs and experiences between the first and third year post-cancer treatment. The researchers survey contained open and closed-ended questions focused on the participants' health, medical history with cancer, follow-up cancer care, and additional topics. Following the survey, researchers initiated interviews to gain information on the understandability and meaningfulness of the survivorship experience (Fitch et al., 2020). Roughly 87% of the respondents experienced at least one physical symptom post-treatment, and 58% indicated three or more. Of the participants, 33% were under the impression that their symptoms were expected with no solution, which led to not seeking additional help (Fitch et al., 2020). Those that expressed physical concerns noted the following: sexual function/activity (45%), hormonal/menopause or fertility (37%), and fatigue/tiredness (33%). Gastrointestinal problems (63%) and pain (61%) were the symptoms for which respondents most frequently sought help. However, more than onethird of respondents who sought help indicated that it was difficult to obtain for most of their symptoms. Seeking help for changes in concentration and memory was particularly challenging (48% experienced difficulty) (Fitch et al., 2019, p. 2980) Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 9 of 61 Krok-Schoen et al. (2018) utilized a survey design to explore the influences that inhibited fear of cancer recurrence (FCR) among older female cancer survivors. A total of 4,259 participants with different types of cancer completed an online-based survey that recorded cancer type and treatment data (Krok-Schoen et al., 2018). Researchers measured participants' FCR using an eight-item Cancer Worry Scale (CWS). Participants reported general psychological well-being, physical symptoms, and quality of life. Researchers found that nearly 16% of the participants reported a high FCR based on factors like chemotherapy, high symptom scores, and older age (Krok-Schoen et al., 2018). Similarly, Galica et al. (2021) found that as the number of cancer survivors continues to increase, FCR is the most significant factor limiting this population. FCR is associated with an overall decrease in quality of life, increased anxiety, and higher rates of depression (Galica et al., 2021). The researchers indicate that previous findings show cancer survivors want help to cope with their FCR; however, this concept is still under-recognized, and the needs remain unmet (Galica et al., 2021). The researchers found that survivors within this population are experiencing unmet and unrecognized needs, warranting oncology nurses to assess, care for, and provide intervention for these increasing numbers of patients (Galica et al., 2021). Impact on Occupational Performance Side effects of cancer treatment impact every category of occupation, including ADLs (Activities of Daily Living), IADLs (Instrumental Activities of Daily Living), rest and sleep, work, leisure, and social participation (American Occupational Therapy Association, 2014). First, experts define ADLs as activities directed at taking care of one's own body, such as sexual activity, toileting and toilet hygiene, feeding, functional mobility, and personal hygiene and grooming (American Occupational Therapy Association, 2014). Hwang and colleagues (2015) Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 10 of 61 investigated cancer survivors functional deficits and their impact on quality of life. The researchers conducted a one-group, nonrandomized study. They had 68 cancer survivors respond to the Post Cancer Outcome Survey (PCOS) and Cantril's Self-Anchoring Striving Scale to measure perceived functional deficits and quality of life. On the PCOS, cancer survivors frequently reported that sexual activity was an occupation in which they experienced difficulty due to a lack of sexual enjoyment from decreased sexual drive, negative body image, and discomfort during sex following cancer treatment. Researchers found that the occupational performance limitations survivors faced were associated with reduced quality of life (Hwang et al., 2015). Cancer survivors also listed toileting and toilet hygiene as an occupational performance deficit in research conducted by Marciniak et al. (1996). Researchers identified functional impairments resulting from cancer and its treatment among 159 cancer survivors using the Functional Independence Measure (FIM) in a non-experimental, retrospective study at the Rehabilitation Institute of Chicago. Cancer survivors indicated that they experienced gastrointestinal problems such as constipation, diarrhea, and incontinence following treatment which impacted their toileting occupations (Marciniak et al., 1996). Lastly, cancer survivors reported that another area of occupational performance deficit was functional mobility. Lyons and colleagues (2018) used a mixed-methods sequential explanatory approach to identify and reduce disability among cancer survivors. Participants in the study were 65 years and older and were cancer survivors who were experiencing disability due to cancer treatment. Researchers used the Health Through Activity Program intervention, which required participants to reflect on pleasurable and beneficial activities to their physical and mental health, create goals to engage in said activities, and then reflect on their experience and Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 11 of 61 success with those weekly activities with an occupational therapist. During the completion of the intervention, survivors reported that functional mobility, such as walking, was an area of performance deficit due to side effects such as sensory loss, pain, and edema (Lyons et al., 2018). These findings indicate that survivors face occupational performance deficits in the occupational category of ADLs due to the side effects of cancer treatment. ADLs are impacted by the effects of intensive cancer treatment, but IADLs are also negatively influenced. IADLs are activities that benefit daily living throughout the community and home and involve more complex interactions such as child-rearing, home establishment and management, health management and maintenance, and driving and community mobility (American Occupational Therapy Association, 2014). Hwang et al. (2015) and Lyons et al. (2018) found that side effects negatively influence ADLs. Researchers also discovered performance issues in health management and maintenance, an IADL. Cancer survivors indicated difficulties exercising/working out due to treatment effects such as fatigue, decreased energy levels, nausea, and pain (Hwang et al., 2015; Lyons et al., 2018). Another IADL that drastically changes for survivors following cancer treatment is home establishment and management. In a cross-sectional, descriptive survey study with 368 participants in Iran and Canada, researchers found that survivors reported limitations in home establishment and management (Shahidi et al., 2014). Survivors reported that constraints were present in their abilities to complete house chores such as laundry and cleaning following treatment due to muscle weakness, fatigue, and sensory loss (Shahidi et al., 2014). Not only have performance deficits in ADLs and IADLs been found in cancer survivors due to the side effects of treatment, but researchers discovered that the occupation of rest and sleep also suffers. Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 12 of 61 Individuals reported rest and sleep activities restore engagement in other occupations (American Occupational Therapy Association, 2014). Researchers found that survivors' side effects hinder sleep participation during or after cancer treatment. Engstrom et al. (1999) used a qualitative, multi-institutional sleep study to explore the impact, type, frequency, and severity of sleep disturbances among 150 cancer survivors. Participants completed interviews and phone surveys using an 82-item sleep questionnaire to obtain data regarding cancer survivors' sleep participation following cancer treatment. Survivors reported that sleep participation was disturbed by side effects such as insomnia, sleeping at unusual times, having trouble with dreams or nightmares, and psychological distress following cancer treatment (Engstrom et al., 1999). Carpenter et al. (2004) further explored sleep participation limitations among cancer survivors in a cross-sectional, descriptive, comparative pilot study using questionnaires and monitoring sessions to compare differences in sleep quality and disturbance between cancer survivors and healthy women who have hot flashes. Researchers discovered that cancer survivors experience poor sleep quality and high levels of sleep disturbance (Carpenter et al., 2004). As sleep participation limitations can lead to symptoms such as fatigue, poor cognition, and depression, which can impact other areas of occupation, it is essential to consider how sleep participation can be affected by the side effects of cancer treatment (Durmer & Dinges, 2005). The occupation of work includes labor, construction, organizing and planning services or processes, and committed occupations which may consist of financial reward (American Occupational Therapy Association, 2014). Many cancer survivors reported that the side effects of cancer treatment negate job performance. Groeneveld de Boer and Frings-Dresen (2013) used interviews in a qualitative, phenomenological study to evaluate how cancer treatment had impacted 10 participants work participation. Researchers explored survivors experiences with Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 13 of 61 returning to work and work performance, a physical exercise intervention, and the link between physical exercise and work. Survivors reported that their job performance and work productivity had declined following treatment due to side effects such as fatigue, feeling sick, cognitive deficits, impairments in concentration, memory deficits, and increased stress levels. Survivors also explained that absenteeism increased following treatment due to feeling ill, overly tired, or unmotivated to go to work (Groeneveld et al., 2013). Fangel and colleagues (2013) further explored cancer survivorship's influence on job performance in a descriptive, exploratory, crosssectional, and qualitative study using Katz's index and Lawton's index to assess functional capability and its correlation with the quality of life among 42 cancer survivors. Participants reported difficulties with work performance due to decreased independence, limited functional capability, and the presence of psychosocial issues following cancer treatment (Fangel et al., 2013). Leisure participation is another area of occupation hindered by the presence of cancer treatment side effects. Experts define leisure activity as an activity that is not an obligation but is intrinsically motivated and completed during a discretionary time (American Occupational Therapy Association, 2014). Keesing et al. (2018) conducted a mixed-methods Delphi study to explore the possible role of occupational therapists in the care of female cancer survivors. The researchers found survivors faced many challenges engaging in and resuming meaningful leisure occupations following treatment because of functional, emotional, and psychosocial side effects. Further, researchers supported the idea that occupational therapists could play a significant role in helping survivors address these occupational performance limitations. Occupational performance limitations related to leisure participation can also occur among survivors due to arm morbidities, such as pain, limited range of motion, and lymphedema of the arm following Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 14 of 61 cancer treatment. These side effects are especially common among breast cancer survivors (Thomas-Maclean et al., 2008). In a longitudinal, qualitative cohort study conducted by Thomas et al. (2015), 40 cancer survivors reported in interviews that side effects including arm morbidity, physical discomfort, and psychological distress reduced their abilities to engage in leisure activities. Researchers have identified specific forms of leisure participation limitations in the literature that involve difficulties engaging in travel and active leisure participation (Thomas et al., 2015). The final occupation that cancer survivors have reported experiencing deficits in following cancer treatment is social participation. Social participation involves activities supporting social engagement and interdependence with community members, family, peers, and friends (American Occupational Therapy Association, 2014). Johnson et al. (2017) conducted a quality improvement study focusing on multidisciplinary management of distress that survivors face. Researchers also explored survivors satisfaction with the distress management they received. Data was collected from electronic health records using a convenience sample of 65 gynecologic cancer survivors. Using the National Comprehensive Cancer Network Distress Thermometer and Patient Related Outcome Measures Information Systems QOL, researchers found that survivors experienced great psychosocial distress following treatment that hindered their social participation. Side effects of treatment that negatively influenced survivors social support were anxiety, depression, emotional distress, and feelings of psychological isolation (Johnson et al., 2017). Not only does psychosocial distress negatively influence cancer survivors social activities and social function, but survivors have also reported that physical functioning has impacted their social participation. In a cohort study completed by Syrjala et al. (2010), researchers used the Social Activity Log (SAL) to explore the social activities of 100 cancer Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 15 of 61 survivors following hematopoietic stem cell transplantation. Researchers found that survivors face many physical challenges such as fatigue, incontinence, and increased functional dependence due to muscle weakness following treatment that negatively impact one's desire to engage in social participation (Syrjala et al., 2010). Hair loss is another common physical side effect following treatment that many cancer survivors state has negatively influenced their desire to engage in social participation. Survivors report being embarrassed and upset by hair loss, limiting their willingness to participate in social activities with family, friends, and peers (Petruseviciene, 2018). These occupational performance deficits impact the quality of life of cancer survivors; therefore, it is essential to utilize screening tools to evaluate the need for rehabilitation services such as occupational therapy. Current Survivorship Screening Tools While none currently screen for the specific need for occupational therapy, screening tools are available that screen for side effects of cancer treatment and the need for rehabilitation services. In an observational study, Henneghan et al. (2018) implemented the Patient-Reported Outcomes Measurement Information System (PROMIS) Item Bank, perceived stress scale (PSS), UCLA Loneliness scale, Pittsburgh sleep quality index (PSQI), and the functional assessment of cancer therapy-cognitive function instrument (FACT-Cog) to measure anxiety, depression, fatigue, stress, loneliness, and sleep quality on perceived cognitive function. There were ninety female breast cancer survivors three years post-chemotherapy treatment that participated in the study. The researchers reported that breast cancer survivors who felt high stress levels, social isolation, and poor sleep quality might also have a lower perceived cognitive function (Henneghan et al., 2018). Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 16 of 61 Boronowski et al. (2012) conducted a research study to determine the interrater reliability, intrarater reliability, predictive validity, and concurrent validity of the Occupational Therapy Discharge Needs Screen (OTDNS). Professionals use this screening tool to identify clients with more complex discharge needs (Boronowski et al., 2012). The hospital dischargeplanning process for complex needs often includes a home assessment conducted by an occupational therapist before being discharged. Pre-discharge home visits lead to quicker discharge times and play a role in fall prevention post-discharge. The researchers conducted a prospective study in a convenience sample of 89 participants in a community hospital's rehabilitation and transitional care unit that were about to be discharged. Categories on the OTDNS include functioning, disability, and contextual factors. Functioning and disability include items related to medical condition, mobility, and activities of daily living. Contextual factors included items related to social support, physical/environmental barriers, and perceived readiness for discharge (Boronowski et al., 2012). Researchers found that the OTDNS can contribute to the efficiency of the discharge-planning process (Boronowski et al., 2012). Many individuals affected by stroke(s) often have physical, cognitive, psychosocial, or behavioral challenges (Jaber et al., 2018). Identifying self-perceived challenges to daily participation helps occupational therapists create client-centered goals and support long-term community engagement after stroke. According to Jaber et al. (2018), strokes impact several different areas of occupation including activities of daily living, instrumental activities of daily living, work, leisure, and social participation. Researchers recruited 25 participants receiving occupational therapy services from the American Stroke Foundation and had met the inclusion criteria. Researchers implemented a demographic questionnaire, the Canadian Occupational Performance Measure (COPM), and the Montreal Cognitive Assessment (MOCA). Researchers Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 17 of 61 used the COPM to identify patients' self-perception of performance in everyday living, and the MOCA was used to identify mild cognitive impairments. Patients reported IADLs, leisure participation, and ADLs as the top three challenges on the COPM. Survivors frequently report that driving and community mobility are challenging IADLs. They also noted that employment seeking and functional mobility are challenging. The participants self-efficacy indicated that they were not yet satisfied with their occupational performance. (Jaber et al., 2018). Not only is there a lack of an occupational therapy screening tool available in survivorship care, but there are other gaps in survivorship care that impact the overall quality of life for survivors. Gaps in Survivorship Care Some gaps in survivorship care include lack of education of the healthcare provider, survivors' lack of knowledge about the SCP, lack of communication between the survivor and the healthcare provider, and poor care coordination. The gaps in care can lead to the needs of survivors being left unmet. First, healthcare providers lack education, which can make them feel unconfident in treating survivors' late side effects or managing their symptoms. Many providers do not understand what late side effects are and how survivors still experience deficits even after remission. Researchers identified these issues with both PCPs and nurses. Barton (2014) investigated oncologists and PCPs infrequently providing SCPs. Researchers used data from the Survey of Physician Attitudes Regarding the Care of Cancer Survivors, a 2009 national poll of 1,020 PCPs and 1,130 oncologists. The researchers looked at post-treatment follow-up care for patients surviving breast or colon cancer. Researchers used four outcome variables: how often oncologists supply survivors with a written SCP, how much oncologists discuss the SCP with patients and who will be providing care for them, PCPs discussion of recommendations, and how often oncologists supply the written SCP and discuss the plan with patients. The researchers Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 18 of 61 found that PCPs with less training in survivorship care were 43% less likely to have discussions with survivors. Only 12% of PCPs reported having full conversations of survivorship care with their patients. The author suggested a low percentage of PCPs having full discussions because of the lack of physician training and care coordination (Barton, 2014). Similarly, in 2014, Lester et al. studied nurses' knowledge of cancer survivorship care through a descriptive, cross-sectional study in a Midwestern comprehensive cancer center. This study included 223 registered and advanced practice nurses and used an online survey with 50 questions created from the Institute of Medicine report and related publications (Lester et al., 2014). The researchers found that less than 50% of the nurses felt knowledgeable about the impact cancer could have on survivors and their families, how to prevent certain conditions after cancer treatment, and the side effects survivors may face (Lester et al., 2014). The authors concluded that there are definite gaps in knowledge regarding cancer survivorship care with nurses (Lester et al., 2014). Cheung et al. (2013) conducted a quantitative cross-section study that surveyed PCPs and oncologists in 2013. The researchers looked at PCP and oncologists views on self-efficacy regarding the follow-up care of cancer survivors, such as their ability to detect recurrence and manage the effects of cancer and various treatments (Cheung et al., 2013). They designed survey questions to assess both the PCP and oncologists' views, knowledge, and care coordination methods regarding post-treatment care in cancer survivors (Cheung et al., 2013). The researchers also listed questions regarding PCPs' attitudes and preferences. In this study, participants identified their preferred survivorship care model regarding who has the most responsibility in the care plan. Their options in the final survey about who they preferred for the responsibility of care included PCPs having the primary responsibility, PCPs sharing the responsibility with other Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 19 of 61 cancer specialists, or oncologists having the primary responsibility. Researchers utilized the initial survey to determine which participants were eligible through a telephone screening process and followed up with a survey in the mail for the eligible participants. In this study, there were 2,026 total participants. Out of these participants, 938 were PCPs, and the other 1,088 were oncologists. The study found that 51% of PCPs supported a PCP/shared model of care, 59% of cancer specialists preferred an oncologists model of care, and 23% of physicians favored the specialized clinic models (Cheung et al., 2013). The study also found 70% of oncologists were confident in their ability to manage long-term effects in cancer survivors, while only 19% of PCPs felt confident in their ability to provide adequate care (Cheung et al., 2013). Overall, the authors concluded that PCPs and oncologists have different model preferences for cancer survivorship care. These preferences can affect communication and role delineation, affecting the survivors' care (Cheung et al., 2013). Another issue with the current SCP is that survivors do not have knowledge of what a SCP is, and they do not know how to understand the plan if they do have one. Casillas and colleagues (2011) explored how confident young adult cancer survivors are in managing their care. Researchers recruited 376 participants from the LIVESTRONG Survivorship Center of Excellence Network sites aged 18-39 years old. This self-report survey study looked at 57 items in six domains. The six domains included sociodemographic information, cancer diagnosis and treatment, experiences with doctors, survivors' knowledge of late side effects, current health status, and opinions regarding the availability of resources for survivors. Researchers found that one-third of participants did not have copies of their medical records, 48% did not have a written treatment summary, and 55% did not have a written survivorship care plan (Casillas et al., 2011). The researchers found that patients lack the knowledge they need when it comes to their medical Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 20 of 61 records and SCPs, which leads to them not being able to get the care they need. The authors of this study concluded that if survivors receive the SCPs, they will better manage their care and understand their past medical history. If provided with a SCP, survivors would likely better understand their past medical history and have more information on late side effects that they may experience, which could lead to improved communication with their healthcare providers. The final issue is the lack of communication between the healthcare provider and the survivor. Benci et al. (2018) conducted research to identify cancer survivors' barriers when sharing their SCP with their healthcare provider. The researchers in this quantitative study used data from 3231 cancer survivors who used the OncoLink SCP resource between the years 20092016. Researchers found that 87% of users rated their satisfaction with their SCP good or better; however, only 70% of survivors planned to share their SCP with their health care provider (HCP) due to the feeling that they would not care (Benci et al., 2018). The researchers found that some survivors are not communicating their SCP and their needs with their HCP because they feel that their needs will be ignored. The researchers in this study concluded that the primary goals of the SCP are to facilitate the transmission of information from the oncologist to survivor to the longterm care team and serve as a communication bridge between survivors and providers. However, there is an alarming disconnect with survivors feeling comfortable sharing their SCP with their healthcare provider (Benci et al., 2018). The lack of role delineation for treating the long-term effects of cancer in the cancer survivorship stage is another detriment that substantially impacts overall cancer care (Cheung et al., 2013). Some believe ongoing cancer survivorship care falls under the role of oncologists, who specialize in cancer, while others think primary care physicians (PCPs) should monitor this care (Greenfield et al., 2009). There are currently no guidelines stating what health care Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 21 of 61 professionals are in charge of cancer survivors; therefore, there are disparities because people do not have adequate follow-up care. Some oncologists feel monitoring and treating long-term effects resulting from cancer treatments is their role, while others believe they do not have time for this portion of cancer care and think it should be in the hands of primary care physicians (Klabunde et al., 2013). Similarly, some PCPs feel they should oversee follow-up cancer survivorship care, whereas others do not feel comfortable treating the adverse effects of cancer (Cheung et al., 2013). Cheung et al. (2013) conducted a quantitative cross-section study that surveyed primary care physicians (PCPs) and oncologists' views on self-efficacy regarding the follow-up care of cancer survivors. In this study, researchers also examined what cancer survivorship model PCPs and oncologists preferred to develop new strategies for follow-up cancer care. They designed survey questions to assess both the PCP and oncologists' views, knowledge, and care coordination methods regarding post-treatment care in cancer survivors (Cheung et al., 2013). The three possible survivorship model preferences were a shared model involving PCPs and oncologists together, care only by oncologists, or specialized survivor clinics that include physicians that exclusively focus on cancer care with skilled nurses, physician assistants, and nurse practitioners. Researchers examined participants' attitudes regarding their views on personal self-efficacy related to detecting cancer recurrence and the ability to manage cancer and its effects. The initial survey determined eligible participants through a telephone screening process, followed by a mailed version of the formal survey packet to eligible participants. In total, 2,026 participants consisted of 938 PCPs and 1,088 oncologists. The study found that 51% of PCPs supported a PCP/shared model of care, 59% of cancer specialists preferred an oncologist lead model of care, and 23% of physicians favored the specialized survivor clinic models Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 22 of 61 (Cheung et al., 2013). Researchers found that 70% of oncologists were confident in their ability to manage long-term effects in cancer survivors. However, PCPs were less optimistic in their ability to provide adequate care, with only 19% reporting high self-efficacy (Cheung et al., 2013). Researchers concluded that the discrepancy in preference of PCP or oncological care in treating cancer survivors might fail to coordinate care between providers adequately. A 2016 qualitative study, conducted by Smidt et al. (2016), focused on the perceptions of Australian oncologists in terms of cancer-related cognitive changes (CRCC) in patients and the impact of their views on patient care. The main questions researchers addressed in this study include how oncologists perceive CRCC and address these issues with their patients during the survivorship phase (Smidt et al., 2016). After receiving verbal consent, the researchers used telephone interviews, where interviews were audio-recorded and then transcribed verbatim. The interviews ranged from 15 to 30-minute intervals on average and consisted of 18 oncologists. The critical points asked in the interview were: (1) the beliefs about the impact of cognitive function among cancer survivors, (2) perceptions of which party is more likely to address cognitive changes, (3) uncertainty of how to manage CRCC, and (4) the role of oncologists in CRCC (Smidt et al., 2016). The researchers discovered that the participating oncologists treat cancer survivors that have side effects of cancer treatment. However, the patients indicated that they were given little information from their oncologists regarding CRCC. Researchers showed a minimal number of oncologists in this study referred patients to other healthcare professionals, including nurses, occupational therapists, and social workers (Smidt et al., 2016). They concluded that the lack of guidelines for cancer survivor treatment, and the number of survivors not experiencing the CRCC, has created a barrier in practice that has prevented survivors from the best care possible. This study successfully highlighted the barriers Australian oncologists Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 23 of 61 face when delivering survivorship care, which can impact the patient's care and overall quality of life (Smidt et al., 2016). Similarly, Klabunde et al. (2013) also investigated PCPs and oncologists' self-reported roles in follow-up care of cancer patients. Their focus was to assess the roles of PCP's and oncologists in the follow-up cancer care process. Researchers also determined what factors are involved in follow-up care and how clinicians utilize care coordination and communication (Klabunde et al., 2013). The researchers in this cohort study used data from the 2009 Survey of Physicians' Attitudes Regarding the Care of Cancer Survivors (SPARCCS), which surveys both PCPs and oncologists. The researchers primarily focused on the follow-up care of breast and colon cancer survivors; therefore, they excluded physicians who reported to never, or not in the past year, care for patients with these forms of cancers (Klabunde et al., 2013). The final study sample included 1,014 PCPs and 1,125 oncologists. Researchers assessed the physician's roles by asking how often treatment services were provided in their practice and evaluated the participants' beliefs on the role of PCPs in cancer survivorship (Klabunde et al., 2013). They specifically asked PCPs how often they received a summary of the patient's cancer treatment or recommendations for future care from the treating oncologists. Researchers found that many PCPs reported co-managing survivor care with other oncologists unless screening for new primary cancers in patients. The PCPs that reported receiving summaries from the treating oncologists were also more likely to prefer the co-managing role pattern (Klabunde et al., 2013). These researchers found that many PCPs feel that they have an active role in cancer survivorship but often accompany co-management of oncologists. However, oncologists reported they directly provide follow-up care without assistance from the PCPs. The authors noted the discrepancies of reports in co-management care from PCPs and oncologists and believe this emphasizes the need Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 24 of 61 for a shared-care model when treating cancer survivors to meet the patient's needs (Klabunde et al., 2013). Finally, a mixed-method study, conducted by Suija et al. (2016) focused on the current role general practitioners play in caring for cancer patients and the unmet needs that cancer patients in primary care face. Researchers conducted a study at general practice locations in Estonia that included patients with various stages of cancer but excluded patients with terminal diagnoses (Suija et al., 2016). Researchers (2016) used the qualitative portion to understand the current phenomenon through interviews, where patients expressed their personal experiences. Ten interviews lasted from 35 to 120 minutes and were recorded, transcribed verbatim, and analyzed using thematic analysis. A questionnaire was later developed as a form of quantitative research to collect data based on previous findings. The questionnaire focused on demographics, illness, treatment methods, follow-up care, and statements related to their diagnosis and their medical professional's role (Suija et al., 2016). There were 300 questionnaires distributed to eligible participants throughout Estonia, and 113 participants responded. The researchers found that 92% of survivor participants were satisfied with the GP's work, 77% felt their GP was competent in cancer care, and 79.5% reported their oncologists thoroughly investigated them (Suija et al., 2016). The most common unmet need reported by patients was poor communication, where 19.5% had negative attitudes toward communication with their physicians, and 30% stated they could not understand the doctor's explanations. Finally, 39.9% of participants reported that they felt their oncologists and general practitioners did not collaborate in shared survivorship care (Suija et al., 2016). Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 25 of 61 Unmet Needs of Survivors Due to gaps in care and a lack of referral to rehabilitation services such as occupational therapy, survivors live with unmet needs. Thorsen et al. (2011) published a cross-sectional study where researchers focused on assessing the rehabilitation needs of cancer survivors and exploring factors that are associated with these needs. The other aims of the study were to estimate the need for complex rehabilitation and its associated factors, address unmet needs in rehabilitation services, and assess the factors related to these needs (Thorsen et al., 2011). The researchers used a questionnaire to determine the patient's need for certain rehabilitation services relating to their type of cancer and what patients had been offered and utilized the rehabilitation services. The final number of participants was 1,325, where 37% reported no need for therapy, and 63% needed at least one form of rehabilitation that was listed (Thorsen et al., 2011). The highest reported need was physical therapy at 43%, followed by the need for more than one form of therapy at 40% (Thorsen et al., 2011). The authors concluded that most patients reported the need for some form of rehabilitation service, and physical therapy was the most indicated need. They believe the results from the study help to enforce that cancer patients need rehabilitation services in each phase of treatment, and that rehabilitation is often only offered after initial treatment (Thorsen et al., 2011). They also concluded that the need for rehabilitation remains present for the first few years after diagnosis and often remains relatively constant for years after (Thorsen et al., 2011). Binkley et al. (2012) conducted a mixed-methods study that focused on the unmet needs of breast cancer patients. The researchers hypothesized that the frequency of unmet needs could result from the lack of awareness of the potential long-term effects of cancer treatments. Researchers used a prospective surveillance model to explore various articles that included issues Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 26 of 61 regarding lymphedema, fatigue, upper extremity dysfunction, neuropathy, etc. (Binkley et al., 2012). The data was collected through systematic reviews, focus groups, and questionnaires to obtain the primary data sources (Binkley et al., 2012). The qualitative results suggest that patients need long-term attention, specifically shoulder and trunk strength and range of motion. The researchers also found few women are referred for rehabilitation services while receiving or after the conclusion of treatment for breast cancer (Binkley et al., 2012). They concluded that patients need consistent care, such as rehabilitation services, to treat short- and long-term effects of breast cancer (Binkley et al., 2012). Jang and Jeong (2021) performed a cross-sectional descriptive study focusing on the unmet needs of cancer patients and their families following diagnosis. Researchers hypothesized that these unmet needs would lead to a decreased quality of life in the patients (Jang & Jeong, 2021). The researchers utilized a questionnaire to collect patients' demographics, disease-related characteristics, unmet needs, and quality of life. Both cancer patients and family members completed the questionnaire, with 115 patient-family dyads participating in the study (Jang & Jeong, 2021). Researchers found that the patients unmet needs decreased their physical function and overall quality of life. Researchers also found that the patients unmet needs led to decreased mental quality of life in patients families (Jang & Jeong, 2021). The authors concluded that intervention programs are necessary to improve cancer patients' and their families quality of life (Jang & Jeong, 2021). In summary, researchers have indicated the need for an occupational therapy screening tool in cancer survivorship care. Survivors experience many side effects of treatment, such as fatigue, pain, sensory loss, and cognitive impairment that may impact occupational performance and overall quality of life (Brekke et al., 2019). These side effects can result in deficits in areas Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 27 of 61 of occupation such as personal hygiene and grooming, toileting, sleep, work, and sexual activity (Hwang et al., 2015; Marciniak et al., 1996; Petruseviciene et al., 2018). Although survivors face performance deficits resulting from cancer treatment, many do not receive referrals to occupational therapy. Occupational therapy practitioners are skilled in addressing these late side effects and occupational performance deficits for improved overall quality of life in cancer survivors. However, Pergolotti et al. (2014) found that only 32% of their total sample received referrals to occupational therapy within the first two years of their cancer diagnosis. Survivorship care requires an occupational participation approach which includes regular screening for occupational therapy services. Currently, no developed screening tools are indicating the need for referral to occupational therapy in survivorship care. Researchers previously developed the SOCS-OTS to screen for occupational performance deficits and the need for occupational therapy services in cancer survivors. The purpose of this study is to identify the level of consensus on which items should be included in this tool using a Delphi technique. Researchers will explore which items on the SOCS-OTS reach 80% consensus for inclusion, which do not reach a level of 80% consensus for exclusion, and additional items to include in the tool. Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 28 of 61 Building the Screen of Cancer Survivorship - Occupational Therapy Services (SOCSOTS): A Delphi Study Abstract Background: Occupational therapy is needed in cancer survivorship care to bridge the gaps in care and treat the unaddressed life activities experienced by this population. The Screening of Cancer Survivorship - Occupational Therapy Services (SOCS-OTS) tool is available but requires a true consensus from experts in the field to indicate which items to include in its final rendition. The researchers in this study aim to identify the level of consensus on which items should be included in the final rendition of the SOCS-OTS tool. The purpose of the tool is to survey cancer survivors to assess their need for occupational therapy. Introduction: This paper reviews the lack of occupational therapy services provided to cancer survivors post-treatment. The researchers of this study set out to create a screening tool that depicted the need for therapeutic interventions for these individuals. The Model of OccupationalParticipation for Cancer Survivorship (MOPCS) helped guide the development of this study and the screening tool. Methods: Researchers used a classical Delphi methodology to assess 14 expert opinions and indicate which items meet consensus for inclusion on the SOCS-OT tool through an online survey development software program. Researchers used thematic analysis and open, axial, and selective coding to interpret experts' comments and feedback and guide appropriate modifications to the survey before sending it out for subsequent rounds. Researchers removed items not reaching 80% consensus from the tool. In each round, participants received an overview of participants feedback from the previous round. Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 29 of 61 Results: At the conclusion of the Delphi methodology process, 20 items met consensus for the final rendition of the SOCS-OT tool. Researchers modified several items throughout the process and removed three items from the tool. Conclusions: With the given information, the need for occupational therapy services in oncology is prevalent and requires additional research and assessment tools. The development of the SOCS-OTS provides a rise for further investigation. Recommendations/Implications: It is imperative that individuals in the field of oncology adopt and implement the SOCS-OTS into standard cancer survivor treatment. Researchers will utilize validity and reliability tests to confirm the tool's psychometric properties. Keywords: Cancer survivorship, Occupational Therapy, Screening Tool, Delphi Method Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 30 of 61 Introduction As of 2016, experts estimated that there were 15.5 million cancer survivors in the United States, and they predicted that by the year 2026, that number will rise to 20.3 million (National Cancer Institute, 2018). A cancer survivor is anyone with or who had cancer from the time of diagnosis to the end of life (National Cancer Institute, 2019). As the number of cancer survivors increases, it is essential to consider what factors may impact their quality of life following cancer treatment. Quality of life is inversely related to occupational performance deficits, which can occur due to side effects of cancer treatment such as fatigue, pain, sensory loss, and cognitive impairments (Brekke et al., 2019). Occupational performance is the accomplishment of an occupation which is a purposeful activity that has meaning to the individual (American Occupational Therapy Association, 2014). In 2006, the Institute of Medicine (IOM) called for the implementation of cancer survivorship recommendations and plans to improve care coordination and follow-up care and assure patient outcomes. The American Society of Clinical Oncology (ASCO) Survivorship Care Plan (SCP) is a document that includes a treatment summary and follow-up care plan to improve communication and coordination of care for cancer survivors. It helps patients track check-ups or follow-up tests, maps out possible late side effects of treatment, and provides ideas for staying healthy (Centers for Disease Control and Prevention, 2018). Researchers have indicated that a lack of coordination in survivorship care can contribute to poor care delivery and adverse patient outcomes (Klabunde et al., 2013). The ASCO SCP addresses concerns related to emotional and mental health, physical functioning, memory or concentration loss, fatigue, parenting, school/work, and sexual functioning. However, the SCP in care coordination does not include various kinds of life Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 31 of 61 activities (occupations) found which impact cancer survivorship in the literature (American Society of Clinical Oncology, 2019). Researchers have recommended an occupational participation approach to cancer survivorship care to address gaps in care (Yim Loh & Jonsson, 2016). Although survivors face performance deficits resulting from cancer treatment, many do not receive referrals to occupational therapy. An occupational participation approach is necessary in survivorship care, including regular screening for occupational therapy services. Currently, no developed screening tools indicate the need for referral to occupational therapy in survivorship care. However, a previously developed Screening of Cancer Survivorship - Occupational Therapy Services (SOCS-OTS) tool is available but requires a true consensus from experts in the field to indicate which items are necessary in its final rendition. The researchers in the study aim to identify the level of consensus on which items should be included in the SOCS-OTS tool. Method Study Design Researchers used a classical Delphi methodology to assess expert opinion on a screening tool to indicate which items meet consensus for inclusion on the tool. The classical Delphi methodology is a consensus technique used to obtain and evaluate the views of an expert panel who have extensive knowledge and experience in oncology care (Sekayi & Kennedy, 2017). We used an expert panel for the ability to have multiple skillful opinions of how to adapt our screening tool to best address the concerns and problems of the cancer survivorship population. It also allows for knowledge sharing between the panelist and researchers. Lastly, it alters any researchers bias that may occur throughout the developmental process (Avella, 2016). Our study consisted of four rounds in which experts gave their opinions on whether to include an item in Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 32 of 61 our screening tool or not. Our study included a set of open-ended questions allowing for freedom of response. Sekayi and Kennedy (2017) indicated that a classical Delphi methodology is often used in health and social science research when developing a screening tool due to the ability to converge opinions from a wide variety of experts and reach consensus. Further, the Delphi methodology was appropriate for this study as it allowed researchers to use several rounds of feedback for revision and improvement of the screening tool after each consecutive round (Hasson et al., 2000). Delphi study methodology is used in occupational and physical therapy practice to provide the foundational psychometric testing needed to validate a survey tool in areas where evidence and research are lacking, such as oncology care (Falzarano & Pinto Zipp, 2013). Previous to this project, a group performed the first round of this Delphi study, including a deductive and inductive approach to item writing and included a set of open-ended questions allowing for freedom of response. The deductive approach was conducted by thematically analyzing oncology literature and using the Occupational Therapy Practice Framework to guide item writing specific to occupational performance limitations in survivorship. Researchers used an inductive approach to verify the items that were issues relevant to cancer survivor panelists. Participants While researchers that have used Delphi methodology have not clearly defined an expert, experts may include informed individuals, specialists in the field, or someone who knows about a specific subject (Keeney et al., 2001). An expert can also include an individual who has worked within an area for a certain length of time (Hardy et al., 2004; Jeffery et al., 2009). Qualified expert panelists included occupational therapists (OT), certified occupational therapy assistants (COTA), and OT researchers who practice and study in oncology. The inclusion of OT Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 33 of 61 practitioners required expert panelists to have at least five years of clinical experience with a 30% caseload of adult cancer survivors. OT researchers required a published oncology-related article. Exclusion from this study involved OT practitioners serving the pediatric oncology population because the SOCS-OTS is for the adult population. Purposive and snowball sampling recruitment methods occurred through our professional networks, posting on forums on AOTA.org, and social media platforms. Instrument Under the leadership of the principal investigator, a previous group of students developed an electronic questionnaire, The Screening of Cancer Survivorship-Occupational Therapy Services (SOCS-OTS), to indicate the need for occupational therapy services in survivorship care. The questions ask about everyday activities of daily living performed by cancer survivors, e.g., My cancer has made it difficult to engage in sexual activity with a partner or myself. Survivors indicated their level of agreement with each question on the tool on a five-point scale: I cannot do this, I have a lot of problems with doing this, I have some problems doing this, I can do this well, I can do this very well. A five-point Likert scale is the most commonly utilized Likert scale in empirical research. Researchers indicate that a 5-point Likert scale produces greater validity, reliability, and variance in response than scales with fewer items (Dawes, 2012). The current tool requires a true consensus from experts in the field to indicate item inclusion in its final rendition, which researchers will gather in this study. See Appendix A for an original questionnaire of SOCS-OTS. Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 34 of 61 Data Collection Round 2 The second round of the overall classical Delphi study for this project consisted of a survey containing quantitative and qualitative methods that researchers developed from cancer survivors in Round 1. Researchers sent an ordinal questionnaire to participants in Round 2. Expert panelists indicated whether or not to include each item on the tool through a yes, yes with revisions, or remove ordinal questionnaire and provided qualitative feedback on improvements for each item. An overall additional qualitative question at the end of the survey asked experts to indicate missing items they felt should be included on the tool. Additionally, expert panelists provided feedback about the scale used in the SOCS-OTS and any additional general feedback. Round 2 concluded after 24 days, with follow-up emails sent to expert panelists on day 7, day 12, and day 14. Due to the limited number of responses, our initial response time frame was changed from 14 days to 24 days to gain more participants. Round 3 In Round 3, researchers sent out another ordinal questionnaire to panelists to determine which items were essential to include on the SOCS-OTS. The expert panelists rated each item on a 5-point Likert scale of importance, rating 1 (Unimportant) to 5 (Very Important). Additionally, panelists provided feedback on the updated format of the tool itself and any additional general feedback about items. Round 3 concluded after 18 days, with follow-up emails sent out to expert panelists on day 7, day 12, day 14, and day 17. Due to the limited number of responses, our initial response time frame was changed from 14 days to 18 days to gain more participants. Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 35 of 61 Round 4 In the fourth and final round, researchers sent the revised questionnaire to expert panelists following further adjustment to the tool using expert feedback from Round 3. The final questionnaire consisted of items that met consensus after Round 3. Panelists indicated whether the item must be included or removed from the tool. Round 4 concluded after 35 days. Researchers sent follow-up emails to the panelists after 7 days, 9 days, 11 days, 12 days, 13 days, 24 days, and 29 days. Researchers intended to close Round 4 after 14 days, but due to limited participation was extended to 35 days. Round 4 received 14 responses, and the researchers verified the final version of the SOCS-OTS. On the final version, 20 items remained after researchers removed 2 items due to unmet consensus. Data Analysis Panelists responses were collected and analyzed using Qualtrics (Qualtrics, Provo, UT), which is an online survey development software. Researchers collected these responses after each round to obtain quantitative data. Although there is no set consensus value when using the Classical Delphi technique, many studies use 80% consensus, which was the consensus chosen for this study (Keeney et al., 2006). To be in consideration for the next rendition of the screening tool, items needed to reach the minimum consensus. Researchers used thematic analysis and open, axial, and selective coding to interpret experts' comments and feedback and guide appropriate modifications to the survey before sending it out for subsequent rounds. Researchers analyzed data through all three rounds regardless of the attrition of expert panelists. After the Delphi process, researchers sent the final results to the participating panelists through Qualtrics. Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 36 of 61 Results Round 2 In Round 2 of our Delphi study, researchers sent the survey to 75 panelists through Qualtrics and gathered 27 responses. Nine panelists did not meet expert criteria, so researchers only included 18 responses in data collection. See Appendix A for Round 2 screening tool sent for expert feedback. After analysis of feedback provided by participants, researchers made changes to the items on the SOCS-OTS for clarity based on themes generated. Five items did not meet consensus and were modified using expert feedback. Items that did not meet consensus included Engage in sexual activity with a partner or myself, Maintain closeness and intimacy with a romantic partner, Move from one position or place to another, Do my yard work, and Fully return to work. Six items including Drive and move around the community, Manage my health, Toilet and toilet hygiene, Engage in religious/spiritual activities, organizations, and/or practices, Dress/undress, and Personal hygiene and grooming were added to the screen using expert recommendations. See Table 1 for Round 2 consensus levels. Per expert panelist feedback on the scaling technique, researchers changed the tool to a check all that apply format. Instead of having clients rate their difficulty level, this new format allows clients to indicate which items they find difficult and would like assistance completing. Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 37 of 61 Table 1 Consensus Levels for Round 2 Items Consensus Bathe and/or shower Engaging in sexual activity with a partner or myself Maintain closeness and intimacy with a romantic partner Provide care for other people and/ or pets Move from one position or place to another Manage finances Maintain my exercise routine and physical fitness 100% 64.70%* 70.59%* 88.89% 61.11%* 100% 83.33% Manage my medications 94.44% Clean my home 83.33% Do my yard work 77.78%* Perform home maintenance and repairs 83.33% Plan, prepare, serve and/or clean up meals 83.33% Grocery shop 83.33% Rest and sleep 94.44% Fully return to work 72.22%* Perform my job duties at prior level of expectation 88.89% Engage in educational activities 88.89% Participate in leisure activities 94.44% Socialize with my family and friends 100% Participate in community events 100% Note. * indicates items that did not meet consensus. Round 3 In Round 3, researchers collected 15 total responses. Based on the feedback received, two items did not meet consensus, including Doing my yard work and Performing home maintenance and repairs. Researchers removed these two items from the SOCS-OTS entirely and sent out an updated revision in round 4. See Table 2 for Round 3 consensus levels. Researchers modified a few of the items with added clarification, where the experts expressed Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 38 of 61 appreciation for the use of the updated vocabulary. In regards to the check all that apply format, the experts provided positive feedback, expressing that the new set-up is relevant and easier for the readers comprehension. Table 2 Consensus Levels for Round 3 Items Consensus Bathe and/or shower 100% Manage finances 93.33% Clean my home 86.67% Do my yard work 66.67%* Perform home maintenance and repairs 53%* Plan, prepare, serve and/or clean up meals 93.33% Rest and sleep 100% Engage in educational activities 80% Participate in leisure activities 100% Socialize with my family and friends 100% Participate in community events 86.67% Engage in sexual activity and/or sexual expression (e.g., hugging, kissing, foreplay, masturbation, oral sex, intercourse) 100% Engage in activities to give and receive affection needed to successfully interact in close personal relationships (e.g., friends, family members, intimate partners) 93.33% Provide care for others (e.g., childcare, caring for older parents, etc.) 93.33% Move self from one position or place to another (e.g., reaching, moving in bed, moving in wheelchair, performing transfers, walking during tasks and transporting items) 100% Maintain my desired exercise routine and physical fitness 93.33% Manage my medications (e.g. filling prescriptions at the pharmacy, understanding medication instruction, taking medications on a routine basis, refilling prescriptions in a timely manner) 93.33% Grocery shop (e.g., prepare grocery list, order online/go to store, bag groceries, unloading groceries, paying) 86.67% Engage in desired work performance and/or returning to work 93.33% Drive and move around the community (e.g., using public or private transportation) 93% Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 39 of 61 Manage my health (e.g., communicate with healthcare providers, understand recommendations for care plan, manage symptoms and conditions, etc.) 93.33% Toilet and toilet hygiene 100% Engage in religious/spiritual activities, organizations, and/or practices 86.67% Dress/undress (e.g., fasten and adjust clothing and shoes, remove personal devices/prosthetic devices/splints) 93.33% Personal hygiene and grooming 93.33% Note. * indicates items that did not meet consensus. Round 4 In Round 4 of our Delphi Study, we collected 14 survey responses from expert panelists. Three items did not meet consensus, which included Engage in leisure activities, Participate in community events, and Engage in religious/spiritual activities, organizations, and/or practices. See Table 3 for Round 4 consensus levels. Researchers removed these three items from the SOCS-OTS entirely. Researchers did not modify any items following the conclusion of this round as the remainder of the items reached consensus. Experts expressed general positive feedback about the SOCS-OTS and that it will be a valuable tool to identify the need for OT services. See Appendix D for the final version of SOCS-OTS. Table 3 Consensus Levels for Round 4 Items Consensus Bathe and/or shower 100% Manage finances 100% Clean my home 85.71% Plan, prepare, serve and/or clean up meals 100% Rest and sleep 100% Engage in educational activities 57.14%* Participate in leisure activities 100% Socialize with my family and friends 100% Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 40 of 61 Participate in community events 57.14%* Engage in sexual activity and/or sexual expression (e.g., hugging, kissing, foreplay, masturbation, oral sex, intercourse) 100% Engage in activities to give and receive affection needed to successfully interact in close personal relationships (e.g., friends, family members, intimate partners) 100% Provide care for others (e.g., childcare, caring for older parents, etc.) 92.86% Move self from one position or place to another (e.g., reaching, moving in bed, moving in wheelchair, performing transfers, walking during tasks and transporting items) 85.71% Maintain my desired exercise routine and physical fitness 92.86% Manage my medications (e.g. filling prescriptions at the pharmacy, understanding medication instruction, taking medications on a routine basis, refilling prescriptions in a timely manner) Grocery shop (e.g., prepare grocery list, order online/go to store, bag groceries, unloading groceries, paying) 100% 85.71% Engage in desired work performance and/or returning to work 100% Drive and move around the community (e.g., using public or private transportation) 100% Manage my health (e.g., communicate with healthcare providers, understand recommendations for care plan, manage symptoms and conditions, etc.) Toilet and toilet hygiene 92.86% 100% Engage in religious/spiritual activities, organizations, and/or practices Dress/undress (e.g., fasten and adjust clothing and shoes, remove personal devices/prosthetic devices/splints) Personal hygiene and grooming Note. * indicates items that did not meet consensus. 78.57%* 100% 100% Discussion In this modified Delphi study, researchers aimed to identify the level of consensus on which items should appear on the final SOCS-OTS tool. There are currently no developed screening tools used in practice to indicate the need for referral to occupational therapy in survivorship care, despite evidence that occupational performance limitations occur from side effects of cancer treatment. Pergolotti et al. (2020) found in ovarian cancer survivors, functional limitations lead to physical, social, and emotional problems, which occupational therapy can Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 41 of 61 address. Survivors reported deficits in areas of daily living, work, and physical activity, which correlate with decreased quality of life (Pergolotti et al., 2020). Martin et al. (2020) further explored the impact of survivorship on occupational performance. They identified six limited domains of occupation: social activity, physical activity, sexual activity, employment and role functioning, physical functioning, and self-care. Side effects of cancer treatment, including urinary dysfunction, fatigue, anxiety, weakness, and pain, impact these occupational domains (Martin et al., 2020). Per Martin et al. (2020), these limitations can result in depression, anxiety, and reduced quality of life among survivors. Thus, the side effects of cancer treatment can have detrimental implications on occupational performance. According to Hwang et al. (2015), among 30 of the 68 participants (45.5%) who received referrals, 13 participants (19.7%) reported having a physical therapy referral for survivorship care, yet only 3 (4.5%) received occupational therapy. Similarly, Pergolotti et al. (2014) conducted a population-based survey finding that of the 87% of older cancer survivors in need of occupational therapy, only 32% saw occupational therapy within the first two years of their cancer diagnosis, further reinforcing the underutilization of occupational therapy in cancer survivorship. While survivors continue to experience occupational performance deficits following cancer treatment and occupational therapy services are being underutilized, there is also a lack of referral to occupational therapy services (Martin et al., 2020). The ASCO SCP does not include various kinds of life activities (occupations) inhibited in cancer survivorship and would indicate a referral to needed occupational therapy services (American Society of Clinical Oncology, 2019). Doucet and Gutman (2013) called for the need for occupational therapy researchers to design measurement tools that provide quantifiable data on function in areas including body Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 42 of 61 impairment, activity limitation, and participation restriction. Using this quantifiable data, practitioners could indicate the need for occupational therapy services, justify their role in the healthcare system, and improve the quality of life among clients with functional impairments (Doucet & Gutman, 2013). Researchers in the current study gathered consensus from experts in oncology to determine item inclusion on the SOCS-OTS final rendition. The items on the SOCS-OTS include everyday activities of daily living that are frequently stated as participation restrictions by cancer survivors, e.g., My cancer has made it difficult to engage in sexual activity with a partner or myself. According to the American Occupational Therapy Association (2014), cancer treatment can negatively impact every aspect of the occupation. The most highly rated items on the final SOCS-OTS addressed the following areas of occupation: bathing and dressing, managing finances, feeding/eating, rest and sleep, social participation, sexual activity and intimacy, medication management, work, and community mobility. Literature shows that cancer survivors experience limitations in social participation, leading to decreased quality of life (Martin et al., 2020). Chemotherapy and other cancer treatments can lead to a decline in strength, fatigue, depression, and pain which influences the ability to return to work (Martin et al., 2020). Occupational therapy can positively impact these factors related to their ability to return to work (Wallis et al., 2020). Hwang et al. (2015) stated that cancer survivors often report experiencing decreased sexual drive, poor body image, and sexual discomfort, which limit their ability to participate in sexual activity. Survivors listed hygiene as one of the most important occupational performance deficits experienced by cancer survivors in a study conducted by Marciniak et al. (1996). Hwang et al. (2015) identified the occupational performance limitations cancer survivors face leading to a decreased quality of life. Items of Engage in education activities," "Participate Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 43 of 61 in community events," and "Engage in spiritual/religious activities, organizations, and/or practices" did not meet consensus. There was limited research to support these items, which may have impacted the experts recommendations to remove these items from the tool. Limitations and Future Research It is important to recognize the limitations of this study. First, we faced attrition in this study with 27 initial panelists in round 2; therefore, we had a small sample size of expert panelists that diminished to 14 by round 4. Literature on Delphi methodology states that 30 panelists are ideal (Hasson et al., 2000; Powell, 2003). In accordance with previous Delphi studies, researchers expected an attrition rate of 20% for a Delphi study of 3 rounds (Henderson & Rubin, 2012). Some possible issues related to this more significant attrition rate were that active data collection happened around a holiday break and during a global pandemic. The first round of the Delphi study included a majority of participants who were breast cancer survivors. Therefore, this may be problematic when considering the development of the screening tool as certain forms of cancer can have different effects on various occupations. Future research supporting the SOCS-OTS should focus on developing its psychometric properties, such as a formal validation of its scale and exploring how many responses indicate the need for an OT referral. Additionally, reliability studies are warranted involving a variety of cancer diagnoses. Future researchers should also explore distress screeners or current survivorship care plans to screen for side effects of cancer and identify which items on these screening tools would trigger the need to use the SOCS-OTS for possible OT referral. Implications for Occupational Therapy Practice To address the broad spectrum of occupational performance issues related to survivorship care, health care providers must recognize what clients require an occupational therapy referral at Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 44 of 61 various points in the survivorship continuum. Occupational therapy practitioners can take action with improving screening services for cancer survivors in the following ways: Educate referral sources on the distinct value of OT in oncology care. OT has distinct value in oncology care because of the skill set. Occupational therapists work with survivors on their physical and psychosocial needs to improve various occupational performance deficits they face due to cancer treatment. While many healthcare providers focus on the side effects survivors face, OTs focus on how those side effects affect their everyday function and performance in daily tasks (Sleight & Duker, 2016). Discuss with oncology teams the importance of screening for occupational performance deficits using screening tools like SOCS-OTS. Introduce SOCS-OTS to frontline practitioners in oncology care, including nurse navigators, oncologists, and other members of multidisciplinary oncology teams. Adopt and incorporate the SOCS-OTS into screening procedures and care coordination, including its potential implementation into distress screening tools and survivorship care plans. Conclusion There is currently no developed screening tool indicating occupational performance deficits and the need for referral to occupational therapy in the cancer survivor population. This gap in screening services led to the development and need for formal validation of the SOCSOTS. Items included in the final version of the SOCS-OTS tool, following expert consensus, addressed the degree of difficulty clients have performing occupations following cancer treatment. They specifically addressed activities of daily living and instrumental activities of daily living. Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 45 of 61 In the first round of the Delphi study, researchers used the opinion of cancer survivors for validation of screening tool items they developed from a thorough literature review. In the second round (and current study), researchers used expert panelists, including occupational therapists (OT), occupational therapy assistants (OTA), and OT researchers that practice and contribute to the research in the field of occupational therapy in oncology. In health science research, researchers commonly select a Delphi approach to eliminate biases, allow opinions from a variety of experts, and have the opportunity for revision and feedback following each round of the Delphi until they reach consensus (Avella, 2016; Hasson et al., 2000; Sekayi & Kennedy, 2017). Practitioners in oncology care can use the SOCS-OTS tool to identify activities that the client cannot perform to their satisfaction. Further work may be needed to refine and test the tool in a clinical setting to ensure its feasibility and effectiveness in client-centered care. Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 46 of 61 References American Occupational Therapy Association. (2014). 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Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 57 of 61 Appendix A SOCS-OTS Please rate your level of functioning as it pertains to each item presented below. I cannot do this I have a lot of problems with doing this I have some problems with doing this I can do this well I can do this very well Bathe and/or shower Engage in sexual activity with a partner or myself Maintain closeness and intimacy with a romantic partner Provide care for other people and/or pets Move from one position or place to another Manage finances (i.e. processes of paying bills, budgeting, simple money transaction) Maintain my exercise routine and physical fitness Manage my medications Clean my home Do my yard work Perform home maintenance and repairs Plan, prepare, serve, and/or clean up meals. Grocery shop Rest and sleep Fully return to work Perform my job duties at prior level of expectation Engage in educational activities Participate in leisure activities Socialize with my family and friends Participate in community events Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 58 of 61 Appendix B Screen of Cancer Survivorship Occupational Therapy Services (SOCS-OTS) Instructions: Please check all items that you would like assistance with improving. Item Please check all that apply Bathe and/or shower Engage in sexual activity and/or sexual expression (e.g., hugging, kissing, foreplay, masturbation, oral sex, intercourse) Engage in activities to give and receive affection needed to successfully interact in close personal relationships (e.g., friends, family members, intimate partners) Provide care for others (e.g., childcare, caring for older parents, etc.) Move self from one position or place to another (e.g., reaching, moving in bed, moving in wheelchair, performing transfers, walking during tasks and transporting items) Drive and move around the community (e.g., using public or private transportation) Manage finances Maintain my desired exercise routine and physical fitness Manage my medications (e.g. filling prescriptions at the pharmacy, understanding medication instruction, taking medications on a routine basis, refilling prescriptions in a timely manner) Clean my home Do my yard work Perform home maintenance and repairs Plan, prepare, serve and/or clean up meals Grocery shop (e.g., prepare grocery list, order online/go to store, bag groceries, unloading groceries, paying) [modified item Rest and sleep Engage in desired work performance and/or returning to work Engage in educational activities Participate in leisure activities Socialize with my family and friends Participate in community events Manage my health (e.g., communicate with healthcare providers, understand recommendations for care plan, manage symptoms and conditions, etc.) Toilet and toilet hygiene Engage in religious/spiritual activities, organizations, and/or practices Dress/undress (e.g., fasten and adjust clothing and shoes, remove personal devices/prosthetic devices/splints) Personal hygiene and grooming Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 59 of 61 Appendix C Screen of Cancer Survivorship Occupational Therapy Services (SOCS-OTS) Instructions: Please check all items that you would like assistance with improving. Item Please check all that apply Bathe and/or shower Engage in sexual activity and/or sexual expression (e.g., hugging, kissing, foreplay, masturbation, oral sex, intercourse) Engage in activities to give and receive affection needed to successfully interact in close personal relationships (e.g., friends, family members, intimate partners) Provide care for others (e.g., childcare, caring for older parents, etc.) Move self from one position or place to another (e.g., reaching, moving in bed, moving in wheelchair, performing transfers, walking during tasks and transporting items) Drive and move around the community (e.g., using public or private transportation) Manage finances Maintain my desired exercise routine and physical fitness Manage my medications (e.g. filling prescriptions at the pharmacy, understanding medication instruction, taking medications on a routine basis, refilling prescriptions in a timely manner) Clean my home Plan, prepare, serve and/or clean up meals Grocery shop (e.g., prepare grocery list, order online/go to store, bag groceries, unloading groceries, paying) [modified item Rest and sleep Engage in desired work performance and/or returning to work Engage in educational activities Participate in leisure activities Socialize with my family and friends Participate in community events Manage my health (e.g., communicate with healthcare providers, understand recommendations for care plan, manage symptoms and conditions, etc.) Toilet and toilet hygiene Engage in religious/spiritual activities, organizations, and/or practices Dress/undress (e.g., fasten and adjust clothing and shoes, remove personal devices/prosthetic devices/splints) Personal hygiene and grooming Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 60 of 61 Appendix D Screen of Cancer Survivorship Occupational Therapy Services (SOCS-OTS) Instructions: Please check all items that you would like assistance with improving. Item Please check all that apply Bathe and/or shower Engage in sexual activity and/or sexual expression (e.g., hugging, kissing, foreplay, masturbation, oral sex, intercourse) Engage in activities to give and receive affection needed to successfully interact in close personal relationships (e.g., friends, family members, intimate partners) Provide care for others (e.g., childcare, caring for older parents, etc.) Move self from one position or place to another (e.g., reaching, moving in bed, moving in wheelchair, performing transfers, walking during tasks and transporting items) Drive and move around the community (e.g., using public or private transportation) Manage finances Maintain my desired exercise routine and physical fitness Manage my medications (e.g. filling prescriptions at the pharmacy, understanding medication instruction, taking medications on a routine basis, refilling prescriptions in a timely manner) Clean my home Plan, prepare, serve and/or clean up meals Grocery shop (e.g., prepare grocery list, order online/go to store, bag groceries, unloading groceries, paying) [modified item Rest and sleep Engage in desired work performance and/or returning to work Participate in leisure activities Socialize with my family and friends Manage my health (e.g., communicate with healthcare providers, understand recommendations for care plan, manage symptoms and conditions, etc.) Toilet and toilet hygiene Dress/undress (e.g., fasten and adjust clothing and shoes, remove personal devices/prosthetic devices/splints) Personal hygiene and grooming (e.g., using a razor, applying cosmetics, combing or brushing hair, caring for nails, applying deodorant, brushing/flossing teeth, denture care) Document Ref: XRFVX-UNFIU-DBXKN-D3NR6 Page 61 of 61 Signature Certificate Document Ref.: XRFVX-UNFIU-DBXKN-D3NR6 Document signed by: Katie Polo Verified E-mail: polok@uindy.edu IP: 184.170.166.188 Date: 15 Dec 2021 13:19:32 UTC Kate DeCleene Huber Verified E-mail: decleenek@uindy.edu IP: 199.8.28.36 Date: 15 Dec 2021 13:26:27 UTC Document completed by all parties on: 15 Dec 2021 13:26:27 UTC Page 1 of 1 Signed with PandaDoc.com PandaDoc is a document workflow and certified eSignature solution trusted by 25,000+ companies worldwide.  ...