A Remotely Delivered, Peer-Led Physical Activity Intervention for Younger Breast Cancer Survivors (Pink Body Spirit): Protocol for a Feasibility Study and Mixed Methods Process Evaluation

Lauren S Weiner, Stori Nagel, H Irene Su, Samantha Hurst, Sheri J Hartman, Lauren S Weiner, Stori Nagel, H Irene Su, Samantha Hurst, Sheri J Hartman

Abstract

Background: Younger breast cancer survivors consistently report a greater impact of their cancer experience on quality of life compared with older survivors, including higher rates of body image disturbances, sexual dysfunction, and fatigue. One potential strategy to improve quality of life is through physical activity, but this has been understudied in younger breast cancer survivors, who often decrease their activity during and after cancer treatment.

Objective: The aim of this study is to explore the feasibility and acceptability of a technology-based, remotely delivered, peer-led physical activity intervention for younger breast cancer survivors. We will also assess the preliminary impact of the intervention on changes in physical activity and multiple aspects of quality of life.

Methods: This study is a community-academic partnership between University of California, San Diego and Haus of Volta, a nonprofit organization that promotes positive self-image in younger breast cancer survivors. This ongoing pilot study aims to recruit 30 younger breast cancer survivors across the United States (<55 years old, >6 months post primary cancer treatment, self-report <60 min of moderate-to-vigorous-intensity physical activity [MVPA]) into a 3-month peer-delivered, fully remote exercise program. Participants will complete 6 biweekly video chat sessions with a trained peer mentor, a fellow younger breast cancer survivor. Participants will receive a Fitbit Charge 3; weekly feedback on Fitbit data from their peer mentor; and access to a private, in-app Fitbit Community to provide and receive support from other participants and all peer mentors. At baseline, 3 months, and 6 months, participants will complete quality of life questionnaires, and MVPA will be measured using the ActiGraph accelerometer. Feasibility and acceptability will be explored through a mixed methods approach (ie, quantitative questionnaires and qualitative interviews). Intervention delivery and adaptations by peer mentors will be tracked through peer mentor self-evaluations and reflections, review of video-recorded mentoring sessions, and monthly templated reflections by the research team.

Results: Recruitment began in September 2019. As of February 2020, the physical activity intervention is ongoing. Final measures are expected to occur in summer 2020.

Conclusions: This study explores the potential for physical activity to improve sexual function, body image, and fatigue, key quality of life issues in younger breast cancer survivors. Using peer mentors extends our reach into the young survivor community. The detailed process evaluation of intervention delivery and adaptations by mentors could inform a future hybrid-effectiveness implementation trial. Finally, remote delivery with commercially available technology could promote broader dissemination.

Trial registration: ClinicalTrials.gov NCT04064892; https://ichgcp.net/clinical-trials-registry/NCT04064892.

International registered report identifier (irrid): DERR1-10.2196/18420.

Keywords: breast cancer; cancer survivors; fitness trackers; mobile phone; peer mentors; physical activity; pilot study; quality of life.

Conflict of interest statement

Conflicts of Interest: None declared.

©Lauren S Weiner, Stori Nagel, H Irene Su, Samantha Hurst, Sheri J Hartman. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 08.07.2020.

Figures

Figure 1
Figure 1
Flow diagram of the Pink Body Spirit pilot study.
Figure 2
Figure 2
Visual depiction of how Fitbits will be used to support increasing physical activity in the Pink Body Spirit pilot study.
Figure 3
Figure 3
Sample posts from the private, in-app Pink Body Spirit Fitbit Community (note: app screenshots have been redacted to maintain confidentiality).

References

    1. Miller K, Nogueira L, Mariotto A, Rowland JH, Yabroff KR, Alfano CM, Jemal A, Kramer JL, Siegel RL. Cancer treatment and survivorship statistics, 2019. CA Cancer J Clin. 2019 Sep;69(5):363–85. doi: 10.3322/caac.21565. doi: 10.3322/caac.21565.
    1. Ademuyiwa F, Cyr A, Ivanovich J, Thomas M. Managing breast cancer in younger women: challenges and solutions. Breast Cancer (Dove Med Press) 2016;8:1–12. doi: 10.2147/BCTT.S68848. doi: 10.2147/BCTT.S68848.
    1. Murphy BL, Day CN, Hoskin TL, Habermann EB, Boughey JC. Adolescents and young adults with breast cancer have more aggressive disease and treatment than patients in their forties. Ann Surg Oncol. 2019 Nov;26(12):3920–30. doi: 10.1245/s10434-019-07653-9.
    1. van Leeuwen M, Husson O, Alberti P, Arraras JI, Chinot OL, Costantini A, Darlington A, Dirven L, Eichler M, Hammerlid EB, Holzner B, Johnson CD, Kontogianni M, Kjær TK, Morag O, Nolte S, Nordin A, Pace A, Pinto M, Polz K, Ramage J, Reijneveld JC, Serpentini S, Tomaszewski KA, Vassiliou V, Verdonck-de Leeuw IM, Vistad I, Young TE, Aaronson NK, van de Poll-Franse LV, EORTC QLG Understanding the quality of life (QOL) issues in survivors of cancer: towards the development of an EORTC QOL cancer survivorship questionnaire. Health Qual Life Outcomes. 2018 Jun 4;16(1):114. doi: 10.1186/s12955-018-0920-0.
    1. Pinto A. Sexuality and breast cancer: prime time for young patients. J Thorac Dis. 2013 Jun;5(Suppl 1):S81–6. doi: 10.3978/j.issn.2072-1439.2013.05.23. doi: 10.3978/j.issn.2072-1439.2013.05.23.
    1. Ventura EE, Ganz PA, Bower JE, Abascal L, Petersen L, Stanton AL, Crespi CM. Barriers to physical activity and healthy eating in young breast cancer survivors: modifiable risk factors and associations with body mass index. Breast Cancer Res Treat. 2013 Nov;142(2):423–33. doi: 10.1007/s10549-013-2749-x.
    1. Rabin C, Simpson N, Morrow K, Pinto B. Intervention format and delivery preferences among young adult cancer survivors. Int J Behav Med. 2013 Jun;20(2):304–10. doi: 10.1007/s12529-012-9227-4.
    1. Rabin C. Barriers to increasing physical activity among young adult cancer survivors. J Adolesc Young Adult Oncol. 2017 Jun;6(2):372–6. doi: 10.1089/jayao.2016.0056.
    1. Ottenbacher AJ, Day RS, Taylor WC, Sharma SV, Sloane R, Snyder DC, Kraus WE, Demark-Wahnefried W. Exercise among breast and prostate cancer survivors--what are their barriers? J Cancer Surviv. 2011 Dec;5(4):413–9. doi: 10.1007/s11764-011-0184-8.
    1. Parsons HM, Harlan LC, Lynch CF, Hamilton AS, Wu X, Kato I, Schwartz SM, Smith AW, Keel G, Keegan TH. Impact of cancer on work and education among adolescent and young adult cancer survivors. J Clin Oncol. 2012 Jul 1;30(19):2393–400. doi: 10.1200/JCO.2011.39.6333.
    1. Stone DS, Ganz PA, Pavlish C, Robbins WA. Young adult cancer survivors and work: a systematic review. J Cancer Surviv. 2017 Dec;11(6):765–81. doi: 10.1007/s11764-017-0614-3.
    1. Vetsch J, Wakefield CE, McGill BC, Cohn RJ, Ellis SJ, Stefanic N, Sawyer SM, Zebrack B, Sansom-Daly UM. Educational and vocational goal disruption in adolescent and young adult cancer survivors. Psychooncology. 2018 Feb;27(2):532–8. doi: 10.1002/pon.4525.
    1. Avis NE, Crawford S, Manuel J. Quality of life among younger women with breast cancer. J Clin Oncol. 2005 May 20;23(15):3322–30. doi: 10.1200/JCO.2005.05.130.
    1. Ruddy KJ, Greaney ML, Sprunck-Harrild K, Meyer ME, Emmons KM, Partridge AH. Young women with breast cancer: a focus group study of unmet needs. J Adolesc Young Adult Oncol. 2013 Dec 1;2(4):153–60. doi: 10.1089/jayao.2013.0014.
    1. Hungr C, Sanchez-Varela V, Bober SL. Self-image and sexuality issues among young women with breast cancer: practical recommendations. Rev Invest Clin. 2017;69(2):114–22. doi: 10.24875/ric.17002200.
    1. Leinert E, Singer S, Janni W, Harbeck N, Weissenbacher T, Rack B, Augustin D, Wischnik A, Kiechle M, Ettl J, Fink V, Schwentner L, Eichler M. The impact of age on quality of life in breast cancer patients receiving adjuvant chemotherapy: a comparative analysis from the prospective multicenter randomized Adebar trial. Clin Breast Cancer. 2017 Apr;17(2):100–6. doi: 10.1016/j.clbc.2016.10.008.
    1. Rosenberg SM, Tamimi RM, Gelber S, Ruddy KJ, Kereakoglow S, Borges VF, Come SE, Schapira L, Winer EP, Partridge AH. Body image in recently diagnosed young women with early breast cancer. Psychooncology. 2013 Aug;22(8):1849–55. doi: 10.1002/pon.3221.
    1. Sheppard VB, Hicks J, Makambi K, Hurtado-de-Mendoza A, Demark-Wahnefried W, Adams-Campbell L. The feasibility and acceptability of a diet and exercise trial in overweight and obese black breast cancer survivors: the stepping STONE study. Contemp Clin Trials. 2016 Jan;46:106–13. doi: 10.1016/j.cct.2015.12.005.
    1. Rock CL, Flatt SW, Byers TE, Colditz GA, Demark-Wahnefried W, Ganz PA, Wolin KY, Elias A, Krontiras H, Liu J, Naughton M, Pakiz B, Parker BA, Sedjo RL, Wyatt H. Results of the exercise and nutrition to enhance recovery and good health for you (ENERGY) trial: a behavioral weight loss intervention in overweight or obese breast cancer survivors. J Clin Oncol. 2015 Oct 1;33(28):3169–76. doi: 10.1200/JCO.2015.61.1095.
    1. Chen X, Lu W, Zheng W, Gu K, Matthews CE, Chen Z, Zheng Y, Shu XO. Exercise after diagnosis of breast cancer in association with survival. Cancer Prev Res (Phila) 2011 Sep;4(9):1409–18. doi: 10.1158/1940-6207.CAPR-10-0355.
    1. Schmid D, Leitzmann M. Association between physical activity and mortality among breast cancer and colorectal cancer survivors: a systematic review and meta-analysis. Ann Oncol. 2014 Jul;25(7):1293–311. doi: 10.1093/annonc/mdu012.
    1. Mishra S, Scherer R, Geigle P, Berlanstein DR, Topaloglu O, Gotay CC, Snyder C. Exercise interventions on health-related quality of life for cancer survivors. Cochrane Database Syst Rev. 2012 Aug 15;(8):CD007566. doi: 10.1002/14651858.CD007566.pub2.
    1. Ferrer RA, Huedo-Medina TB, Johnson BT, Ryan S, Pescatello LS. Exercise interventions for cancer survivors: a meta-analysis of quality of life outcomes. Ann Behav Med. 2011 Feb;41(1):32–47. doi: 10.1007/s12160-010-9225-1.
    1. Speck RM, Gross CR, Hormes JM, Ahmed RL, Lytle LA, Hwang W, Schmitz KH. Changes in the body image and relationship scale following a one-year strength training trial for breast cancer survivors with or at risk for lymphedema. Breast Cancer Res Treat. 2010 Jun;121(2):421–30. doi: 10.1007/s10549-009-0550-7.
    1. Howard-Anderson J, Ganz PA, Bower JE, Stanton AL. Quality of life, fertility concerns, and behavioral health outcomes in younger breast cancer survivors: a systematic review. J Natl Cancer Inst. 2012 Mar 7;104(5):386–405. doi: 10.1093/jnci/djr541.
    1. National Cancer Institute. Bethesda MD. Cancer Trends Progress Report. 2020. Mar, [2020-06-08].
    1. Rabin C, Dunsiger S, Ness KK, Marcus BH. Internet-based physical activity intervention targeting young adult cancer survivors. J Adolesc Young Adult Oncol. 2011 Dec;1(4):188–94. doi: 10.1089/jayao.2011.0040.
    1. Valle CG, Tate DF, Mayer DK, Allicock M, Cai J. A randomized trial of a Facebook-based physical activity intervention for young adult cancer survivors. J Cancer Surviv. 2013 Sep;7(3):355–68. doi: 10.1007/s11764-013-0279-5.
    1. Rabin C, Pinto B, Fava J. Randomized trial of a physical activity and meditation intervention for young adult cancer survivors. J Adolesc Young Adult Oncol. 2016 Mar;5(1):41–7. doi: 10.1089/jayao.2015.0033.
    1. Bluethmann SM, Vernon SW, Gabriel KP, Murphy CC, Bartholomew LK. Taking the next step: a systematic review and meta-analysis of physical activity and behavior change interventions in recent post-treatment breast cancer survivors. Breast Cancer Res Treat. 2015 Jan;149(2):331–42. doi: 10.1007/s10549-014-3255-5.
    1. Michie S, Ashford S, Sniehotta FF, Dombrowski SU, Bishop A, French DP. A refined taxonomy of behaviour change techniques to help people change their physical activity and healthy eating behaviours: the CALO-RE taxonomy. Psychol Health. 2011 Nov;26(11):1479–98. doi: 10.1080/08870446.2010.540664.
    1. Bluethmann SM, Bartholomew LK, Murphy CC, Vernon SW. Use of theory in behavior change interventions. Health Educ Behav. 2017 Apr;44(2):245–53. doi: 10.1177/1090198116647712.
    1. Sullivan AN, Lachman ME. Behavior change with fitness technology in sedentary adults: a review of the evidence for increasing physical activity. Front Public Health. 2016;4:289. doi: 10.3389/fpubh.2016.00289. doi: 10.3389/fpubh.2016.00289.
    1. Mercer K, Li M, Giangregorio L, Burns C, Grindrod K. Behavior change techniques present in wearable activity trackers: a critical analysis. JMIR Mhealth Uhealth. 2016 Apr 27;4(2):e40. doi: 10.2196/mhealth.4461.
    1. Lyons EJ, Lewis ZH, Mayrsohn BG, Rowland JL. Behavior change techniques implemented in electronic lifestyle activity monitors: a systematic content analysis. J Med Internet Res. 2014 Aug 15;16(8):e192. doi: 10.2196/jmir.3469.
    1. Michie S, Abraham C, Whittington C, McAteer J, Gupta S. Effective techniques in healthy eating and physical activity interventions: a meta-regression. Health Psychol. 2009 Nov;28(6):690–701. doi: 10.1037/a0016136.
    1. Samdal GB, Eide GE, Barth T, Williams G, Meland E. Effective behaviour change techniques for physical activity and healthy eating in overweight and obese adults; systematic review and meta-regression analyses. Int J Behav Nutr Phys Act. 2017 Mar 28;14(1):42. doi: 10.1186/s12966-017-0494-y.
    1. Michie S, Richardson M, Johnston M, Abraham C, Francis J, Hardeman W, Eccles MP, Cane J, Wood CE. The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Ann Behav Med. 2013 Aug;46(1):81–95. doi: 10.1007/s12160-013-9486-6.
    1. Hartman SJ, Nelson SH, Cadmus-Bertram LA, Patterson RE, Parker BA, Pierce JP. Technology- and phone-based weight loss intervention: pilot RCT in women at elevated breast cancer risk. Am J Prev Med. 2016 Nov;51(5):714–21. doi: 10.1016/j.amepre.2016.06.024.
    1. Hartman SJ, Nelson SH, Myers E, Natarajan L, Sears DD, Palmer BW, Weiner LS, Parker BA, Patterson RE. Randomized controlled trial of increasing physical activity on objectively measured and self-reported cognitive functioning among breast cancer survivors: the memory & motion study. Cancer. 2018 Jan 1;124(1):192–202. doi: 10.1002/cncr.30987. doi: 10.1002/cncr.30987.
    1. Hartman SJ, Nelson SH, Weiner LS. Patterns of FitBit use and activity levels throughout a physical activity intervention: exploratory analysis from a randomized controlled trial. JMIR Mhealth Uhealth. 2018 Feb 5;6(2):e29. doi: 10.2196/mhealth.8503.
    1. Lloyd G, Hoffman S, Welch W, Blanch-Hartigan D, Gavin KL, Cottrell A, Cadmus-Bertram L, Spring B, Penedo F, Courneya KS, Phillips SM. Breast cancer survivors' preferences for social support features in technology-supported physical activity interventions: findings from a mixed methods evaluation. Transl Behav Med. 2020 May 20;10(2):423–34. doi: 10.1093/tbm/iby112.
    1. Robertson MC, Tsai E, Lyons EJ, Srinivasan S, Swartz MC, Baum ML, Basen-Engquist KM. Mobile health physical activity intervention preferences in cancer survivors: a qualitative study. JMIR Mhealth Uhealth. 2017 Jan 24;5(1):e3. doi: 10.2196/mhealth.6970.
    1. Abrol E, Groszmann M, Pitman A, Hough R, Taylor RM, Aref-Adib G. Exploring the digital technology preferences of teenagers and young adults (TYA) with cancer and survivors: a cross-sectional service evaluation questionnaire. J Cancer Surviv. 2017 Dec;11(6):670–82. doi: 10.1007/s11764-017-0618-z.
    1. Israel BA, Schulz AJ, Parker EA, Becker AB. Review of community-based research: assessing partnership approaches to improve public health. Annu Rev Public Health. 1998;19:173–202. doi: 10.1146/annurev.publhealth.19.1.173.
    1. Israel BA, Coombe CM, Cheezum RR, Schulz AJ, McGranaghan RJ, Lichtenstein R, Reyes AG, Clement J, Burris A. Community-based participatory research: a capacity-building approach for policy advocacy aimed at eliminating health disparities. Am J Public Health. 2010 Nov;100(11):2094–102. doi: 10.2105/AJPH.2009.170506.
    1. Hartman SJ, Natarajan L, Palmer BW, Parker B, Patterson RE, Sears DD. Impact of increasing physical activity on cognitive functioning in breast cancer survivors: rationale and study design of memory & motion. Contemp Clin Trials. 2015 Nov;45(Pt B):371–6. doi: 10.1016/j.cct.2015.09.021.
    1. Wu YP, Yi J, McClellan J, Kim J, Tian T, Grahmann B, Kirchhoff AC, Holton A, Wright J. Barriers and facilitators of healthy diet and exercise among adolescent and young adult cancer survivors: implications for behavioral interventions. J Adolesc Young Adult Oncol. 2015 Dec;4(4):184–91. doi: 10.1089/jayao.2015.0028.
    1. Gorman JR, Roberts SC, Dominick SA, Malcarne VL, Dietz AC, Su HI. A diversified recruitment approach incorporating social media leads to research participation among young adult-aged female cancer survivors. J Adolesc Young Adult Oncol. 2014 Jun 1;3(2):59–65. doi: 10.1089/jayao.2013.0031.
    1. Thomas S, Reading J, Shephard RJ. Revision of the physical activity readiness questionnaire (PAR-Q) Can J Sport Sci. 1992 Dec;17(4):338–45.
    1. Wolin KY, Schwartz AL, Matthews CE, Courneya KS, Schmitz KH. Implementing the exercise guidelines for cancer survivors. J Support Oncol. 2012;10(5):171–7. doi: 10.1016/j.suponc.2012.02.001.
    1. Martins RK, McNeil DW. Review of motivational interviewing in promoting health behaviors. Clin Psychol Rev. 2009 Jun;29(4):283–93. doi: 10.1016/j.cpr.2009.02.001.
    1. Motivational Interviewing Step by Step. Academy. [2020-06-08]. .
    1. Carver CS, Scheier MF. Control theory: a useful conceptual framework for personality–social, clinical, and health psychology. Psychol Bull. 1982;92(1):111–35. doi: 10.1037/0033-2909.92.1.111.
    1. Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice Hall; 1986.
    1. Rock CL, Doyle C, Demark-Wahnefried W, Meyerhardt J, Courneya KS, Schwartz AL, Bandera EV, Hamilton KK, Grant B, McCullough M, Byers T, Gansler T. Nutrition and physical activity guidelines for cancer survivors. CA Cancer J Clin. 2012;62(4):243–74. doi: 10.3322/caac.21142. doi: 10.3322/caac.21142.
    1. Diabetes Prevention Program (DPP) Research Group The diabetes prevention program (DPP): description of lifestyle intervention. Diabetes Care. 2002 Dec;25(12):2165–71. doi: 10.2337/diacare.25.12.2165.
    1. Look AHEAD Research Group. Wadden TA, West DS, Delahanty L, Jakicic J, Rejeski J, Williamson D, Berkowitz RI, Kelley DE, Tomchee C, Hill JO, Kumanyika S. The look AHEAD study: a description of the lifestyle intervention and the evidence supporting it. Obesity (Silver Spring) 2006 May;14(5):737–52. doi: 10.1038/oby.2006.84. doi: 10.1038/oby.2006.84.
    1. Creswell J. In: Designing and Conducting Mixed Methods Research. Third Edition. Plano W, Clark VL, editors. Thousand Oaks, CA: SAGE Publications; 2018.
    1. Weiner BJ, Lewis CC, Stanick C, Powell BJ, Dorsey CN, Clary AS, Boynton MH, Halko H. Psychometric assessment of three newly developed implementation outcome measures. Implement Sci. 2017 Aug 29;12(1):108. doi: 10.1186/s13012-017-0635-3.
    1. Freedson PS, Melanson E, Sirard J. Calibration of the computer science and applications inc accelerometer. Med Sci Sports Exerc. 1998 May;30(5):777–81. doi: 10.1097/00005768-199805000-00021.
    1. Nelson SH, Weiner LS, Natarajan L, Parker BA, Patterson RE, Hartman SJ. Continuous, objective measurement of physical activity during chemotherapy for breast cancer: the activity in treatment pilot study. Transl Behav Med. 2019 May 29;:-. doi: 10.1093/tbm/ibz079. epub ahead of print.
    1. Hopwood P, Fletcher I, Lee A, Al Ghazal S. A body image scale for use with cancer patients. Eur J Cancer. 2001 Jan;37(2):189–97. doi: 10.1016/s0959-8049(00)00353-1.
    1. Lewis-Smith H, Diedrichs PC, Rumsey N, Harcourt D. Efficacy of psychosocial and physical activity-based interventions to improve body image among women treated for breast cancer: a systematic review. Psychooncology. 2018 Dec;27(12):2687–99. doi: 10.1002/pon.4870.
    1. Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R, Ferguson D, D'Agostino R. The female sexual function index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther. 2000;26(2):191–208. doi: 10.1080/009262300278597.
    1. Bartula I, Sherman KA. The female sexual functioning index (FSFI): evaluation of acceptability, reliability, and validity in women with breast cancer. Support Care Cancer. 2015 Sep;23(9):2633–41. doi: 10.1007/s00520-015-2623-y.
    1. Halis F, Yildirim P, Kocaaslan R, Cecen K, Gokce A. Pilates for better sex: changes in sexual functioning in healthy Turkish women after pilates exercise. J Sex Marital Ther. 2016 May 18;42(4):302–8. doi: 10.1080/0092623X.2015.1033576.
    1. Lorenz TA, Meston CM. Exercise improves sexual function in women taking antidepressants: results from a randomized crossover trial. Depress Anxiety. 2014 Mar;31(3):188–95. doi: 10.1002/da.22208.
    1. Cella D, Lai J, Jensen SE, Christodoulou C, Junghaenel DU, Reeve BB, Stone AA. PROMIS fatigue item bank had clinical validity across diverse chronic conditions. J Clin Epidemiol. 2016 May;73:128–34. doi: 10.1016/j.jclinepi.2015.08.037.
    1. Jensen RE, Moinpour CM, Potosky AL, Lobo T, Hahn EA, Hays RD, Cella D, Smith AW, Wu X, Keegan TH, Paddock LE, Stroup AM, Eton DT. Responsiveness of 8 patient-reported outcomes measurement information system (PROMIS) measures in a large, community-based cancer study cohort. Cancer. 2017 Jan 1;123(2):327–35. doi: 10.1002/cncr.30354. doi: 10.1002/cncr.30354.
    1. Rogers LQ, Vicari S, Trammell R, Hopkins-Price P, Fogleman A, Spenner A, Rao K, Courneya KS, Hoelzer KS, Robbs R, Verhulst S. Biobehavioral factors mediate exercise effects on fatigue in breast cancer survivors. Med Sci Sports Exerc. 2014 Jun;46(6):1077–88. doi: 10.1249/MSS.0000000000000210.
    1. Beebe J. Rapid Assessment Process: An Introduction. Lanham, MD: AltaMira Press; 2001.
    1. Hamilton A. Qualitative Methods in Rapid Turn-Around Health Services Research. VA's Health Services Research and Development Service. 2013. [2020-06-08]. .
    1. Mobile Fact Sheet. Pew Research Center. 2019. [2019-06-12].

Source: PubMed

Sponsor e collaboratori

Condizioni mediche

Interventi farmacologici

3
Sottoscrivi