Exploring participant perceptions of a virtually supported home exercise program for people with multiple myeloma using a novel eHealth application: a qualitative study.

Introduction

Multiple myeloma (MM) is a plasma cell cancer associated with significant morbidity [ 1 ]. Although incurable, recent advances in treatment have extended median survival to 6 years [ 2 ] and 10 years in autologous stem cell transplantation recipients [ 3 ]. However, MM and its associated therapies cause an array of debilitating side effects, including deformities, pain, reduced mobility and functioning, fatigue, neuropathy, and fracture risk [ 1 ]. Supportive care strategies are needed to bolster patient function in the face of this burden [ 4 ].

One emerging strategy that may be of benefit is exercise [ 5 ]. Exercise has demonstrated numerous physical and psychological benefits for people living with cancer [ 6 ], but there remains a paucity of research into the role of exercise in MM [ 7 ]. The MM community has identified a preference for a combination of light-to-moderate intensity aerobic and resistance exercise [ 8 ], while the American College of Sports Medicine and the International Bone Metastases Exercise Working Group recommend exercise of at least moderate intensity [ 6 , 9 ]. The proportion of people with MM who meet physical activity guidelines is low [ 10 , 11 ]. It has been proposed that program tailoring and supervision might be key factors to ensure successful exercise programming in this population [ 5 ]. Indeed, people with MM identify both exercise individualization and flexibility as important attributes [ 8 ]. These program characteristics are likely important because patients report that MM symptoms and treatment side effects including fatigue, pain, concern about bone fractures, back pain, and fear of infections are key barriers to physical activity [ 12 ]. However, no studies to date have evaluated the acceptability of interventions that employ elements of supervision, tailoring, and flexibility for people with MM.

The Myeloma Progressive Resistance and Aerobic Exercise Study (MY PROGRESS) was a 12-week virtually supported home exercise program delivered using a novel eHealth exercise application, the HEAL-Me app [ 13 ]. It sought to balance the benefits of center-based programming (supervision) with the benefits of home programming (flexibility) using a combination of app-based supervised group exercise sessions and independent exercise sessions. The program employed elements identified by individuals with MM as important, including supervision, tailoring, and flexibility.

The current study seeks to engage with participants to refine the MY PROGRESS program and HEAL-Me app to better meet the needs of people with MM. Qualitative methods, which are being used increasingly to explore the implementation of health research interventions [ 14 ], were chosen for this study. Quantitative methods alone cannot elicit rich descriptions of patient experiences, whereas qualitative methods could explore participant perceptions of the exercise program and app. The purpose of this study was to determine the acceptability of a virtually supported home exercise program based on (i) participants’ perceptions of the virtually supported home exercise program and application and (ii) participants’ perceptions of the strengths and limitations of the exercise program and application.

Methods

Study design

The present study is an acceptability-focused sub-study of MY PROGRESS, a larger multi-method feasibility study. A detailed overview of the exercise intervention, the HEAL-Me app, and quantitative feasibility results from MY PROGRESS are published elsewhere [ 13 ]. This qualitative study represents phase two of the overall study and complements phase one’s quantitative feasibility measures by eliciting participant feedback, thus developing a deeper understanding of program acceptability. Ethics approval was received from the Health Research Ethics Board of Alberta: Cancer Committee on August 26, 2020 (HREBA.CC-20–0201). The study was registered at www.clinicaltrials.gov ( NCT04484714 ). Reporting follows the published Standards for Reporting Qualitative Research (SRQR) [ 15 ].

Procedures

A qualitative description approach was used [ 16 – 18 ]. Qualitative description is used to develop a comprehensive understanding of a phenomenon of interest (i.e., the experience of exercising at home using the HEAL-Me app). Qualitative description stays close to the data, draws from the general tenets of naturalistic inquiry, can employ most purposeful sampling techniques, typically generates data through interviews or focus groups, and employs qualitative content analysis [ 18 ]. This methodology allowed the researchers to gain straight descriptions of participant experiences in order to determine the acceptability of the exercise program and eHealth application. Acceptability was defined as the extent to which participants considered the exercise program and application to be appropriate based on their experienced cognitive and emotional responses, as per the Theoretical Framework of Acceptability [ 19 ].

Purposive sampling was used to recruit for this study in order to capture a diversity of perspectives from participants who were likely to provide rich descriptions of their experiences. Participants who completed MY PROGRESS were recruited until saturation was reached [ 20 ]. Participants were contacted by phone after completing the 12-week exercise program and asked to participate in the semi-structured interview. If interested, an information letter and consent form was sent by email, and written informed consent was obtained prior to the interview. The final sample size of 20 aligns with previous qualitative research investigating exercise in people with MM [ 8 , 12 , 21 ].

One-on-one semi-structured interviews were conducted through Zoom meetings v5.4 (Zoom Video Communications, San Jose, CA). The interview goal was to understand participant experiences and gather insight into how the program and app could be improved. Interviews sought to understand retrospective acceptability with a focus on key constructs from the Theoretical Framework of Acceptability [ 19 ]. The interview guide was developed by the research team based on the research objectives and was structured in three main parts: (1) overall impressions; (2) perceptions of the strengths and limitations of the program and app; (3) suggestions for improvement (see Online Supplement for interview guide). This study’s approach to methodological rigor was oriented within the framework outlined by Guba and Lincoln (1982), following strategies and principles from both Colorafi and Evans (2016) and Hannes (2011) [ 16 , 22 , 23 ]. See Online Supplement for further information on methodological rigor.

Analysis

Transcripts were audio recorded, transcribed using Zoom automated transcription software, reviewed for accuracy, corrected, and uploaded to Atlas.ti, a data organization software. Latent content analysis was used to analyze the data [ 16 , 24 ]. An a priori codebook was developed based on the interview guide and a preliminary analysis of the data. Coding was further guided by the 7 key constructs from the Theoretical Framework of Acceptability, namely affective attitude, burden, ethicality, intervention coherence, opportunity costs, perceived effectiveness, and self-efficacy [ 19 ]. Further information on how these constructs were captured is available in the Online Supplement. Coding was conducted by four researchers (GP, FS, MAO, CE) in three stages. Each stage was initiated after a batch of interviews were completed, allowing our team to continue recruiting until saturation was reached. At each stage, coders were paired up and independently read and coded 3–4 transcripts to facilitate credibility as per Hannes [ 23 ]. This process involved applying codes to segments of data that corresponded to the research objective. Segments of data describing the same idea were coded the same. Each transcript was read multiple times to ensure accuracy throughout the coding process. After coding was complete, independent coders met and resolved coding discrepancies through consensus. Next, the coding team met to discuss data analysis, ensure codes were being assigned consistently across coders, and revise/expand the codebook to reflect emerging codes. This process repeated until all transcripts were completed. Finally, the lead author combined codes into categories, and if possible, combined categories into themes. The research team then met to discuss and refine the themes and categories. Illustrative quotes were selected to support study findings. Quotes have been cleaned as needed to improve readability [ 25 ].

Results

Twenty participants were interviewed, who were 64.9 ± 6.7 years of age and predominantly female ( n = 12; see Table 1 for additional participant characteristics).

The following sections describe participant perceptions of (1) the virtually supported home exercise program, and (2) the strengths and limitations of the program and application. Strengths and limitations are further organized into two themes: One Size Does Not Fit All (sub-themes: Supportive & Responsive Programming and Diverse Exercise Opportunities ) and App Usability (Fig. 1 ) . Illustrative quotes are included throughout to highlight the participants’ voice.

Participant perceptions of the program

Overall, participants enjoyed the exercise program and spoke favorably about their experience. Participants found the program easy to access and begin. Many participants reiterated several times throughout the interview how much they enjoyed it. One participant shared: “I cannot say how grateful I am for this program” (P4) . Indeed, some participants mentioned that they would and/or did recommend the program to others.

The program gave participants the confidence they needed to exercise. As one participant explained: “It gave me back my confidence that I can do more than I thought I could with this disease” (P2) . Participants also explained that the program was appropriate for them, describing it as realistic, safe, and effective. One participant said: “I think [the program] is appropriate for people with [myeloma]… I think it kept it at a spot that was safe, yet effective” (P17).

The virtual nature of the program was regarded positively by participants. Participants shared their perspectives on the strengths and limitations of the program’s virtual delivery. First, participants heavily valued that the virtual program reduced their risk of infection, given their compromised immune system. One participant explained: “a lot of us in our conditions are susceptible to problems with immunity, so it’s very important to have a clean environment. Being at home, you’ve got that” (P6) . Rural/remote participants appreciated the opportunity to participate in the study, which would not have been possible if it had been in-person. Finally, participants described the virtual program as convenient, as it was easier for them to fit exercise into their day.

Despite the overwhelming positive feedback, participants identified limitations of a virtually delivered exercise program. Some participants felt that they could not interact with other participants as well through virtual means. In response, some participants suggested having unstructured catch-up sessions following group classes to allow for more interaction between participants. Some participants also shared that it was challenging to motivate themselves to exercise at home. As one participant explained: “I tend to think that being at home makes us a little bit lazy, though… So that would be the negative side” (P6).

One size does not fit all

A primary theme that emerged from the interviews was One Size Does Not Fit All , which included two sub-themes: Supportive & Responsive Programming and Diverse Exercise Opportunities . Supportive & Responsive Programming was a main strength of the program and was characterized by participants as programming that was tailored to myeloma and the individual, involved active support, and was delivered by appropriately trained personnel. The inclusion of Diverse Exercise Opportunities (i.e., virtually supervised group workouts and independent home workouts) was also regarded as a strength by participants, as it accommodated for varying preferences.

Supportive and responsive programming

Participants valued that the program was specific to MM. One participant said: “what was really good, at least for me, was that it addressed our issues… It’s directed to us, and it’s noticeable… that’s really perfect” (P10) . Participants felt that having a myeloma-specific program allowed them to realize benefits specific to their disease and treatments, such as improved core strength, back strength, and balance.

Participants also valued that their workouts were individually tailored. This included adapting programming based on their MM, comorbidities, goals, preferences, and exercise experience. Participants enjoyed working with the exercise specialist to find alternative exercises that fit them best and felt that tailoring made exercising safer. As one participant shared: “it’s a great program built on my limitations… [with tailoring] you don’t worry about the exercises you’re doing because you know they’re safe” (P5) . For participants, tailoring involved receiving active support from the trainer that was responsive to their needs, mostly through regular specialist-participant check-ins. One participant shared their perspective on the check-ins: “it was wonderful because [the exercise specialist] could see if I was doing the exercises correctly, and I could see [the specialist] adapting some of the exercises… modifying the exercises so that I could do it. That was a great part” (P15) .

Participants thought that having the right program personnel was important. Specifically, participants valued the exercise specialists’ knowledge and expertise. As noted above, safety was a primary concern for participants, and it was very important to participants that the exercise specialists were knowledgeable about how to safely prescribe exercise to people with MM. When asked what the most important part of the program was, one participant stated: “you need to be confident in that the person is giving you the right exercises. So, I would say [the exercise specialist] is number one for sure” (P5). Many participants also felt a layer of safety was added by having their oncologist on board and involved in their exercise clearance.

Diverse exercise opportunities

A strength of the program was the inclusion of both virtually supervised group workouts and independent workouts. This was seen as valuable because some participants preferred the group classes, others preferred the independent workouts, and most liked having access to a combination of both options. A detailed breakdown of the strengths and limitations of each exercise type is available in Table 2 , including representative quotes where appropriate.

App usability

In general, participants had positive perceptions of the app and thought it was user friendly. They described the app as simple, intuitive, and helpful. One participant said: “It was so user friendly, that you know, anybody could use it.” (P12) . Despite positive perceptions, participants shared they did not have much experience using technology, making it harder for them to interact with the app at the beginning. This led to a learning curve as they adjusted to using the technology. However, participants were still able to engage with the app quickly.

Participants identified some aspects of the app that were less intuitive or contained glitches. Some participants were confused by the steps required to log their independent workouts. Participants also identified a known issue with the app where workouts did not log on the patient-facing screen, despite logging properly on the back end. Finally, participants identified cases where the app “acted out” (e.g., participants pressed buttons but the app did not respond or the app stalled during an independent workout before resuming). Interestingly, participants qualified these “glitches” by reiterating their lack of technology experience. As one participant said: “ I found a few… glitches on occasion… I am not on the computer doing those kinds of things all the time, so that could be part of it” (P4) . Importantly, none of the glitches or issues with the app prevented participants from using the app and completing their exercise.

The HEAL-Me app had additional features including tracking and gamification elements. These app features (e.g., goal tracking, music, and rewards) were not used often by participants. Most participants identified that these features might be helpful or motivating to other participants but were unnecessary for themselves. Importantly, these features did not interfere with their ability to use the app. One participant shared: “I didn't look at what points I was earning or whatever trophies. The key thing was that my exercises were there, and I could access them” (P8).

Discussion

The aim of this study was to determine both participants’ overall perceptions and perceptions of the strength and limitations of a virtually supported home exercise program and eHealth application. Participants had positive perceptions of the exercise program. Supportive and responsive programming was seen as a key strength by participants, as they valued that the program was individually tailored and was adjusted through active support from knowledgeable personnel. They also valued that the program offered diverse exercise opportunities including both virtually supervised group workouts and independent home workouts, so they could take part in the exercise format they enjoyed most. Finally, participants felt the app was user friendly, but certain aspects of the app were less intuitive and require revision.

One size does not fit all

This study affirms that one size does not fit all when it comes to exercise programming in MM. Instead, programming should be supportive and responsive to the needs of participants. This supports previous qualitative research, where people with MM identified individualization and tailoring as key program characteristics due to the side effects from MM and MM treatments and differences in exercise experience [ 8 , 21 ]. Indeed, a recent review of the effectiveness of exercise in MM proposed tailoring as a fundamental program feature [ 5 ]. The current study expands on these previous studies by identifying strengths beyond tailoring that contributed to this program’s supportive and responsive nature. Specifically, active support through one-on-one check-ins provided a structured opportunity to modify programming and correct exercise technique. Active support may be of particular importance for home programs, where interaction between the exercise specialist and participant is limited. Participants also felt the program was delivered by appropriate personnel (i.e., a kinesiologist with > 3 years of experience working with the population overseen by a physical therapist with > 20 years of experience in cancer rehabilitation, a certified exercise physiologist, and a hematologist/oncologist). Above all, having qualified personnel delivering the program instilled trust and confidence in participants, which supports findings from Land et al. [ 21 ]. Participants trusted they were in the right hands and were confident that the exercises they were performing were safe. This is likely important because fear of injury, lack of confidence, and lack of knowledge are all patient-reported barriers to exercise in MM [ 11 ]. Tailoring, active support, and appropriate personnel cannot completely eliminate the risks of exercise in this population. However, a supportive and responsive program that employs these strategies can form a safety net around the participant, making exercise safer and more comfortable.

Results from this study also suggest that programs should offer diverse exercise opportunities. Indeed, previous research suggests that participants think programs should be individualized based on exercise preference [ 8 ]. In the context of the current study, offering a combination of virtually supervised group workouts and independent home workouts was seen as a strength, as the two methods of delivery complemented each other. The group workouts allowed participants to interact with each other, despite being in a home program. This social aspect may be of particular benefit, as greater improvements in quality of life have been seen from group exercise than from personal training in other tumor groups [ 26 ]. The current study’s group workouts also created an opportunity for participants to receive supervision and feedback while exercising at home. Exercise supervision has been proposed as a contributor to program success in MM [ 5 ] and is favored by some people with MM [ 8 ]. Indeed, some participants in the current study felt the group class was a safer exercise environment for them. However, people with MM have also identified the importance of flexibility in exercise programming [ 8 ]. This highlights the value of independent home workouts, as participants in the current study valued the flexibility of this exercise format. Future programs should aim to include diverse program options, such as virtually supervised group workouts and independent home workouts, to leverage the benefits of different exercise formats and/or to match participants with the exercise format that aligns with their needs and preferences.

App usability

To our knowledge, this is the first study to employ an eHealth application to deliver exercise programming in MM. The HEAL-Me app appears to be an acceptable eHealth application for this population. Participants described the app as user friendly and simple, despite generally not having much experience with technology. However, certain areas of the app should be revised so participants can more easily log their workouts, so their exercise progress is more reliably reflected on the participant-facing side, and so the app runs smoother to avoid stalls. One of the primary strengths of the HEAL-Me app was the ability for participants to follow along to exercise videos containing demonstrations, explanations, and cueing as they completed their independent home workouts. This is a recommended format for home exercise delivery, as it allows the exercise specialist to provide high quality, engaging exercise guidance for people living with cancer, at home [ 27 ]. The virtual/eHealth delivery was also valuable because most people with MM are immune compromised and are therefore at an increased risk of infection. This model of delivery was thus particularly important during the COVID-19 pandemic, but may also have a role in the future, as risk of infection is a previously reported barrier to exercise in this population [ 12 ]. Participants had varying perspectives on the app’s gamification components, including rewards, achievements, and goal tracking. These gamification components may not be necessary for some given that many older adults are primarily motivated by intrinsic factors, such as the health benefits of exercise and feeling better [ 28 ]. If these features are included in eHealth apps, they should not interfere with the app’s primary purpose of delivering exercise programming. Above all, the chosen application should be simple and easy to use for the patient population [ 29 ].

Limitations

This study is not without limitations. First, the study’s sample included predominantly Caucasian participants and 60% of participants were female, while MM typically affects men more than women [ 30 ]. As such, results may not extend to the entire MM population, particularly non-Caucasian individuals. Secondly, the study employed purposive sampling rather than maximum variation sampling, which is favored by some in qualitative description studies [ 18 ]. In this case, sampling specifically sought out information-rich cases with diverse perspectives, rather than specifically seeking out the varied perspectives. Focusing sampling on heterogenous perspectives may have yielded an even more comprehensive understanding of the acceptability of the program and app. Finally, multiple coders were used in this study, which is inconsistent with Guba and Lincoln’s naturalistic inquiry approach [ 22 ]. However, this strategy was selected for three reasons: (1) to provide coding mentorship for a trainee with less qualitative research experience; (2) it is not uncommon for multiple coders to be employed within a qualitative description approach [ 31 – 33 ]; (3) despite its downsides, it remains a recognized approach for assuring credibility of study findings [ 23 , 34 , 35 ].

Conclusion

The virtually supported home exercise program and eHealth app were acceptable for people with MM. A key strength of the program was its supportive and responsive nature, involving individually tailored programming that was adjusted through active support and delivered by a multidisciplinary team of appropriately trained personnel. This model should be used in future research to create an exercise safety net for participants to minimize and manage the potential risks of exercise in this population. Future studies should also aim to include diverse exercise opportunities, as participants identified this as a strength of the program. This allows researchers to leverage the benefits of both group classes (i.e., supervision) and independent workouts (i.e., flexibility) and ensure programming can match the preferences of participants. The employed eHealth application (HEAL-Me) is acceptable for use by people with MM. Participants described the app as simple and user friendly. The app allowed the intervention to be delivered entirely in a remote format, which is of particular benefit given that most people with MM are immunocompromised. eHealth applications are a promising method to deliver home exercise programming for this population, but the chosen application should be simple to use to ensure technology proficiency is not a barrier for those interested in participating. The next step/phase in the MY PROGRESS study will be to assess the exercise program and HEAL-Me app as part of a larger scale randomized controlled trial in order to determine the efficacy of this feasible and acceptable intervention.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 19 KB)

Acknowledgements

We would like to acknowledge the people living with cancer who took part in this study for their dedication and effort.

Author contribution

GP, CV, PT, and MM were involved in study conception and design. Material preparation, data collection, and analysis were performed by GP, FS, CE, and MAO. The first draft of the manuscript was written by GP. All authors were involved in the reviewing and editing process. All authors read and approved the final manuscript.

Funding

GP was supported by the Government of Alberta through the Alberta Graduate Excellence Scholarship, by the Canadian Institutes for Health Research through the Sir Frederick Banting and Dr. Charles Best Canada Graduate Scholarship—Master’s, and by the University of Alberta through the Walter H Johns Graduate Fellowship.

Data availability

The datasets generated during the current study are available in the Dataverse repository at https://borealisdata.ca/privateurl.xhtml?token=5bc8a006-3c48-4d1b-a6cc-cf6a5b253e42 .

Declarations

Ethics approval

This study was performed in line with the principles of the Declaration of Helsinki. Ethics approval was received from the Health Research Ethics Board of Alberta: Cancer Committee on August 26 th , 2020 (HREBA.CC-20–0201). The study was registered at www.clinicaltrials.gov ( NCT04484714 ).

Consent to participate

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

Competing interests

The authors declare no competing interests.

Footnotes

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

1. Sherman AC, Simonton S, Latif U, Plante TG, Anaissie EJ. Changes in quality-of-life and psychosocial adjustment among multiple myeloma patients treated with high-dose melphalan and autologous stem cell transplantation. Biol Blood Marrow Transplant. 2009;15(1):12–20. doi: 10.1016/j.bbmt.2008.09.023.

2. Munker R, Monohan G. Progress in multiple myeloma. Indian J Med Res. 2019;149(6):693–694. doi: 10.4103/ijmr.IJMR_770_19.

3. Nishimura KK, Barlogie B, van Rhee F, Zangari M, Walker BA, Rosenthal A, et al. Long-term outcomes after autologous stem cell transplantation for multiple myeloma. Blood Adv. 2020;4(2):422–431. doi: 10.1182/bloodadvances.2019000524.

4. Snowden JA, Ahmedzai SH, Ashcroft J, D'Sa S, Littlewood T, Low E, et al. Guidelines for supportive care in multiple myeloma 2011. Br J Haematol. 2011;154(1):76–103. doi: 10.1111/j.1365-2141.2011.08574.x.

5. Gan JH, Sim CY, Santorelli LA. The effectiveness of exercise programmes in patients with multiple myeloma: a literature review. Crit Rev Oncol Hematol. 2016;98:275–289. doi: 10.1016/j.critrevonc.2015.11.005.

6. Campbell KL, Winters-Stone KM, Wiskemann J, May AM, Schwartz AL, Courneya KS, et al. Exercise guidelines for cancer survivors: consensus statement from international multidisciplinary roundtable. Med Sci Sports Exerc. 2019;51(11):2375–2390. doi: 10.1249/mss.0000000000002116.

7. Smith L, McCourt O, Henrich M, Paton B, Yong K, Wardle J, et al. Multiple myeloma and physical activity: a scoping review. BMJ Open. 2015;5(11):e009576. doi: 10.1136/bmjopen-2015-009576.

8. Craike M, Hose K, Courneya KS, Harrison SJ, Livingston PM. Physical activity preferences for people living with multiple myeloma: a qualitative study. Cancer Nurs. 2017;40(5):E1–e8. doi: 10.1097/ncc.0000000000000425.

9. Campbell KL, Cormie P, Weller S, Alibhai SMH, Bolam KA, Campbell A, et al. Exercise recommendation for people with bone metastases: expert consensus for health care providers and exercise professionals. JCO Oncol Practice. 2022;18(5):e697–e709. doi: 10.1200/op.21.00454.

10. Jones LW, Courneya KS, Vallance JK, Ladha AB, Mant MJ, Belch AR, et al. Association between exercise and quality of life in multiple myeloma cancer survivors. Support Care Cancer. 2004;12(11):780–788. doi: 10.1007/s00520-004-0668-4.

11. Craike MJ, Hose K, Livingston PM. Physical activity participation and barriers for people with multiple myeloma. Support Care Cancer. 2013;21(4):927–934. doi: 10.1007/s00520-012-1607-4.

12. Craike MJ, Hose K, Courneya KS, Harrison SJ, Livingston PM. Perceived benefits and barriers to exercise for recently treated patients with multiple myeloma: a qualitative study. BMC Cancer. 2013;13:319. doi: 10.1186/1471-2407-13-319.

13. Purdy GM, Venner CP, Tandon P, McNeely ML. Feasibility of a tailored and virtually supported home exercise program for people with multiple myeloma using a novel eHealth application. Digital Health. 2022;8:20552076221129066. doi: 10.1177/20552076221129066.

14. Holtrop JS, Rabin BA, Glasgow RE. Qualitative approaches to use of the RE-AIM framework: rationale and methods. BMC Health Serv Res. 2018;18(1):177. doi: 10.1186/s12913-018-2938-8.

15. O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245–1251. doi: 10.1097/acm.0000000000000388.

16. Colorafi KJ, Evans B. Qualitative descriptive methods in health science research. HERD. 2016;9(4):16–25. doi: 10.1177/1937586715614171.

17. Sandelowski M. What’s in a name? Qualitative description revisited. Res Nurs Health. 2010;33(1):77–84. doi: 10.1002/nur.20362.

18. Sandelowski M. Whatever happened to qualitative description? Res Nurs Health. 2000;23(4):334–340. doi: 10.1002/1098-240x(200008)23:4<334::aid-nur9>3.0.co;2-g.

19. Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. BMC Health Serv Res. 2017;17(1):88. doi: 10.1186/s12913-017-2031-8.

20. Morse JM. The significance of saturation. Qual Health Res. 1995;5(2):147–149. doi: 10.1177/104973239500500201.

21. Land J, Hackett J, Sidhu G, Heinrich M, McCourt O, Yong KL, et al. Myeloma patients’ experiences of a supervised physical activity programme: a qualitative study. Support Care Cancer. 2022;30(7):6273–6286. doi: 10.1007/s00520-022-07062-x.

22. Guba EG, Lincoln YS. Epistemological and methodological bases of naturalistic inquiry. ECTJ. 1982;30(4):233–252. doi: 10.1007/BF02765185.

23. Hannes K (2011) Chapter 4: Critical appraisal of qualitative research. In: Noyes J, Booth A, Hannes K, Harden A, Harris J, Lewin S, et al., editors. Supplementary guidance for inclusion of qualitative research in Cochrane systematic reviews of interventions. 1st ed.: Cochrane Collaboration Qualitative Methods Group.

24. Mayan MJ (2009) Essentials of qualitative inquiry. Qualitative essentials. Walnut Creek, CA: Left Coast Press

25. Standing K. Writing the voices of the less powerful: research on lone mothers. In: Ribbens J, Edwards R, editors. Feminist dilemmas in qualitative research: public knowledge and private lives. Newbury Park, CA: Sage Publications, Inc; 1998. pp. 186–202.

26. Leach HJ, Covington KR, Voss C, LeBreton KA, Harden SM, Schuster SR. Effect of group dynamics-based exercise versus personal training in breast cancer survivors. Oncol Nurs Forum. 2019;46(2):185–197. doi: 10.1188/19.onf.185-197.

27. Newton RU, Hart NH, Clay T. Keeping patients with cancer exercising in the age of COVID-19. JCO Oncol Pract. 2020;16(10):656–664. doi: 10.1200/op.20.00210.

28. van Velsen L, Broekhuis M, Jansen-Kosterink S, op den Akker H. Tailoring persuasive electronic health strategies for older adults on the basis of personal motivation: web-based survey study. J Med Internet Res. 2019;21(9):e11759. doi: 10.2196/11759.

29. Harrington CN, Ruzic L, Sanford JA. Universally accessible mhealth apps for older adults: towards increasing adoption and sustained engagement. Cham: Springer International Publishing; 2017. pp. 3–12.

30. Canadian Cancer Statistics Advisory Committee . Canadian cancer statistics: a 2022 special report on cancer prevalence. Toronto, ON: Canadian Cancer Society; 2022.

31. Harris E, Eng D, Ang Q, Clarke E, Sinha A. Goals of care discussions in acute hospital admissions – qualitative description of perspectives from patients, family and their doctors. Patient Educ Couns. 2021;104(12):2877–2887. doi: 10.1016/j.pec.2021.09.003.

32. Carlin L, Sibley K, Jenkinson R, Kontos P, McGlasson R, Kreder HJ et al (n.d) Exploring Canadian surgeons’ decisions about postoperative weight bearing for their hip fracture patients. (1365–2753 (Electronic)).

33. Sessions LC, Ness M, Mark H. Exploring the experiences of nursing faculty during the coronavirus (COVID-19) pandemic—a qualitative descriptive study. Teach Learn Nurs. 2022;17(4):477–481. doi: 10.1016/j.teln.2022.05.010.

34. Forman J, Damschroder L. Qualitative Content Analysis. In: Jacoby L, Siminoff LA, editors. Empirical methods for bioethics: a primer. Oxford, UK: Elsevier; 2008. pp. 39–62.

35. Ranney ML, Meisel ZF, Choo EK, Garro AC, Sasson C, Morrow GK. Interview-based qualitative research in emergency care part II: data collection, analysis and results reporting. Acad Emerg Med. 2015;22(9):1103–1112. doi: 10.1111/acem.12735.

Associated Data

Supplementary Materials

Supplementary file1 (DOCX 19 KB)

Data Availability Statement

The datasets generated during the current study are available in the Dataverse repository at https://borealisdata.ca/privateurl.xhtml?token=5bc8a006-3c48-4d1b-a6cc-cf6a5b253e42 .