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Exploring feasibility, perceptions of acceptability, and potential benefits of an 8-week yoga intervention delivered by videoconference for young adults affected by cancer: a single-arm hybrid effectiveness-implementation pilot study

Abstract

Background

Young adults affected by cancer face physical and psychological challenges and desire online supportive care. Yoga can be delivered online and may improve physical and psychological outcomes. Yet, yoga has rarely been studied with young adults affected by cancer. To address this, an 8-week yoga intervention was developed, and a pilot study was deemed necessary to explore feasibility, acceptability, implementation, and potential benefits.

Methods

A mixed-methods, single-arm hybrid effectiveness-implementation pilot study evaluating the yoga intervention was conducted. Feasibility was assessed by tracking enrollment, retention, attendance, completeness of data, and adverse events. Acceptability was explored through interviews. Implementation metrics included training time, delivery resources, and fidelity. Potential effectiveness was evaluated by exploring changes in physical (i.e., balance, flexibility, range of motion, functional mobility) and psychological (i.e., quality of life, fatigue, resilience, posttraumatic growth, body image, mindfulness, perceived stress) outcomes at pre- (week 0), post- (week 8), and follow-up (week 16) time points. Data were analyzed with descriptive statistics, repeated measures analysis of variance, and content analysis.

Results

Thirty young adults participated in this study (recruitment rate = 33%). Retention to study procedures was 70%, and attendance ranged from 38 to 100%. There were little missing data (< 5%) and no adverse events. Though most participants were satisfied with the yoga intervention, recommendations for improvement were shared. Sixty study-specific training hours and > 240 delivery and assessment hours were accrued and fidelity was high. Functional mobility, flexibility, quality of life (energy/fatigue, social well-being), body image (appearance evaluation), mindfulness (non-reactivity), and perceived stress improved significantly over time (all p< 0.050; \(\eta_{p}{}^{2}s=0.124-0.292\)). No other significant changes were observed (all p> 0.050; \(\eta_{p}{}^{2}s=0.005-0.115\)).

Conclusions

The yoga intervention may confer physical and psychological benefits, though intervention and study-specific modifications are required to improve feasibility and acceptability. Requiring study participation and providing greater scheduling flexibility could enhance recruitment and retention. Increasing the frequency of classes offered each week and offering more opportunities for participant interaction could improve satisfaction. This study highlights the value of doing pilot work and provides data that has directly informed intervention and study modifications. Findings could also be used by others offering yoga or supportive care by videoconference to young adults affected by cancer.

Trial registration

Not available—not registered

Peer Review reports

Key messages regarding feasibility:

  • What uncertainties existed regarding the feasibility?

    • Prior to this pilot study, the feasibility of yoga delivered via videoconference to young adults affected by cancer was unknown.

  • What are the key feasibility findings?

    • The yoga intervention and study were partially feasible; recruitment and retention to the study were lower than expected, but for those completing the study attendance rates were high, missing data was low, and there were no adverse events.

  • What are the implications of the feasibility findings for the design of the main study?

    • Modifying recruitment procedures and offering greater scheduling flexibility could enhance aspects of feasibility that were lower than expected.

Background

Young adults diagnosed with cancer between the ages of 18 and 39 years represent roughly 5% of all new cancer diagnoses each year in North America [1, 2]. Though comprising a minority of new diagnoses, this population faces a greater number of life years lost and life years affected by morbidity compared to the general population [3, 4]. Furthermore, many young adults affected by cancer experience adverse and interrelated physical (e.g., weight gain/loss, cachexia, muscle loss, disfigurement) [5,6,7] and psychological effects (e.g., reduced self-esteem, negative perceptions of body image, lowered quality of life, anxiety) [8,9,10] and describe feeling lonely and isolated [11, 12]. Group-based interventions or programs that can positively impact physical and psychological outcomes are required for this population.

Yoga, as practiced in Western societies, typically includes physical postures, mindfulness/meditation, and breathwork. Among older adults with a history of cancer, findings from systematic reviews and meta-analyses suggest yoga can enhance physical (e.g., flexibility, range of motion) and psychological outcomes (e.g., symptoms of anxiety, negative affect, quality of life) [13,14,15]. Among young adults affected by cancer, results from an experimental [16] and cross-sectional study [17] suggest that yoga is desired and may offer similar benefits to those seen among older adults with a history of cancer. Nevertheless, few yoga interventions have been studied, programs in clinical or community settings developed for young adults affected by cancer are rare, and the potential range of benefits yoga may confer for this population remains relatively unexplored.

One reason for limited yoga interventions and programs for young adults affected by cancer may be related to their unique barriers to participation (e.g., small and spread out population, difficulty coordinating schedules amidst conflicting life/work demands, incidental costs to participation) [18, 19]. Telehealth modalities, such as videoconferencing, could address many of these barriers and is a preferred delivery style for interventions among young adults affected by cancer [20, 21]. Indeed, the feasibility and effectiveness of delivering interventions, such as mindfulness and self-compassion, via videoconference within this cohort have been demonstrated [22, 23]. Furthermore, there is experimental evidence showing the benefits of adapted yoga [24] and physical activity [25] delivered by videoconference to adults affected by cancer > 40 years of age.

Studies exploring the effectiveness and implementation of yoga when delivered via videoconference could lay a foundation for future yoga research as well as the development and implementation of programs. Hybrid effectiveness-implementation studies are one way to evaluate interventions and their implementation strategies [26]. However, before proceeding with a full-scale hybrid effectiveness-implementation study, a pilot study is warranted. A pilot study can offer invaluable insights into the feasibility and acceptability of an intervention prior to expending resources on a full-scale study [27]. Thus, the aims of this single-arm hybrid effectiveness-implementation pilot study were to (1) assess feasibility (i.e., recruitment to the study, retention, attendance, adverse events, completion of assessments) and acceptability (i.e., satisfaction) with the yoga intervention and study methods; (2) document markers of implementation (i.e., training time, delivery resources, fidelity); and (3) explore preliminary effectiveness of the yoga intervention via changes over time in physical (i.e., balance, range of motion, flexibility, functional mobility) and psychological (i.e., quality of life, fatigue, resilience, posttraumatic growth, body image, mindfulness, perceived stress) outcomes.

Methods

Study design

A single-arm hybrid effectiveness-implementation pilot study was conducted, and a mixed-methods, embedded approach was used wherein both quantitative and qualitative data were collected [28]. The study protocol was reviewed and approved by the Health Research Ethics Board of Alberta (HREBA.CC-20-0365). To enhance transparency in reporting, relevant aspects of the Consolidated Standards of Reporting Trials extension for pilot and feasibility trials (CONSORT [29]), the Standards for Reporting Implementation Studies (StaRI) statement [30], and the CheckList stAndardising the Reporting of Interventions For Yoga (CLARIFY) guidelines [31] were followed in the preparation of this manuscript (see Additional file 1).

Participants

Young adults affected by cancer from across Canada were eligible to take part in the study if they (1) were diagnosed with cancer between the ages of 18 and 39 years; (2) were at any stage of the cancer trajectory (i.e., diagnosis onward); (3) self-reported being able to participate in mild-to-moderate intensity yoga delivered online; (4) registered to participate in the online intervention in the fall 2020 or winter 2021 wave; and (5) were able to read, understand, and provide informed consent in English.

Procedures

Young adults affected by cancer were recruited to participate in the yoga intervention through email, social media (i.e., Facebook, Twitter, Instagram), and snowball sampling. After registering to take part in the yoga intervention, young adults were then invited to take part in the pilot study to evaluate the interventionFootnote 1. For those who were interested and provided informed consented, assessments were conducted at baseline (week 0), post-intervention (week 8), and follow-up (week 16). The assessments comprised virtually administered physical assessments using videoconference (i.e., Zoom), and an online survey housed on REDCap. Also, post-intervention (week 8) participants completed an interview via videoconference.

Yoga intervention

The yoga intervention was informed by Yoga Thrive, an evidence-based therapeutic yoga program for individuals affected by cancer and their support persons, and the expertise of the study team. Findings from recent systematic reviews [13,14,15], studies describing young adults’ virtual delivery preferences [20, 21], evidence-based behavior change techniques [32, 33], and perspectives from 12 young adults affected by cancer who participated in online pilot yoga classes at the start of the pandemic were also incorporated into the design of the intervention. The result was a yoga intervention for young adults affected by cancer and their support personsFootnote 2 delivered over an 8-week period, with one, 60-min class offered per week. In the fall 2020 wave, two different sessions were offered and in the winter 2021 wave, three different sessions were provided. In each wave, young adults could register in the class day/time that best suited their schedule.Footnote 3 Each class in the intervention had a specific theme comprising a physical focus and energetic intention (e.g., chest opening and shoulder mobility and practicing gratitude) and included physical postures, breath practices, and meditation/relaxation techniques. Also, behavior change support was provided throughout via autonomy-supportive instruction, social support, and journaling and reflection prompts. Throughout classes, participants were offered various modifications (including seated postures), were reminded of common contraindications and provided alternative poses, and were continuously supported in choosing postures that felt appropriate and comfortable for them. See Table 1 for a general sequence of a class within the intervention. The entire 8-week protocol is available, upon reasonable request, from the first author.

Table 1 General sequence of a class within the 8-week yoga intervention

Classes were led by one of three yoga instructors who had completed at least a 200-h yoga teacher training, Thrive Health Exercise Oncology training, Yoga Thrive Teacher Training Certification (or similar), and had practical experience delivering yoga to individuals affected by cancer. Classes were also moderated by two individuals with Thrive Health Exercise Oncology training and practical experience moderating physical activity classes for adults affected by cancer. Moderators welcomed participants to each class, communicated with participants between classes via email, fostered a positive social environment, notified the instructor if/when further instruction or details were needed for a posture, demonstrated seated postures (from a chair in classes with higher risk participants), and managed the chat feature in Zoom during classes.

Measures

Feasibility and acceptability

Feasibility

Throughout the study, to assess feasibility, the number of young adults recruited to the study from the yoga intervention, retention to study procedures, and attendance to the yoga classes were collected. Completion of physical assessments, online surveys, and interview were also tracked, and adverse events were recorded. Recruitment to the study was defined as the number of young adults who enrolled in the study out of the number of young adults who were registered in the yoga intervention. Retention rate was defined as the number of study participants who completed all three assessments within the specified time frame (i.e., within 2 weeks). Attendance was defined as the number of classes engaged in out of eight for those in the yoga study. Completeness of physical assessments, online surveys, and participation in interviews was examined, and the percentage of missing data for each was tracked. Adverse events were defined as any incident causing harm to the participant. Participants were instructed to self-report adverse events, and moderators were trained to report any adverse events occurring during yoga classes using a standardized reporting form (e.g., date, severity, timing, site/location, duration, clinical action taken, outcome).

Aligned with recommendations for conducting pilot studies [34], targets for each feasibility outcome were specified a priori using relevant literature. It was estimated that (1) there would be a 60% recruitment rate from the intervention to the study (i.e., 55 young adults would be recruited to the study) [22, 23]; (2) ≥ 75% of young adults in the study would complete baseline (week 0), post-intervention (week 8), and follow-up (week 16) assessments [35]; (3) > 75% of participants would attend ≥ six of eight yoga classes [22, 23]; and (5) there would be < 10% missing data [36].

Acceptability

Post-intervention (week 8), participants answered questions during a semi-structured interview (see the “Interviews” section) related to their satisfaction with the yoga intervention (e.g., delivery, modality, length, duration, group-based nature) and study methods (e.g., satisfaction with assessments, procedures). The questions asked during the interview can be found in Additional file 2.

Implementation

Throughout the study, all aspects related to the delivery of the yoga intervention, including training time, delivery resources, and fidelity were tracked. Training time was defined as the number of hours required to train moderators on the study protocol (e.g., class facilitation, adverse event responding and reporting, virtual physical assessment conduct) and yoga instructors on the yoga intervention. Delivery resources captured the number of hours of intervention delivery, personnel hours (moderating, instructing, and/or completing physical assessments and interviews), and administrative support (i.e., the time required for intervention outreach, study recruitment, potential communication with prospective and current participants [e.g., responding to queries, coordinating physical assessments and interviews, and sending weekly reminder emails to participants]). Finally, fidelity was defined as whether the intervention was delivered as intended or not. Fidelity was tracked across classes by moderators using a standardized form to document instructors’ greetings and closing remarks, offering modifications, and use of autonomy-supportive language. Also, immediately after each class, yoga instructors completed an additional fidelity checklist to indicate any deviations to the class plan (i.e., additions or omissions of postures/poses).

Potential effects of yoga

Personal and medical factors

At baseline (week 0), participants in the study self-reported their age, location (i.e., province), setting (i.e., rural/urban), biological sex, current gender, marital status, education, annual income, employment status, ethnicity, cancer diagnosis, treatment status, and symptoms.

Physical outcomes

At baseline (week 0), post-intervention (week 8), and follow-up (week 16), participants completed a battery of physical assessments delivered over Zoom by one of three trained assessors who had previous experience administering these tests in-person and online to older adults affected by cancer. Neither assessors nor participants were blinded, which is common in pragmatic and behavioral studies [37, 38]. Assessments included balance using the single-leg balance test [39], flexibility using sit-and-reach [40], shoulder range of motion using the shoulder flexion test [41], and functional mobility via the 30-s sit-to-stand [42]. A more detailed description of the scoring for each of these assessments can be found in Additional file 3.

Psychological outcomes

At baseline (week 0), post-intervention (week 8), and follow-up (week 16), participants completed an online survey, housed in REDCap, comprised of measures of quality of life using the RAND 36-Item Short Form Health Survey [43], fatigue using the FACIT-Fatigue Scale [44], resilience using the Brief Resilience Scale [45], sense of personal growth after cancer with the Posttraumatic Growth Inventory [46], body image using the Multidimensional Body-Self Relations Questionnaire Appearance Scales [47], mindfulness using the Five-Facet Mindfulness Questionnaire [48], and perceived stress with the Perceived Stress Scale [49]. Also, connection to the yoga group was assessed with a modified version of the Group Identification Scale [50] at post-intervention (week 8) only. Further details related to the scoring each of these questionnaires can be found in Additional file 4.

Interviews

Post-intervention (week 8), participants completed interviews following a semi-structured guide, with one of two trained study team members. Participants were asked a series of open-ended questions (with probes) covering acceptability (see the “Acceptability” section). All interviews were conducted via Zoom and were audio-recorded using a Sony ICD-PX240 recorder. During the interviews, questions situating yoga within participant’s cancer experience and exploring additional important outcomes were also collected. These data are not presented herein given the scope of this pilot study reporting on feasibility, acceptability, implementation, and potential effectiveness.

Sample size

No formal sample size calculation was performed based on the study objectives.

Data analysis

Quantitative data were analyzed using IBM SPSS (version 27). Descriptive statistics (i.e., means, standard deviations [SD], frequencies, percentages) were computed to describe the sample at baseline. Following this, data were checked for approximately normal distributionFootnote 4, univariate (z-score greater than 3 or less than − 3) and multivariate outliers (p-value < 0.01 on the Mahalanobis Distance Test), and sphericity. In cases where outliers were identified, sensitivity testing was performed (with and without outliers) to affirm consistent trends in the data and then outliers were removed on a variable-by-variable basis to enhance homogeneity and maximize statistical power. Repeated measures analysis of variance [51] were conducted to examine changes across time points (baseline [week 0], post-intervention [week 8], follow-up [week 16]) in physical and psychological outcomes. Of note, data were not nested based on wave or instructor, no adjustments were made, and a higher type I error probability was set (i.e., an uncorrected significance level of 0.05) to decrease the risk of missing a potentially beneficial effect of yogaFootnote 5. The effect size of these changes was computed with partial eta squared (\(\eta_{p}{}^{2}\); small effect = 0.01, medium effect = 0.06, large effect = 0.14).

To analyze the qualitative data, interviews were transcribed verbatim and uploaded into NVivo (version 12) where they were subsequently analyzed by one author (EM) using conventional content analysis [52]. First, EM read each transcript several times to immerse herself in the data. Next, EM coded transcripts, created labels reflecting key ideas, and sorted the codes into higher-order categories. At this point, the author sent the coding scheme to another author (AW) who had reviewed the transcripts several times and challenged EM’s thoughts and interpretations. Following this, EM generated definitions for each category and selected exemplar quotes from the data to illustrate findings from the interviews. The penultimate coding scheme was then sent to all authors, each of whom was involved in the study design, intervention delivery, and/or data collection, to review and approve. Following this, EM revisited all raw data to ensure participants voices were accurately represented and the coding scheme was finalized. To promote rigor and trustworthiness, several steps recommended in the literature were followed [53]. The two authors who conducted the interviews (EM, KE) and one author who conducted the content analysis (EM) kept reflexivity journals and continuously (re-)examined their own perspectives and how they might influence interpretations. A critical friend (AW) challenged interpretations and sought to ensure the results represented participants’ voices and all authors critically reviewed the findings, and finally, category descriptions and exemplar quotes are available and presented herein to provide transparency.

Results

Participants

As detailed in Table 2, study participants were on average 34.2 (SD = 5.09) years of age at baseline and most self-identified their biological sex as female (n = 28; 93%) and as being of Western European descent (n = 17; 57%). Participants reported having been diagnosed with cancer between 2012 and 2020, and nearly half were diagnosed with breast cancer (n = 13; 43%). Fourteen (47%) reported being on-treatment at the time of the study, and the remainder were off-treatment (n = 13; 43%) or did not report their treatment status (n = 3; 10%). When asked to choose from a list of symptoms they were currently experiencing, the most commonly reported were fatigue (n = 25; 83%), cognitive challenges (n = 18; 60%), and peripheral neuropathy (n = 17; 57)Footnote 6. Although not an objective of this pilot study, visual inspection of available data suggests those who took part in the yoga intervention only (n = 62) did not differ from study participants (n = 30) on age or diagnoses.

Table 2 Personal and medical characteristics of participants

Feasibility and acceptability

Feasibility

Ninety-two young adults registered in the yoga intervention. All were invited to this study, 45 expressed interest, and 30 young adults completed informed consent and participated. Thus, the recruitment rate was 33%, which was below the a priori target of 60% (see Fig. 1).

Fig. 1
figure 1

CONSORT flow diagram

With regard to participant retention to study procedures, of the 30 who consented to participate, 21 (70%) completed all physical assessments, online questionnaires, and interview according to the study schedule. This was below the a priori target of ≥ 75% of young adults in the study completing assessments on time. Of the nine participants who did not complete the scheduled assessments as intended, one dropped out and stopped attending the yoga intervention. When exploring retention to specific aspects of the study, 21 (70%) completed all scheduled physical assessments as intended, 26 (87%) completed all questionnaires capturing psychological outcomes, and 28 (93%) completed the interviews. For participants who completed the assessments as intended, there were < 5% missing data across physical assessments and psychological questionnaires (which met the a priori target of < 10% missing data). Based on Little’s Missing Completely at Random (MCAR) test, data were deemed missing at random (all p>0.05). For the interviews, there was one instance of missed questions due to the participant’s time restrictions.

Participants’ attendance to yoga classes varied from three (38%) to eight (100%) out of eight classes, with an average attendance rate of 6.40 (SD = 1.43) of eight classes (80%). Twenty-four out of 30 (80%) participants attended ≥ 75% (i.e., six or more of the eight classes), exceeding the a priori target (75% of participants would attend six or more classes). Reasons for missed classes included medical appointments (n = 3), scheduling conflicts/competing demands (n = 5), and not feeling well (n = 1). There were 41 unexplained absences despite follow-up emails to participants from the moderators. Of note, four participants attended more than one class per week. No adverse events were reported.

Acceptability

Table 3 includes category descriptions and representative participant quotes from the semi-structured interview questions that probed aspects of program acceptability. Participants shared that, in general, their expectations were met or exceeded in the yoga intervention. Participants appreciated that the yoga intervention was delivered via videoconference, which reduced some of their barriers to attending, and described the personnel delivering the intervention favorably. Indeed, the personnel were viewed as critical to fostering feelings of inclusivity and safety. Similarly, the nature of the yoga intervention, which focused on tailoring and modifying to meet each participant’s needs, was greatly appreciated. The additional class components were also deemed acceptable, with participants sharing how they enjoyed the class themes, music, behavior change support, and journaling and reflection.

Table 3 Selected representative quotes from participants

Though high levels of satisfaction and acceptability were expressed, participants also raised several points of consideration for improving the yoga intervention. Despite having the option to attend more than one class per week, participants commented that they would have preferred this to be built into the structure of the intervention, and that a greater choice (days/week) and flexibility would be appreciated. Beyond this, participants described appreciating the group-based nature of the program but commented that they did not feel connected to their group. Participants in this sample would have appreciated the opportunity to connect more or to other participants and suggested activities and introductions among intervention participants as a way to foster greater connection. Finally, while some participants valued the reflection and behavioral support offered near the end of class, others described a preference for these components to be offered closer to the beginning to facilitate their ability to integrate during class time. No issues relating to study methods were identified and the number, timing, and duration of assessments and study-related procedures were deemed acceptable. Participants reported being grateful to receive yoga and were happy to contribute to the research.

Implementation

Six moderators completed 6 h of study-specific training. This training time excluded their 12-15 h Thrive Health Exercise Oncology, 8 h Thrive Center, and 3 h general moderator training. Three yoga instructors completed 8 h of study-specific training. This training time excluded their pre-existing minimum 200-h yoga teacher training, 12–15-h Thrive Health Exercise Oncology training, and a minimum of 30 h completing their Yoga Thrive teacher training (or equivalent). With regard to delivery resources, each 8-week yoga session constituted 12 delivery hours (one class/week for a 60-min yoga class plus a minimum of 15 min before and after each class), wherein two moderators and one instructor were present (totaling 36 personnel hours). Between fall 2020 and winter 2021, five yoga sessions were provided (fall 2020 n = 2 sessions; winter 2021 n = 3 sessions). Thus, there was a total of 180 delivery hours. Physical assessments and interviews took a total of 55 h for research staff (who were also trained moderators). Administrative support summed to an additional 20 h outside of intervention delivery and assessment/interview time, including tasks such as sending email reminders and scheduling assessments.

In terms of the fidelity checklist completed by moderators, there were no instances of deviation across instructors and classes in terms of greeting and closing classes, offering modifications, and using autonomy-supportive language. For the yoga instructors, fidelity checks over the two waves (fall 2020/winter 2021) and five sessions indicated a total of six recorded instances of posture omission (due to time constraints) and 23 instances of a posture being taught at another time in class (i.e., before or after it was intended) out of the 186 postures covered within the 8-week yoga intervention.

Potential effects of yoga

Physical outcomes

Participants’ scores on physical assessments at baseline varied from within normal ranges to poor (or low), see Table 4. Specifically, scores on balance and shoulder range of motion were within normal ranges, whereas scores for functional mobility and flexibility were below normative age-related values. With regard to changes, there were large, significant changes in functional mobility (i.e., sit-to-stand test; F(2, 40) = 8.261, p ≤ 0.001, \(\eta_{p}{}^{2}=0.292\)) and flexibility (i.e., sit and reach test) on both the right (F(2, 40) = 3.959, p = 0.027, \(\eta_{p}{}^{2}=0.165\)) and left sides over time (F(2, 40) = 3.524, p = 0.039, \(\eta_{p}{}^{2}=0.150\)), indicative of improvements in these outcomes. There were no significant differences observed over time (baseline, post-intervention, follow-up) on physical assessments of balance or shoulder range of motion (all p>0.05), and effect sizes ranged from small to medium (\(\eta_{p}{}^{2}s=0.048-0.098\)).

Table 4 Potential effects of the yoga intervention

Psychological outcomes

As seen in Table 4, participants’ scores at baseline on the psychological questionnaires were low relative to scale ranges, indicative of generally poorer quality of life; worse symptoms of fatigue; low amounts of resilience, posttraumatic growth, body image, and mindfulness; and moderate levels of stress. There were significant changes over time with medium to large effect size on participants’ quality of life (subscales of energy/fatigue [F(2, 50) = 3.523, p = 0.37, \(\eta_{p}{}^{2}=0.124\)] and social functioning [F(2, 50) = 3.894, p = 0.027, \(\eta_{p}{}^{2}=0.135\)]) body image (subscale of appearance evaluation [F(1.619, 38.850) = 3.198, p = 0.036, \(\eta_{p}{}^{2}=0.140\)]), mindfulness (subscale of non-reactivity to inner experience [F(2, 48) = 3.922, p = 0.026, \(\eta_{p}{}^{2}=0.140\)]), and stress ([F(2, 48) = 4.912, p = 0.011, \(\eta_{p}{}^{2}=0.170\))]), indicative of improvements in each of these outcomes. There were no significant differences over time on the remaining psychological outcomes (all p>0.05), with effect sizes ranging from small to medium (\(\eta_{p}{}^{2}s=0.005-0.115\)). Finally, participant’s score on group identification, measured post-intervention only (mean = 4.91; SD = 1.00), indicated that participants did not identify with their yoga group.

Discussion

The purpose of this single-arm hybrid effectiveness-implementation pilot study was to better understand feasibility, perceptions of acceptability, implementation, and potential effects of yoga delivered via videoconference to young adults affected by cancer. Although recruitment and retention to the study was lower than has been reported elsewhere [22, 23], for those completing the study, attendance rates were high and missing data was low. Participants were generally satisfied with the intervention and found the intervention and study methods acceptable. Importantly, participants also provided recommendations to improve the intervention. Overall, these findings provide early evidence supporting the potential benefits associated with yoga among young adults affected by cancer and highlight critical modifications to study and intervention components that support gathering further evidence for the effectiveness and implementation of yoga delivered via videoconference for this cohort.

Despite relatively large numbers within the yoga intervention (n = 92), recruitment to the study was low (n = 30, out of n = 45 interested). It is possible that many in this cohort simply did not wish to take part in research, which has been described elsewhere [54]. It is also possible that the additional time required for the study assessments was a deterrent to young adults who already manage a number of competing work/life demands [18, 19]. Indeed, retention to assessments was lower than has been reported previously [55, 56], which could be reflective of scheduling conflicts, burdensome assessments, or lack of interest to complete the assessments, though this was not mentioned in the interviews. Finding ways to maximize scheduling flexibility for participants and reducing study-related barriers should be explored, but this must be balanced alongside the practical considerations of conducting a study (e.g., personnel schedules). Another strategy that may enhance recruitment and adherence to assessments could be sharing videos that show what the assessments involve so participants can have a clear idea of what is required.

Notwithstanding the lower than anticipated recruitment and retention rates, nearly all participants remained engaged in the yoga intervention and attendance was higher than anticipated [22, 23]. Participants in this sample reported valuing the nature of the intervention and the opportunity to engage online. These findings extend prior work wherein young adults have expressed satisfaction and appreciation for young adult-specific supportive care opportunities [22]. Aligning this intervention with young adults’ delivery style [20, 21] and activity preferences [57] was seemingly well-received. Looking ahead, providing opportunities for modification, integrating autonomy-supportive strategies, and continuing to deliver online may be critically important when offering yoga to young adults affected by cancer.

Beyond sharing aspects of the intervention that were appreciated, participants in this sample also offered several useful considerations for improvement, including offering the intervention at a greater frequency (e.g., 2 times/week) and integrating reflection and behavioral support throughout the practice, versus at the end of each class. This feedback has been incorporated, and Yoga for Young Adults Affected by Cancer is now a 12-week intervention (to support behavior change), offered 2 times/week, and it is being evaluated via a full-scale mixed-methods, hybrid effectiveness-implementation study (clinicaltrials.gov identifier: NCT05314803).

In terms of implementation, the study team devoted substantial time and resources to ensuring adequately prepared yoga instructors and moderators. The importance of well-trained personnel when delivering physical activity for individuals living with and beyond cancer has been iterated upon elsewhere [58] and is critical to ensuring safety and fidelity. In terms of the assessments, collecting quantitative (objective and self-reported) and qualitative data within this study afforded deeper insights into aspects of feasibility, acceptability, and implementation and may aide in gaining a more comprehensive understanding of the role of yoga within the young adult cancer experience. Nevertheless, considering ways to reduce the resources required, at both research and intervention implementation levels, may be warranted. Conducting assessments with multiple participants at the same time could be explored. However, this would need to be balanced with participant safety, comfort, and scheduling logistics, as well as the assessors’ ability to accurately administer the assessments. Finally, although the administrative time for this study was relatively low—likely due to shared responsibilities across study team members and email templates—processes have been further streamlined (e.g., using automated reminders via REDCap and an online scheduling system for physical assessments and interviews) and are being implemented in the full-scale study that is currently underway (see above referenced clinicaltrials.gov identifier: NCT05314803).

With regard to the potential effects of yoga, findings suggest that this yoga intervention may augment participants’ functional mobility, flexibility, aspects of quality of life (energy/fatigue, social functioning), body image (appearance evaluation), and mindfulness (non-reactivity to inner experience), while lowering perceived stress. These findings are similar to what has been reported previously in the adult cancer yoga literature [59,60,61]. Furthermore, while there were no statistically significant changes in the remaining physical and psychological outcomes, some (e.g., quality of life subscales of role limitations due to physical health and emotional well-being and the fatigue measure) met the cutoffs for minimal clinically important differences (MCIDs) [62,63,64]. For outcomes that were non-significant and that did not meet MCIDs, it is possible that findings are due to the small sample and pilot data collected or that yoga does not impact this outcome for this cohort. Looking ahead, identifying additional meaningful outcomes for this cohort will be important and is being explored in the full-scale study (see above) and in forthcoming work.

Notably, group identification, an important factor promoting adherence and supporting behavior change [50], was low in this sample. This was a somewhat surprising finding as young adults affected by cancer have reported social isolation in the context of COVID-19 [65, 66] and desiring opportunities to connect with other young adults [67]. Simply bringing young adults together to participate in a yoga intervention may not be enough to promote group identification. Including strategies within the yoga classes (e.g., icebreaker questions, breakout rooms) to facilitate the connection between participants was suggested by participants as a possible way to promote group identification (and has been incorporated in the full-scale study described above). However, it is also plausible that the online nature of the intervention may not be conducive to facilitating the depth of social support that young adults expected or desired. Exploring the type of connection desired, how to foster connection online, and how to determine what “connection” means for this cohort will be necessary for future work.

When interpreting the results from this pilot study, there are several considerations to keep in mind. First, participants did not always have the same individual performing their physical assessments, which may have reduced the reliability of the assessment and results. Efforts were taken to mitigate this through extensive training for moderators and protocol documentation. Second, the physical assessments were performed via videoconference and thus may reflect more variability than similar assessments conducted in person. Ongoing work is examining assessments conducted virtually [68]. Also, participants had varied equipment (e.g., chair heights, measuring tools) available to them at home. Though every effort was made to document instances of assessment modification based on participants’ home settings, this could have also impacted the results. Third, there were 14 instances of protocol violations (i.e., assessments conducted > week 2) at the baseline (week 0) assessment for the 14 participants who registered in the fall 2020 wave. This was due to the timing of receiving ethical approval to recruit to the study after the yoga intervention had launched. Though these violations could contribute to washing-out effects, the decision was made to retain these participants’ data given the nature of this pilot study. Fourth, the sample described herein was predominantly female, residing in urban locations, and likely represents highly motivated young adults who are both interested in yoga and keen to contribute to research. Looking ahead, exploring strategies to minimize selection bias and recruit a more diverse sample will be important. Fifth, data were gathered from a single group; thus, it is possible that improvements noted herein were a function of time or other factors, unrelated to the yoga intervention. Relatedly, data were not nested and no statistical adjustments to the significance level were made despite running a number of tests, inflating type I error. This decision was made given the pilot nature of this work.

Taken together, findings suggest that an online yoga intervention delivered to young adults affected by cancer across Canada is potentially feasible and safe and may afford both physical and psychological benefits. However, important modifications to the intervention and study are required to enhance feasibility and acceptability. Supporting recruitment efforts by providing intervention and research details, offering greater scheduling flexibility, increasing the frequency of classes/week, and enhancing opportunities for participant interaction could improve feasibility and acceptability. This study provided invaluable data that has been used to refine the yoga intervention, underscoring the value of pilot studies, and represents an important step towards better understanding and promoting yoga to more young adults affected by cancer across Canada.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Notes

  1. Offering the intervention (yoga) independently from the study was a choice informed by pragmatic considerations and relevant research. Ethics board approval timelines, the distressing nature of the COVID-19 pandemic (and need to offer supportive care in a timely fashion), and documented study recruitment challenges in this cohort all influenced the decision to offer the intervention and subsequently recruit into the study.

  2. Support persons were not approached for participation in this study.

  3. Young adults were allowed to “register” and participate in more than one session (i.e., attend more than one class/week).

  4. Data were generally normally distributed. Instances where the assumption of normality was violated have been documented in Table 4.

  5. This decision was purely exploratory, as pilot studies are not typically powered to assess the statistical significance but can provide data to inform sample size calculations for full-scale studies.

  6. Does not sum to 100% because participants could select all symptoms that applied.

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Acknowledgements

The authors would like to thank the individuals who participated in the yoga intervention and study for their time, the organizations who aided with recruitment, Julianna Dreger for the assistance with REDCap, and Amy Chen and Kate Fougere for aiding with the interview transcription.

Funding

No funding supported this study. AW was supported by a Canadian Institutes of Health Research fellowship, Training in Research and Clinical Trials in Integrative Oncology fellowship, and Alberta Innovates Fellowship while the study was conducted. EM was supported by a Vi Riddell Pediatric Rehabilitation Graduate Studentship and a Canadian Institutes of Health Research and Canadian Graduate Scholarship – Master’s award while the study was conducted, and the manuscript was prepared while supported by a Canadian Institutes of Health Research, Canadian Graduate Scholarship – Doctoral, and the Eyes High Doctoral Recruitment Scholarship from the University of Calgary.

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Authors and Affiliations

Authors

Contributions

AW contributed to the conceptualization, developed the study protocol and received ethics approval, delivered the yoga intervention, analyzed the qualitative data, analyzed the quantitative data, and contributed to the writing—original draft and writing—review and editing. EM developed the study protocol and received ethics approval; contributed to the participant recruitment, yoga intervention registration, study eligibility, and informed consent; conducted the physical activity assessments; moderated the yoga intervention; conducted the interviews; analyzed the qualitative data; analyzed the quantitative data; and contributed to the writing—original draft and writing—review and editing. KH contributed to the participant recruitment and organization of the study assessments, conducted the physical activity assessments, moderated the yoga intervention, and contributed to the writing—review and editing. KE conducted the physical activity assessments, moderated the yoga intervention, conducted the interviews, and contributed to the writing—review and editing. AC moderated the yoga intervention, transcribed the interviews, and contributed to the writing—review and editing. LC delivered the yoga intervention and contributed to the writing—review and editing. HM delivered the yoga intervention and contributed to the writing—review and editing. DD moderated the yoga intervention and contributed to the writing—review and editing. ME moderated the yoga intervention and contributed to the writing—review and editing. SNC-R contributed to the conceptualization, developed the study protocol and received ethics approval, and contributed to the writing—review and editing. All  author(s) read and approved the final manuscript.

Corresponding author

Correspondence to Amanda Wurz.

Ethics declarations

Ethics approval and consent to participate

The study protocol was reviewed and approved by the Health Research Ethics Board of Alberta (HREBA.CC-20-0365). Participants provided informed consent to participate.

Consent for publication

Not applicable.

Competing interests

AW, EM, KH, KE, AC, LC, HM, DD, and MME declare that they have no competing interests. SNCR is a co-founder of Thrive Health Services Inc., who provides delivery of training for yoga instructors and moderators, as well as educational lead for the Yoga Thrive Teacher Training Program.

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Supplementary Information

Additional file 1.

Relevant checklists.

Additional file 2.

Semi-structured interview questions asked to explore perspections of acceptability.

Additional file 3.

Description and scoring of physical assessments.

Additional file 4.

Description and scoring of questionnaires used to assess psychological outcomes.

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Wurz, A., McLaughlin, E., Hughes, K. et al. Exploring feasibility, perceptions of acceptability, and potential benefits of an 8-week yoga intervention delivered by videoconference for young adults affected by cancer: a single-arm hybrid effectiveness-implementation pilot study. Pilot Feasibility Stud 9, 37 (2023). https://doi.org/10.1186/s40814-023-01244-y

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