J Canc Educ (2016) 31:47–54

DOI 10.1007/s13187-014-0785-9

A Wellness Program for Cancer Survivors and Caregivers:

Developing an Integrative Pilot Program with Exercise, Nutrition,
and Complementary Medicine
Mark Stoutenberg & Alyssa Sogor & Kris Arheart &
Stacy E. Cutrono & Julie Kornfeld

Published online: 10 February 2015

# Springer Science+Business Media New York 2015

Abstract The Integrative Wellness Program (IWP) at the the overall wellness of cancer patients, survivors, and their
University of Miami Sylvester Comprehensive Cancer Center caregivers.
(SCCC) sought to provide integrative wellness education to
cancer patients, survivors, and caregivers by offering instruc-
Keywords Integrative wellness . Cancer . Physical activity .
tion in exercise, nutrition, and complementary and alternative
Nutrition
medicine. The objective of this study was to assess the impact
of the IWP on the overall wellness of the individuals partici-
pating in the program. Three different 10-week versions of the
IWP were conducted over a 1-year period. Each session fo-
cused on a different wellness topic presented through interac-
Introduction
tive lectures and applied activities. A series of self-report ques-
tionnaires were administered at baseline and again at the com-
As of January 2012, there were an estimated 13.7 million
pletion of the program to assess improvements in physical
cancer survivors in the USA [1]. With the increasing number
activity levels, dietary habits, sleep hygiene, and quality of
of survivors, a greater need to address the unique challenges of
life. Participants were generally older, Caucasian, female,
survivorship in achieving and maintaining a high quality of
had higher levels of education, and still currently receiving
life has emerged [2]. There are numerous side effects to cancer
treatment. Significant changes were observed in two mea-
treatment that can include muscle wasting or atrophy, reduced
sures: Starting the Conversation (−2.0±2.40, p=.037) and
physical functioning, unfavorable changes in body composi-
the Sticking To It subscale of the Self-Efficacy and Eating
tion, depression, and fatigue [3]. Research also indicates that
Habits Survey (1.7±1.22, p=.0013). A trend for improvement
cancer survivors are as inactive, or more inactive, than the
in the Reducing Fat subscale of the Self-Efficacy Eating
general population and other populations with chronic condi-
Habits (0.44±0.60, p=.056) was also observed. Participant
tions. Population-based estimates indicate that only one quar-
satisfaction surveys indicated high levels of satisfaction and
ter to one third of survivors meet the public health recommen-
applicability of the material presented. The significant im-
dations for aerobic or strength training activities [4]. Cancer
provements detected related to dietary habits, combined with
survivors are also more likely to be overweight or obese, as
the responses from the participant satisfaction surveys, sug-
they often decrease their physical activity (PA) levels, eat poor
gest that the IWP was well received and can positively impact
quality diets, and gain weight over the course of their cancer
treatment [5].
M. Stoutenberg (*) : A. Sogor : K. Arheart : J. Kornfeld
Exercise has emerged as an effective intervention to im-
Department of Public Health Sciences, University of Miami Miller
School of Medicine, 1120 NW 14th Street, Suite 1008, prove quality of life (QOL), cardiorespiratory fitness, physical
Miami, FL 33136, USA functioning, fatigue, negative treatment-related side effects, as
e-mail: mstoutenberg@med.miami.edu well as disease-specific outcomes such as reduced risk of re-
currence and long-term survival [4, 6]. Resistance training
S. E. Cutrono
Sylvester Comprehensive Cancer Center, University of Miami Miller provides additional beneficial effects in reducing muscle
School of Medicine, Miami, FL, USA wasting, regaining lost muscle mass, and improving muscle
48
function [3]. Conventional exercise regimens, however, can
be challenging for cancer survivors who have undergone sur-
gery, chemotherapy, and/or radiation treatment, and who are
also experiencing the additional burden of anxiety and stress
about the possibility of recurrence [7]. Similarly, nutrition
counseling has also been found to improve dietary intake in
cancer patients who face increased risk of malnutrition, there-
by improving outcomes and timely healing [8].
For cancer survivors, the focus of dietary and lifestyle in-
terventions is to generally promote healthy weight manage-
ment and produce a moderate rate of weight loss in the over-
weight or obese patient through modified intakes and in-
creased PA [9, 10]. Previous research conducted among both
adult and pediatric cancer survivors indicates that most survi-
vors have high levels of interest in diet and exercise interven-
tions and experience a Bteachable moment^ for changing their
lifestyle behaviors upon diagnosis, but often slip back into
unhealthful lifestyle practices, such as being overweight or
sedentary behavior [11]. During the post-treatment phase,
the American Cancer Society (ACS) recommends setting
goals for weight management, engaging in regular PA, and
adhering to a healthy diet, as important tools to promote over-
all health and QOL [5].
Many cancer survivors also turn to complementary and
alternative medicine (CAM) therapies, in addition to their
conventional treatment, to deal with health issues such as re-
curring pain, insomnia, and ongoing psychological distress
[12]. Cancer survivors report that they seek CAM in order to
gain a sense of control to manage symptoms, to improve
QOL, and to boost their immune systems [12]. Use of Qi
Gong and meditation in cancer survivors has been shown to
improve QOL, mood, fatigue, and inflammation in a popula-
tion of breast cancer survivors [13, 14]. Acupuncture has also
shown promise as a component of supportive cancer care [13],
while meditation is a CAM therapy that is often utilized as a
non-pharmacological intervention to help control depression,
anxiety, sleep disturbances, pain, fatigue, and stress levels in
cancer patients [14].
Multiple unhealthy behaviors often co-occur, such as phys-
ical inactivity and a poor diet [15]. Targeting change in mul-
tiple versus single health behaviors offers the potential of in-
creased health benefits, maximized health promotion, and re-
duced health-care costs [15]. Interventions targeting multiple
health behaviors, specifically promoting improvements in diet
and activity behaviors, have been used to ameliorate the ad-
verse effects of cancer and its treatment [15–17] while inter-
ventions incorporating multiple components such as behavior-
al, cognitive, and supportive techniques known as mind-body
or holistic interventions, have been effective in reducing stress
and improving QOL in patients [18]. Therefore, comprehen-
sive programs for cancer survivors should incorporate exer-
cise, nutrition, and CAM practices to improve health behav-
iors and potentially long-term health outcomes.
J Canc Educ (2016) 31:47–54
The Integrative Wellness Program (IWP) at the University
of Miami Sylvester Comprehensive Cancer Center (SCCC)
sought to provide a comprehensive, integrative wellness edu-
cation program specifically tailored for cancer survivors and
caregivers in Miami-Dade County. The IWP seeks to address
the shortcomings of previous programs that focused on isolat-
ed models of care by offering a holistic wellness program that
incorporated instruction in multiple lifestyle modification be-
haviors. The objective of this study was to assess the effec-
tiveness of the IWP on the effects of PA, nutrition, sleep hy-
giene, and QOL in participants that completed the program.
Materials and Methods
The IWP was offered to local cancer survivors and caregivers
of the SCCC. Three different 10-week offerings of the IWP
were conducted over a 1-year period of time. Each weekly
session focused on a different wellness topic presented
through interactive lectures and applied activities. Question-
naires were administered at baseline and again after the com-
pletion of the program to assess improvements in PA and
dietary habits, sleep, QOL, and overall wellness.
Participants
Participants in the IWP were local cancer survivors, including
current patients, or caregivers who were recruited by adminis-
trative and program staff through emails to the cancer center
listserv, presenting patients with study flyers, and referrals from
the SCCC oncologists. Interested individuals were asked to
contact the IWP personnel for more information and to deter-
mine if the program suited their current needs. During the first
session of the IWP, interested individuals were provided with
information about the program and asked if they would be
willing to participate in the research study. If an individual
chose not to participate in the study, they were still eligible to
continue their participation in the IWP. Those interested in par-
ticipating in the study were then asked to complete an informed
consent process where the risks and benefits of the study were
explained to them in detail. The informed consent process was
conducted in a group setting, and participants were able to
speak directly to an IWP member if they had questions. The
study and its materials were approved by the human subjects
review board of the University of Miami and the SCCC.
Behavioral Foundation for the IWP Curriculum
The IWP was designed to engage participants in an active
learning process to improve their knowledge and lifestyle
habits related to topics including PA, nutrition, sleep hygiene,
and CAM. The content of the program was adapted from
similar programs offered by the Integrative Medicine Program
J Canc Educ (2016) 31:47–54 49

at the H. Lee Moffitt Cancer Center & Research Institute [19]
and the Stanford Center for Integrative Medicine [20]. The
sessions were designed to incorporate key strategies from
the Social Cognitive Theory (SCT) [21] and the Health Belief
Model (HBM) [22] applied to health promotion in cancer
survivors. In the SCT, knowledge of health risks and benefits
personal efficacy plays a central role in creating the precondi-
tion for change [21]. To incorporate the SCT into the IWP,
sessions focused on providing knowledge about the benefits
of different health practices, such as various resistance and
cardiovascular exercises, eating habits, and mindfulness tech-
niques. Additionally, the IWP curriculum engaged individuals
in applied experiences (i.e., practicing resistance training ex-
ercises) to develop positive Bpast^ performances, thereby in-
creasing one’s perceived self-efficacy in their ability to
achieve future health goals. The HBM is an intrapersonal
health education model and has been administered across mul-
tiple health domains, such as nutrition education [22] and PA
in adults [23]. The HBM has four characteristics: first, that
new behaviors will benefit the health, economy, social, family,
and cultural lives of an individual. Second, health educators
must be aware of the barriers related to choosing healthy be-
haviors. Within the IWP, mobility issues, fatigue, and special-
ized nutrition recommendations were taken into consideration
during content development. Third, educational programs
should provide appropriate information about susceptibility
of developing a condition. Among our cancer survivors, at-
tention was given to educating participants about risk of both
physical and psychosocial complications related to their treat-
ment. Fourth, it is necessary to use cues to action, thus the
IWP included individual training and educational media, such
as demonstrations of how to successfully interact with calorie-
tracking websites.
Using these guiding behavioral principles, a total of ten
core sessions were developed. A list of program sessions
and activities are provided in Table 1. Prior to conducting
the IWP as a whole, each session was individually piloted
during the fall of 2011 and winter of 2012 and modified based
on staff observations and participant feedback. After piloting
the sessions, they were combined to form a comprehensive
10-week program that was conducted in three different times
at two campus locations.
The IWP Core Sessions
The IWP was led by a trained facilitator who began each
session with group introductions and encouraged participants
to share their personal story with newcomers, followed by a
Bcheck in^ that focused on their success implementing the
previous week’s lessons in their daily lives. During the edu-
cation portion of the IWP, a facilitator provided an overview
of the lesson plan and led the participants through an interac-
tive discussion related to the session topic. These sessions
Table 1 The Integrative Wellness Program (IWP) curriculum
Week Topic Details
Session 1 General lifestyle Reducing sedentary behaviors and
activity increasing daily activity
Session 2 Resistance training Safely performing resistance training
exercises
Session 3 Aerobic activity Exercising to improve cardiovascular
fitness and fatigue
Session 4 General nutrition Basics to general nutrition
Session 5 Cancer nutrition Nutrition needs during treatment,
recovery, and long-term survivorship
Session 6 Healthy shopping Applying recommendations in practice
at the local grocery supermarket
Session 7 Weight Maintaining a healthy body weight
management
Session 8 Quality sleep Improving sleep hygiene
Session 9 Acupuncture Overview of acupuncture and Chinese
and Chinese medicine practices such as Qi Gong
medicine
Session 10 Mindfulness Using mindful meditation to manage
emotions, reduce stress, and improve
mind–body connection
involved presentations, videos, and visual examples inter-
spersed with interactive question and answer segments and
engaged participants in problem-solving activities. To incor-
porate light PA throughout the session, participants were en-
couraged to sit on exercise balls and sitting time was
interrupted by frequent standing activities.
After the educational portion of the session, participants
were engaged in applied activities, such as learning resistance
exercises that can be performed at home and reading nutrition
labels to understand calories, sugar, and protein content. The
program ended with a PA period, which included various ac-
tivities, such as moderate walking, aerobic conditioning, and
light resistance exercise. Attempts were made to link the PA
period with the core material of the session (i.e., mindful walk-
ing during the mindfulness session). At the conclusion of the
session, participants were assigned life skill challenges de-
signed to apply key strategies from the session, such as track-
ing daily steps using a pedometer or using online dietary pro-
grams to analyze daily dietary consumption, into their daily life
prior to the next IWP session. Finally, participants were pro-
vided with print resources related to the session’s topic, as well
as further online resources in a follow-up email the next day.
Assessments
A series of six questionnaires, that took approximately 15–
20 min to complete, were administered pre- and post-IWP to
all study participants. The questionnaires consisted of the Self-
Efficacy and Exercise Habits Survey, Self-Efficacy and Eating
Habits Survey, Godin Leisure–Time Survey, Starting the
50 J Canc Educ (2016) 31:47–54

Conversation (STC), the Pittsburgh Sleep Quality Index Data Analysis

(PSQI), and the Short-Form Health Survey (SF-36).
The Godin Leisure–Time Survey has been found to be The data from the questionnaires were entered into an excel
appropriate for assessing leisure time activity in a community spreadsheet, reviewed for completeness, and checked for er-
setting and has been used in previous studies involving cancer rors and inconsistencies. Demographic information was sorted
survivors [24–26] with two week test–retest reliability coeffi- and analyzed using Chi-squared analysis. Paired t tests were
cients of 0.48 for mild, 0.46 for moderate, and 0.94 for stren- conducted using SAS 9.3 software (SAS Institute, Cary, NC)
uous exercise [27]. The questionnaire is brief, easily adminis- to determine differences between baseline and post-
tered, reliable, and demonstrates concurrent validity with oth- intervention scores among participants who completed the
er tools [28]. program. Chi-squared analyses were then conducted to deter-
The Self-Efficacy and Eating Habits Survey and the Self- mine if there were baseline differences between program com-
Efficacy and Exercise Habits Survey were created to assess an pleters and non-completers. Completion of the program was
individual’s ability to be self-efficient when making healthy defined as finishing both the pre- and post-program surveys.
dietary decisions or to engage in independent PA [29, 30]. Statistical significance was defined a priori at a p value of
Participants were asked to report how sure they were that they <.05.
could perform various behaviors on a 5-point Likert-type scale
from 1 (I know I cannot) to 5 (I know I can), with the addi-
tional option to mark, BDoes not apply^ [30]. The Self-
Efficacy and Exercise Habits Survey is a sum of two scales
Results
(Sticking To It and Making Time) while the Self-Efficacy and
Eating Habits Survey was a compilation of four subscales
Baseline demographics are presented in Table 2. Enrollment at
(Sticking To It, Reducing Calories, Reducing Salt, and Reduc-
each of the three offerings of the IWP consisted of 7, 8, and 6
ing Fat). These questionnaires have been previously used in
individuals, of which 3, 5, and 3 participants, respectively,
overweight and obese men [31] and overweight/obese post-
completed the program. Of those initially enrolled in the
menopausal women [30].
The STC questionnaire is an eight-item simplified food
frequency instrument designed for use in primary care and Table 2 Participant demographics
health promotion settings that can be administered by individ-
uals other than a dietitian [32]. The STC has been previously All Completers Non-
Participants completers
used in research with cancer survivors and is considered less
burdensome and less likely to influence behavior than using Age (mean, SD) 62.5 (10.9) 62.8 (12.2) 62.0 (9.8)
food diaries [32]. A lower STC score is considered to be Gender (n)
consistent with healthier eating habits [32]. Male 5 1 4
The PSQI is a 19-question survey, which assesses sleep Female 15 10 5
quality and disturbances over a 1-month time interval [33]. Age at Diagnosis (mean, SD) 58.9 (12.1) 55.6 (10.4) 53.7 (20.7)
It is a compilation of seven subscales: subjective sleep quality, Race (n)
sleep latency, sleep duration, habitual sleep deficiency, sleep White 15 8 7
disturbances, use of sleep medication, and daytime dysfunc- African American 2 1 1
tion [33]. The final scoring of the PSQI can range from a Hispanic 3 2 1
minimum of 0 to a maximum of 21. For the current analysis, Cancer type
the overall PSQI score, comprised of 19 items scored on a 4- Breast 9 7 2
point Likert scale (0=Bnot during the past month^ to 3=Bthree
Multiple 2 1 1
or more times a week^) was used. Higher scores indicate
Prostate 2 1 1
poorer quality of sleep [34]. The PSQI has been successfully
Gastric 1 1 0
used in various cancer survivor populations [34, 35].
Multiple myeloma 1 0 1
The sixth questionnaire, the SF-36, is a multi-purpose,
Pancreatic 1 0 1
short-form health survey consisting of 36 questions grouped
N/A (caregivers) 4 1 3
in eight sections: vitality, physical functioning, bodily pain,
Education
general health perceptions, physical role functioning, emo-
Some college 5 1 4
tional role functioning, social role functioning, and mental
Bachelor’s or greater 15 10 5
health. The SF-36 is used as a general measure of QOL and
has been used extensively in clinical research, and in cancer One participant did not complete the demographic questionnaire, but did
survivors [36, 37]. complete all other baseline assessments
J Canc Educ (2016) 31:47–54 51

program, participants were generally older, Caucasian, fe-
male, had higher levels of education, and disclosed that they
were still currently receiving treatment. On average, individ-
uals who participated in the program were primarily still re-
ceiving treatment (n=8) or within 1 year of completing their
treatment (n=3). Only three IWP participants reported being
five or more years from the end of their cancer treatment.
There were no significant differences in age, race/ethnicity,
education, and gender between participants who completed
the program and participants who did not. The types of cancer
represented in the participants were diverse representing sev-
eral different cancer sites.
Statistically significant changes in participant responses
were observed in two surveys: the STC (−2.0 ± 2.40,
p=.037) and the Sticking To It subscale of the Self-Efficacy
and Eating Habits Survey (1.7±1.22, p=.0013). A trend for
improvement in the Reducing Fat subscale of the Self-
Efficacy Eating Habits (0.44±0.60, p=.056) was also ob-
served (see Table 3). Participant satisfaction surveys complet-
ed at the end of the program indicated a high level of satisfac-
tion and applicability of the material to the daily lives of the
cancer survivors participating in the IWP (see Table 4).
Discussion
The aim of the IWP was to improve QOL and health-related
behaviors, such as PA, nutrition, sleep hygiene, and QOL in
cancer survivors, and caregivers. Our results suggest that the
IWP had a significant impact on some of the participants’
behaviors, particularly those related to dietary behavior. Ad-
ditionally, participants expressed a high level of satisfaction
with the IWP and were in agreement about its applicability to
their cancer recovery and the relevance of the information
provided during sessions to their situations.
Over the course of the IWP, significant improvements were
observed in the ability and confidence of participants to inte-
grate more nutrient-dense food into their diets through the
STC, as well as increased self-efficacy in adopting healthy
dietary behaviors Sticking To It subscale of the Self-Efficacy
and Eating Habits Survey. These findings are supported by
previous work that showed that group-based, cognitive behav-
ioral programs have an impact on confidence and self-efficacy
with regards to long-term dietary gains [38, 39].
There were several factors that may have influenced the
lack of significant results over the other domains evaluated
in this study. Given the limited sample size, which is consis-
tent with other proof of concept studies [40–42], our results
suggest that positive improvements seen in most of our study
outcomes may have been statistically significant given a larger
cohort of individuals. Additionally, some participants
disclosed current medical conditions that may have affected
their ability to implement or adopt some of the recommenda-
tions from the IWP, such as mobility impairments, chronic
debilitating conditions like spinal stenosis, and recommenda-
tions from their physician to limit strenuous activity like tak-
ing the stairs. In a previous study exploring participant bar-
riers, the ability of colorectal cancer survivors to participate or
adhere to an exercise program was significantly related to lack
of time, non-specific treatment side effects, fatigue, prescrip-
tion drug usage, nausea, diarrhea, and surgical complications
[43]. It is therefore possible that participants struggling with
these barriers would also find it challenging to improve their
PA levels. This is supported by the fact that significant im-
provements occurred in several of the dietary subscales related
to choosing more nutrient-dense and healthier foods, suggest-
ing that participants may have felt a greater degree of control
over changing their dietary behaviors. Another potential ex-
planation for the lack of changes in PA attitudes may be relat-
ed to participant sleeping habits. Research has demonstrated

Table 3 Changes in outcomes for individuals who completed the Integrative Wellness Program

Survey na Baseline mean (SD) Post-intervention mean (SD) Mean change (SD) Pr>|t|

Self-Efficacy and Exercise Habits/Sticking to It 11 4.65 (0.78) 4.75 (0.73) 0.094 (0.82) .708
Self-Efficacy and Exercise Habits/Making Time 11 4.36 (0.72) 4.60 (1.04) 0.242 (0.83) .356
Godin Leisure–Time Exercise Questionnaire 10 19.59 (12.17) 22.40 (6.78) 4.450 (9.09) .156
Starting the Conversation 9 5.54 (2.9) 4.11 (2.62) −2.000 (2.40) .036
Self-Efficacy and Eating Habits/Sticking to it 10 3.86 (0.83) 5.62 (1.05) 1.765 (1.22) .001
Self-Efficacy and Eating Habits/Reducing Calories 10 3.72 (0.83) 4.20 (0.65) 0.48 (0.92) .131
Self-Efficacy and Eating Habits/Reducing Salt 10 4.60 (1.13) 4.54 (0.94) −0.055 (0.60) .778
Self-Efficacy and Eating Habits/Reducing Fat 9 4.73 (0.77) 5.1 (0.74) 0.44 (0.60) .056
Pittsburgh Sleep Questionnaire 10 9.60 (6.75) 8.40 (4.93) −1.20 (4.59) .43
SF-36 (Physical Summary Score) 10 39.27 (9.14) 39.82 (10.39) 0.66 (10.71) .85
SF-36 (Mental Summary Score) 10 48.22 (13.48) 49.84 (7.54) 1.62 (15.48) .748
a
Some individuals did not complete all survey items at both baseline and post-intervention leading to varying sample sizes for each measure
52
Table 4 Results from the participant satisfaction survey
As a result of this program I feel empowered to achieve overall physical and mental wellness.
The 90-minute length of each program sessions was appropriate.
The location of each program session was appropriate.
I would be willing to participate in this program if it were delivered in an online, webinar format.
The educational discussion of each wellness topic was informative and useful in my daily life.
The skill building activities were useful in my daily life.
The program activities (e.g., walking, resistance exercises) were appropriate.
The take home assignments provided after each session helped me make positive wellness changes.
Some individuals did not fully complete the satisfaction survey leading to varying sample sizes for each measure. No individuals indicated that they
strongly disagreed with any of the survey statements
that sleep loss affects exercise tolerance, motivation, and
mood [44]. The optimal PSQI value is 0; at baseline, the aver-
age score of our participants was 9.6 indicating that they were
struggling with obtaining quality sleep. The fact that these sur-
vey scores did not improve during the IWP may have hindered
the participants’ ability to adhere to PA recommendations.
There were several strengths to the IWP; the first of these
being participant satisfaction. Participant satisfaction is con-
sidered an immediate, positive result of the program as it re-
flects participant self-efficacy and value of the course content
[45]. Data from the IWP satisfaction survey indicates that
participants were highly satisfied with the program, with the
majority reporting that they Bstrongly agreed^ that the IWP
was successful in enhancing knowledge about diverse well-
ness topics and providing skill building and PA opportunities
that were appropriate to their survivorship needs. Participants
also praised the ability of the program leader to engage them
in the program and deliver information. Previous research
indicates accessibility to a health center and social support is
helpful for participants’ adherence [46]. The IWP incorporat-
ed social and group support through group exercises, active
discussion, and activities in a wellness center, with access to
exercise equipment and resources of the center.
Future studies involving integrative programs for cancer
survivors may wish to expand upon our evaluation model by
adding qualitative methodology. Quantitative methodology
has its limitations due to an inability to detect significant
changes in some aspects of behavior change [14]. Adding
qualitative research methods to future research trials can im-
prove understanding of these integrative approaches by in-
creasing the breadth and depth of information regarding par-
ticipants’ circumstances and increase our understanding of the
feasibility and applicability of the intervention in real life and
time [47]. Using a mixed methods approach could potentially
provide more information and allow participants to expand on
some of the comments provided in their quantitative assess-
ments. Finally, conducting follow-up assessments of the long-
term impact of the IWP on behavioral changes will be
J Canc Educ (2016) 31:47–54
Disagree Neutral Agree Strongly Agree
0 0 6 11
0 0 6 11
1 1 2 12
1 6 6 4
0 0 3 14
0 0 5 12
0 0 1 14
0 2 7 9
important in assessing its long-term benefits. Baron et al. con-
cluded that it can take up to 4 months of consistent aerobic
activity to improve insomnia in patients struggling with sleep-
lessness or poor sleep hygiene [44].
Our pilot study has several limitations that should be
considered. One of these limitations was the dropout rate
seen in participants who originally enrolled in the IWP. The
observed dropout out rate (~52 %) was similar to other
exercise interventions conducted among cancer survivors
[42]. Adherence and retention could potentially be im-
proved in future studies through the utilization of tailored
print communication, motivational interviewing, and/or
online and web-based materials [40, 48]. Motivational
interviewing allows for individual participants to receive
personalized feedback and encouragement, while web-
based materials are known to provide supplement informa-
tion and support outside of face-to-face sessions [49]. There
were only two male participants enrolled in the IWP, which
is consistent with previous research that indicates female
cancer patients and survivors are 2.1 times more likely to
engage in CAM practices than males [50]. An effort to
recruit and retain male participants may be enhanced by
using male recruiters [51] and providing more direct and
primary education from trusted health professions for males
to increase awareness and interest [52]. Another limitation
was lack of objective assessments. Future iterations of the
IWP may benefit from objective physiological assessments,
such as biological samples of inflammatory markers, cho-
lesterol, and glucose levels, in addition to the self-report
questionnaires. Utilization of accelerometers can also pro-
vide objective data regarding the PA levels of the partici-
pants as has been done in previous studies involving cancer
survivors [53]. Finally, there were no assessments that eval-
uated the participants’ attitudes and beliefs towards the
CAM components of the IWP nor were there any efforts
to contact survivors who did not complete the program to
assess the barriers and factors that lead to them dropping
out of the program.
J Canc Educ (2016) 31:47–54
Conclusion
The data collected from the IWP presents promising results
regarding the effectiveness of the program on improving
dietary behaviors and other personal wellness characteris-
tics. Significant improvements were detected in several
subscales related to dietary habits, and responses from the
participant satisfaction surveys suggest that the IWP was
well received and had a great deal of applicability and con-
tent value to the participants. Future programs could benefit
from a diverse array of qualitative and quantitative assess-
ments that more thoroughly capture all of the benefits of the
IWP. By incorporating several beneficial, health-related
components together in one specialized wellness program,
the IWP was able to create a more integrated approach to
improving QOL and health behavior in cancer patients, sur-
vivors, and caregivers.
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