Acceptability and satisfaction of project MOVE: A pragmatic feasibility trial aimed at increasing physical activity in female breast cancer survivors

Abstract Objective Despite the physical and psychological health benefits associated with physical activity (PA) for breast cancer (BC) survivors, up to 70% of female BC survivors are not meeting minimum recommended PA guidelines. The objective of this study was to evaluate acceptability and satisfaction with Project MOVE, an innovative approach to increase PA among BC survivors through the combination of microgrants and financial incentives. Methods A mixed‐methods design was used. Participants were BC survivors and support individuals with a mean age of 58.5 years. At 6‐month follow‐up, participants completed a program evaluation questionnaire (n = 72) and participated in focus groups (n = 52) to explore their experience with Project MOVE. Results Participants reported that they were satisfied with Project MOVE (86.6%) and that the program was appropriate for BC survivors (96.3%). Four main themes emerged from focus groups: (1) acceptability and satisfaction of Project MOVE, detailing the value of the model in developing tailored group‐base PA programs; (2) the importance of Project MOVE leaders, highlighting the value of a leader that was organized and a good communicator; (3) breaking down barriers with Project MOVE, describing how the program helped to address common BC related barriers; and (4) motivation to MOVE, outlining how the microgrants enabled survivors to be active, while the financial incentive motivated them to increase and maintain their PA. Conclusion The findings provide support for the acceptability of Project MOVE as a strategy for increasing PA among BC survivors.

reduced mortality and BC reoccurrence. [8][9][10] In spite of the benefits associated with being physically active, up to 70% of BC survivors are not meeting the minimum recommended guidelines of 150 minutes of moderate to vigorous PA per week. [11][12][13] While PA programs designed for BC survivors have shown potential in increasing engagement, [14][15][16] many of these programs do not meet the specific needs of BC survivors. 17,18 One promising approach to address this gap is the combined use of microgrants and financial incentives.
The microgrant model refers to a scheme in which small amounts of funds are awarded to successful community-based applicant groups to develop and/or implement a community program or initiative. Although relatively unique to the health promotion field, a small number of studies have shown that these schemes can stimulate community health-related activities, help build confidence to undertake and engage in health promoting behaviors, and provide an outlet for social interaction. [19][20][21][22][23] It has also been reported that similar microgrant schemes have aided in improving PA and healthy eating behaviors in priority communities, such as ethnic minorities and low socioeconomic groups. 21,23 The microgrant model has been framed within social ecological models of behavior change 24 whereby environmental, social, and individual factors may be impacted for enacted change in behavior. Aligned with social cognitive theory, 25 financial incentives within the microgrant model also provide feedback and reinforcement of behavior change success that may enhance self-efficacy and sustained behavior change. 26 Within this context, Project MOVE 27 was created to prompt and sustain PA among BC survivors by combining the use of microgrants and financial incentives.
This unique combination was used to promote PA in the context of BC by returning some of the decision-making power back to BC survivors and instilling a sense of control over their health. Thus, the purpose of this study was to examine the feasibility of this model by gaining a greater understanding of the acceptability and satisfaction with Project MOVE.

| Participants and recruitment
Participants were recruited as pre-existing or newly formed groups of 8 to 12 adult (18+ years) female BC survivors living in the Okanagan region of British Columbia, Canada. Individual women who were not able to form a group independently were asked to contact the research team who facilitated connections to join an existing group or lead a group. Support women (eg, sisters, friends) were allowed to participate in the groups, with a caveat that the groups composed of at least 50% BC survivors. A variety of recruitment methods were utilized including face-to-face meetings with community stakeholders (eg, Canadian Cancer Society [CCS], BC Cancer Agency), attendance at relevant community events (eg, Run for the Cure), and advertisements through local print, radio media, and social media (eg, Facebook, Twitter).
To address the purpose of the current study, participants included women who were part of an existing Project MOVE group and attended the 6-month follow-up data collection session. All participants completed written informed consent at baseline, and verbal consent was renewed prior to each focus group session. Ethical approval was obtained from the University of British Columbia's Behavioral Research Ethics Board (#H14-02502).

| Project MOVE intervention
A full description of the Project MOVE intervention has been previously reported. 27 In brief, BC survivors were encouraged to come together as a group to develop and implement their own PA initiative based on their needs and preferences, and more importantly, to address any unique circumstances and specific barriers that may have limited them from being active. Groups were then invited to apply for a microgrant of up to $2000 to support these initiatives. Once submitted, all grants were reviewed by a grant review panel, consisting of members from the research team, representatives from CCS, and the target population. Upon recommendation from the panel, microgrant funds were distributed to the successful applicant groups (Table 1). Unsuccessful applicant groups (n = 5 groups) were provided with feedback and encouraged to revise and re-submit their application for re-review. Participant groups were also informed that if they increased the group's combined PA (assessed at 6 months), they would be awarded a further $500 to support more PA sessions or a group social event (see supplemental Appendix 1). Each group included a leader who was responsible for communicating with the research team, organizing participants, and coordinating activities.

| Measures and procedures
The 6-month follow-up consisted of a brief self-report program evaluation questionnaire and participation in a focus group.

| Program evaluation questionnaire
Participants (n = 72) were asked to rate their Project MOVE experience on a 5-point Likert scale, with 1 representing "strongly disagree" and 5 representing "strongly agree." The questionnaire included a total of 5 questions related to program satisfaction, acceptability, and appropriateness.

| Focus groups
Participants' experiences with the program were explored with focus group methodology. One focus group was held for each Project MOVE group with a total of 52 participants (groups ranging 3-7 participants).
Each focus group was held at a time and location convenient for participants, lasted 35 to 60 minutes, and was audio-recorded using a digital SonyTM recorder (ICD-PX333).
Semi-structured open-ended questions and prompts were used to guide the discussion (see supplemental Appendix 2), 28 and sticky notes, flip charts, and pens 29 were also available to generate involvement from participants. Similarly, non-BC women who were part of the groups were part of the focus groups to encourage discussion. Any written material that was not captured verbally in discussion and perceptions from non-BC survivors within the groups were not included in the analysis.

| Analysis
The responses from the program evaluation questionnaire were reported as percentages. Focus group discussions were transcribed verbatim, and all identifiable information was removed to ensure anonymity and confidentiality following transcription. A thematic content analysis 30 was conducted to explore participants' experiences with Project MOVE. All data were independently coded and categorized by 2 research team members using NVivo11™. Each team member systematically read the transcripts multiple times, highlighted segments of interest, identified, and coded potential themes. Once coding was complete, themes were discussed among the 2 researchers to ensure bias was minimized. Any discrepancies that arose during analysis were presented and discussed further until a consensus was reached.

| Sample characteristics
Baseline demographic data were collected for a total of 87 participants (see supplemental Appendix 3). At 6-month follow-up, data were collected for a total of 72 participants (15 non BC survivors). There were no statistical differences between those who completed the follow-up assessment versus those who dropped out (see supplemental Appendix 1) between baseline and 6 months. Of the 72 participants (15 non BC survivors) that completed the 6-month follow-up, 52 participants (11 non BC survivors) also participated in the focus groups.
Those that completed the 6-month follow-up (n = 72) were primarily BC survivors (79%), white (95%), and married (68%), with a mean age of 58.5 ± 8.8 years. Mean group PA increased by 990 steps per day from baseline to 6-month follow-up.

| Program evaluation results
Results from the program evaluation questionnaire represent responses from those identified as BC survivors (n = 57). These partic-

| Focus group results
Four themes emerged from the focus group data. Findings from each theme are summarized with representative quotes from participants who were BC survivors (n = 41).

| The importance of Project MOVE leaders
Many groups indicated that having a leader who communicated regularly with the group was important. One group highlighted the impressive level of engagement from their leader: "She really was invested. Like she went above and beyond for us. She really wanted us to succeed. And we did" (group 8, participant 6). Many groups also valued having a leader who initiated discussion on how to utilize the funds but also provided group members with the opportunity to offer input and participate in the decision-making process.
By contrast, groups with leaders who were not as engaged with their group reported less enjoyment, as described by

| Breaking down barriers with Project MOVE
Many women spoke about the choice of activities and the close com-

| Motivation to MOVE
The majority of participants indicated that being part of Project MOVE, in general, was a motivating factor to start or continue being active. Participants also reported that the positive health benefits they were beginning to experience motivated them to continue engaging in PA post-intervention. One participant noticed her strength improved from 1 class to the next and commented, "I can't believe how much better I've gotten, suddenly I was getting stronger" (group 7, participant 3). Other participants also noticed improvements; "My breathing and my endurance is better" (group 7, participant 2) and "we can recover so much faster" (group 7, participant 1).
Some participants also suggested that goal setting was important in motivating them to be more active and remain active in the future, further recommending that the first Project MOVE session should be dedicated to setting achievable individual and group goals. As indicated by 1 participant, "Having some sort of goals at the start I think would really help motivate us. And being able to say part way through, hey guys we're on track or we're not" (group 10, participant 2).
Several groups also reported that a list of community PA programs and additional educational resources specific to PA and BC would further motivate them to get more involved and try different things. Consistent with many responses, one participant explained; "I think a list of resources would be really helpful… here's where you can go to rent a bike or rent a paddleboard" (group 10, participant 2). Additionally, participants recommended that health professionals (eg, dieticians, physiotherapists) could be invited to speak at one of the sessions as they valued learning about how to continue to make healthy lifestyle choices from credible professionals.

| DISCUSSION
Consistent with models of post-traumatic growth and PA, 14,31 one of the key findings was that Project MOVE offered an opportunity for women to be active with "similar others" and this fostered social support. By participating in community-based initiatives among "similar others," it has been suggested that BC survivors build autonomy and confidence in their ability to perform PA. 14 had engaged and involved leaders reported more accountability to their group, which may have fostered group cohesion that was associated with higher enjoyment and participation. These findings mimic common outcomes in sport and exercise literature. 35,36 Based on these findings, microgrant models may be enhanced by providing leadership training and highlighting common strategies to build group cohesion (eg, group member roles, group norms, group goals).
Unique to Project MOVE was the addition of a $500 financial incentive for groups that increased their mean PA at 6 months follow-up. The use of financial incentives among adults has been found to have a significant positive effect on PA session attendance, adherence, and maintenance over a 6 month period. 26,37 The financial incentives in Project MOVE acted to motivate participants to increase their activity and provided them with a sense of accountability to attend each PA session. While not discussed in the focus groups, 1 caution to this financial incentive may be a fostering of introjected regulation, which is a controlling form of motivation that could hinder longer-term engagement. 38 As such, the financial incentive may have a functional timing that needs to be limited. Nonetheless, introjected regulation may be an important form of motivation to get women started in their PA pursuits. 39 In the duration and timing of Project MOVE, there were more benefits to the financial incentive in providing reinforcement for achievement.

| Study limitations
The views presented reflect a specific population and thus cannot be generalized across the many diverse populations and settings across

| Clinical implications
The Project MOVE model (microgrants + financial incentives) shows promise as a strategy for initiating and maintaining PA engagement within the BC population. Most importantly, this model provided a starting point for survivors to overcome some of the barriers they often face (eg, lack of self-confidence, financial constraints). As such, participants have been provided with the education and tools they need to self-manage and sustain their future PA. Moreover, with the funds received, participants were able to try new activities at many community facilities and with a number of health and fitness professionals. The community partnerships that developed during the sessions may aid in further sustainability as participants are now more confident to take advantage of the many centres throughout the community. In turn, many of these facilities and professionals are more aware of the unique needs of this population and could offer more cost-effective programs that are of interest to this population. In addition, Project MOVE was primarily focused on supporting engagement in PA organically; thus, few resources were provided, and little time was spent discussing other health behaviors. The absence of these was identified by many participants and thus needs to be considered in refining this model for wider dissemination.

| Conclusion
Prioritizing Project MOVE participant views is an important first step in determining the feasibility of this novel program for long-term initiation. Project MOVE provided a positive and autonomous environment for participants and enabled them to overcome many of the barriers to PA. This innovation shows great promise for increasing PA among BC survivors.