Experiences of young adults affected by cancer within an 8-week yoga intervention delivered by videoconference: a qualitative interview study

Abstract

Background

Yoga may reduce negative cancer- and treatment-related effects and help improve a range of outcomes, including flexibility, mindfulness, and quality of life among adults affected by cancer. Yet there is little evidence for the role of yoga among young adults (18–39 years) affected by cancer.

Purpose

The purpose of this study was to explore the experiences of young adults affected by cancer in an 8-week yoga intervention delivered by videoconference.

Methods

Young adults who were diagnosed with cancer between the ages of 18 and 39 years, at any stage of the cancer trajectory, who were living in Canada, and who completed an 8-week yoga intervention were approached to complete a semi-structured interview. A social constructivist paradigm was adopted. Interviews were transcribed verbatim and analyzed using reflexive thematic analysis.

Results

Twenty-eight young adults (Mean age = 34.67 ± 5.11 years; n = 25 female) with varied cancer diagnoses participated. Participants’ perspectives were represented across 6 themes: (1) I was juggling a number of challenges and changes throughout the yoga intervention; (2) I noticed some improvements in my mental and physical health; (3) I made time to discover new strategies to take care of myself; (4) I was able to see what my body is capable of; (5) I was held accountable and I appreciated that, and; (6) I was able to be around similar others in a safe (virtual) space.

Conclusions

Findings suggest that an 8-week yoga intervention may offer some benefits for young adults affected by cancer. Self-care, self-compassion, mindfulness, feelings of physical competence, establishing a routine, and being around similar others were viewed as important components of the intervention and may have contributed to the benefits experienced. Findings underscore the potential utility of yoga as a supportive care intervention for young adults affected by cancer.

KEY MESSAGES

1. Young adults affected by cancer described changed physical and mental health after an 8-week yoga intervention delivered by videoconference.

2. Taking time for oneself, practicing self-compassion and mindfulness, enhanced feelings of physical competence, and establishing a routine were important elements of the intervention.

3. Young adults appreciated being around similar others (i.e., other young adults affected by cancer) and felt connected in this videoconference-based intervention.

Keywords:

• Online
• virtual
• movement
• mindfulness
• oncology
• survivorship
• rehabilitation

Introduction

Cancer among young adults between 18–39 years of age is relatively rare, with approximately 7,000 new diagnoses in Canada each year [1]. Though survival rates are improving for some of the most commonly diagnosed cancers (e.g. thyroid, testicular, lymphoma; [1]), the disease remains a leading cause of death and morbidity in this age group [2,3] and is associated with detrimental effects spanning physical (e.g. increased pain, decreased strength and range of motion), psychosocial (e.g. elevated depression and anxiety, decreased quality of life), and cognitive domains (e.g. decrements in attention and processing speeds; [4–8]). In addition, young adults must navigate challenges related to their age at diagnosis, which co-occurs with a critical developmental period that may include meeting milestones such as establishing autonomy, completing school, or starting a career [9,10].

Supporting young adults affected by cancer (i.e. those who have received a diagnosis and are living with or beyond their cancer; [11]) has been identified as a priority [12]. Yoga, a practice that in Western societies typically includes movement, breathwork, and mindfulness [13,14], may mitigate some of the negative effects of cancer and enhance quality of life [15]. As such, yoga is recommended for adults affected by cancer by national cancer support organizations [16–18]. Further, findings from systematic reviews suggest yoga may help minimize symptoms of fatigue, improve sleep, and reduce depression and anxiety among samples comprised of adults (aged 18 years or older) affected by cancer [19,20] and a recent meta-analysis including 29 trials and 3,245 adults (21-87 years old) affected by cancer at varying stages of the cancer trajectory found that yoga improved symptoms of stress, sleep quality, and cognitive functioning [21]. While the studies presented within these reviews and meta-analyses may have included young adult participants, no studies or reviews specifically focused on young adults affected by cancer.

Consequently, among young adults affected by cancer, there is little evidence for the role of yoga. One study testing the effects of a 7-week, unsupervised, DVD-based yoga intervention among young adults with non-curative cancer (n = 4; mean age = 33.75 ± 1.5 years) has been published [22]. Results suggest the intervention was acceptable and that it improved functional, physical, and spiritual well-being and overall quality of life (η_p²=0.38 for functional well-being to η_p²=0.78 for functional well-being, which represent large effects; [22]). In another study, young adults affected by cancer who were off-treatment completed a survey to identify reasons for and predictors of yoga participation, and the authors concluded that this cohort had a strong desire to participate in yoga [23]. The lack of yoga resources to meet the unique needs of young adults is problematic. While trends in yoga’s effect may be similar, there is some work to suggest young adults may experience different responses to physical activity and possibly differences in outcomes that are deemed important following supportive care interventions. Thus, understanding experiences and effects of yoga for young adults affected by cancer will more accurately inform future programs and interventions that are age-appropriate.

Many young adults affected by cancer desire online, accessible, dynamic interventions that are group-based and delivered close to (or at) home [24]. Videoconference delivery (i.e. synchronous, real-time program delivery, which can been accessed via platforms such as Zoom) is flexible, allows for real-time interaction from the comfort of one’s own home [25], and accounts for the preferences of many young adults [24]. Additionally, this form of delivery may enhance access to yoga as a low-risk form of physical activity [26]. There is also evidence to suggest that yoga delivered by videoconference is feasible and acceptable among older adults (>39 years) affected by cancer, conferring similar benefits to yoga offered in-person [27].

Thus, we developed an 8-week yoga intervention delivered by videoconference and conducted a pilot trial evaluating the yoga intervention delivered by videoconference for this population. We found the yoga intervention was safe (i.e. no adverse events) and feasible with respect to little missing data, high attendance rates, and no adverse events. However, recruitment (33%) and retention (70%) were lower than the a priori targets of 60% and ≥75%, respectively. Suggestions for improving recruitment and retention for future studies included: requiring study participation and providing greater scheduling flexibility for yoga classes [28]. In addition, the yoga intervention was acceptable and potentially beneficial with significant improvements and large effects observed over time in scores on measures of functional mobility (ηp² = 0.29), flexibility (ηp²s = 0.15 for right leg to 0.17 for left leg flexibility), perceived stress (ηp² = 0.17), and selected quality of life and mindfulness domains (η_p²s = 0.12 for the quality of life subscales of energy/fatigue to 0.149 for functional mobility;[28]. While these findings provide insight into the potential benefits of an 8-week yoga intervention, these measures alone do not capture participants’ perspectives of the yoga intervention delivered by videoconference, limiting our overall understanding of yoga for this cohort. To foster a deeper understanding of the role of yoga among young adults affected by cancer, we conducted interviews to examine young adults’ experiences within our 8-week yoga intervention delivered by videoconference.

Methods

As part of our larger pilot trial testing the effectiveness and implementation of the 8-week yoga intervention delivered by videoconference [28], data exploring participants’ experiences within the intervention were collected. A social constructivist paradigm was adopted [29,30] and semi-structured interviews were conducted. To ensure transparency in reporting, the COnsolidated criteria for REporting Qualitative (COREQ) research checklist [31] and the CheckList stAndardising the Reporting of Interventions For Yoga (CLARIFY) guidelines [32] were followed (see Supplementary file 1). The study was reviewed and approved by the Health Ethics Research Board of Alberta (HREBA.CC-20-0365).

Recruitment and participants

Young adults affected by cancer across Canada were recruited to the yoga intervention through the trial team contacts, cancer support organizations and networks, and social media. Young adults affected by cancer were eligible to participate in the intervention 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. from diagnosis onward), and; (3) self-reported being able to participate in a mild-to-moderate intensity yoga; and (4) were able to read and understand English. Upon registering for the intervention, participants were given the choice to opt in or out of the trial to evaluate the feasibility, acceptability, implementation, and potential benefits of the yoga intervention.

Procedures

After completing online informed consent, participants gained access to online surveys assessing sociodemographic and medical information. In addition, at baseline participants completed online psychological outcome surveys and a physical assessment. Following this, participants completed the 8-week yoga intervention. The same psychological outcome surveys and physical assessments were completed post-intervention (week 8) and at follow-up (week 16), with the exception of an additional post-intervention (week 8) semi-structured interview, which is the focus of this manuscript. For more details regarding the larger pilot trial, psychological outcome surveys, and physical assessments see Wurz et al. [28].

Yoga intervention

Over a period of four months, we consulted reviews [19, 20] and studies describing the delivery preferences of young adults diagnosed with cancer [24, 33], behaviour change experts, the evidence-based Yoga Thrive program, and experiences of 12 young adults affected by cancer who participated in pilot work to develop the intervention. The result was the 8-week yoga intervention that was delivered by videoconference one time per week for 60 min per class by a yoga instructor who had at least 200-h yoga teacher training, Thrive Health Exercise Oncology training, Yoga Thrive Teacher Training Certification (or similar), and had previously delivered yoga to individuals affected by cancer. Classes included a theme with both a physical focus and energetic intention, physical postures, breath practices, and meditation/relaxation techniques. Classes also included behavior change support with autonomy-supportive instruction, social support, and journaling and reflection prompts. The entire protocol can be accessed by emailing the corresponding author and further details regarding yoga intervention can be found in Wurz et al. [28]. In addition, all classes were monitored and supported by two student moderators who completed the Thrive Health Exercise Oncology training, and had previous experience moderating physical activity classes for adults affected by cancer delivered by videoconference. Classes were assessed for fidelity by moderators using a standardized form to document instructors’ greetings and closing remarks, offering modifications, and use of autonomy-supportive language. Additionally, instructors completed a separate fidelity checklist to track any deviations from the class plan [28].

Data collection

The sociodemographic and medical information survey was researcher generated and collected participants’ self-reported information covering 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. These details were collected to describe the sample. The semi-structured interview guide was developed through an iterative process wherein the research team developed and then piloted the interview guide with members of the research team. Interviews were conducted by one of two trained female Master of Science students (EM, KE) by videoconference. The interviewers (EM, KE) had prior experience conducting qualitative interviews and had completed graduate courses in qualitative research and study-specific training. Interviews started with brief introductions wherein the interviewers introduced themselves and shared their role in the study (i.e. study coordinator, moderators). Interviewers then asked participants how they were and how their day was going. Following this, a series of open-ended questions and probes were asked to gain a better understanding of participants’ experience within the yoga intervention and to explore what (if anything) they might attribute to the changes they noticed over the course of the intervention (see Supplementary file 2for the semi-structured interview guide). Of note, additional questions were asked to acquire an understanding of the feasibility and acceptability of the yoga intervention, which is reported elsewhere [28]. All interviews were audio recorded using a Sony ICD-PX240 recorder.

Data analysis

Sociodemographic and medical information were managed and analyzed using IBM SPSS (Version 26). Descriptive statistics (i.e. mean scores, standard deviations, frequencies, percentages) were computed to describe the sample. Semi-structured interviews were transcribed verbatim and uploaded into NVivo (Version 12) and analyzed following guidelines for reflexive thematic analysis [34]. Two members of the trial team (EM, NA) familiarized themselves with the data by reading the transcripts, and then inductively began generating codes from the raw interview data. Following this, three members of the trial team (EM, NA, AW) met and reviewed codes, challenged one another’s interpretations, and began to develop main themes and subthemes. Through this iterative process a theme table was drafted, including theme and subtheme labels with descriptions and representative quotes. This theme table was then shared with a member of the trial team (SNCR) and the Yoga for Young Adults Patient Advisory Board, who critically reviewed the table. Once the table was finalized, to enhance readability of participant quotes, repetitive words or excess or additional information within quotes was replaced with “[…]” and unique participant identifiers (i.e. numbers) were used.

To enhance transparency and ensure rigor within this study, the trial team conducted semi-structured interviews to enable participants to openly discuss their experience within the yoga intervention. Based on the interviews, the trial team then developed descriptions of themes and subthemes with representative quotes that highlighted the trial teams’ interpretation of the data, while maintaining the participants’ voices and experience. Critical friends also reviewed the theme table (SNCR and Patient Advisory Board Members [i.e. five young adults affected by cancer who had previously participated in the trial and other yoga offerings from the trial team]) and challenged EM, NA, and AW’s interpretations to ensure they centred participants’ experiences. Throughout, trial team members involved in data collection and data analysis engaged in reflexivity practices to examine their own positionality in relation in the research (see Supplementary file 3 for reflexivity statements). This was done to acknowledge the trial team member’s prior experiences, assumptions, and beliefs, which may have influenced the collection, analysis, and interpretation of participants’ experiences [35].

Results

Of the 30 young adults who opted into the trial [28], 28 completed interviews¹. Of the 28 young adults, 25 (89%) identified as female, 2 (7%) identified as male, and 1 (4%) identified as other. Participants were of varying ethnicities, including Western European (n = 17; 61%), British (n = 15; 54%), and Eastern European (n = 7; 25%), and had varying cancer diagnoses, including breast (n = 12; 43%), blood (n = 8; 29%), and thyroid (n = 2; 7%). On average, the young adults were 34.67 ± 5.11 years of age at the time of recruitment, and at varying stages of their cancer journey ranging from on- (n = 13; 46%) to off-treatment (n = 12; 43%)². Young adults were from 7 provinces in Canada, including Alberta (n = 14; 50%), Ontario (n = 6; 21%), and Saskatchewan (n = 3; 11%). Participants also reported experiencing a range of symptoms including fatigue (n = 23; 82%), cognitive challenges (n = 16; 57%), and peripheral neuropathy (n = 15; 54%). The broad eligibility criteria resulted in a heterogenous study population with participants at different stages in their cancer journey, which was consistent with the pre-defined recruitment strategy. Of note, visual inspection of the characteristics of participants who agreed to interviews (n = 28) were generally similar on all aspects of the sociodemographic and medical information to those in the larger trial (n = 30). Semi-structured interviews ranged in length from 19.82–67.80 min (average = 38.59 ± 12.46 min). Table 1 provides an overview of interview participant characteristics.

Table 1. Personal and medical characteristics of participants.

	Interview participants (n=28)	Study participants (n=30)
Personal factors
Age^†	34.67 (5.11)	34.20 (5.09)
Location (n)
Alberta	14	16
British Columbia	02	02
Manitoba	01	01
New Brunswick	01	01
Newfoundland and Labrador	01	01
Northwest Territories	00	00
Nova Scotia	00	00
Nunavut	00	00
Ontario	06	06
Prince Edward Island	00	00
Quebec	00	00
Saskatchewan	03	03
Yukon	00	00
Setting (n)
Urban location (defined as >100,000 people)	22	24
Rural/remote location (defined as all non-urban locations)	06	06
Biological sex (n)
Female	26	28
Male	02	02
Current gender (n)
Female	25	27
Male	02	02
Other	01	01
Marital status (n)
Never married	10	10
Married	13	14
Common law	05	06
Education (highest level attained) (n)
Some university/college	02	02
Completed university/college	17	19
Some graduate school	03	03
Completed some graduate school	06	06
Annual income
< $20,000	01	01
Between $ 20,000 - $ 39,000	02	02
Between $ 40,000 - $ 59,000	03	03
Between $ 60,000 - $ 79,000	04	05
Between $ 80,000 = $ 99,000	07	07
> $ 100,000	11	12
Employment status (n)
Disability	09	11
Part time	09	09
Homemaker	01	01
Full time	08	08
Temporarily unemployed	01	01
Ethnicity (n)^§
British	15	15
Western European	17	17
Eastern European	07	08
Northern European	04	04
Southern European	01	01
Aboriginal	01	01
East and Southern Asia	02	02
Southern Asia	00	01
Western Asia	00	00
Pacific Islands	01	01
Arab	00	00
Latin/Central and South America	01	01
Caribbean	00	00
African	00	00
Other	00	00
Medical factors
Diagnosis (n)^‡
Blood	09	09
Breast	12	13
Digestive	00	00
Genitourinary	00	00
Gynecological	01	01
Head and Neck	01	01
Lung	01	01
Metastases	08	08
Neurological	01	02
Other	01	01
Skin	01	01
Thyroid	02	02
Treatment status (n)^¦
On-treatment	13	14
Off-treatment	12	13
On-treatment (current treatment) (n)
Surgery	00	00
Chemotherapy	04	04
Radiation	00	00
Hormone therapy	10	11
Biological therapy	01	01
Other	02	02
On-treatment (completed treatment) (n)
Surgery	12	13
Chemotherapy	10	11
Radiation	09	09
Hormone therapy	01	01
Biological therapy	01	01
Other	03	03
Off-treatment (completed treatment) (n)
Surgery	07	07
Chemotherapy	07	07
Radiation	05	05
Hormone therapy	00	00
Biological therapy	00	00
Other	02	02
Diagnosis date
1990–1995	00	00
1995–2000	00	00
2001–2005	00	00
2006–2010	00	00
2011–2015	05	05
2016–2020	23	25
Not provided	00	00
Symptoms (n)
Fatigue	23	25
Pain	14	16
Lymphedema (swelling)	04	05
Peripheral neuropathy (tingling, numbness) or other nerve damage	15	17
Osteoporosis or bone loss	02	02
Ostomy (colostomy, ileostomy, J-pouch, urostomy)	00	00
Cognitive challenges (learning or memory problems, chemo brain, brain fog)	16	18
Weight maintenance issues	11	13
Breathing issues	05	06
Heart issues	02	02
Communication issues (speaking or hearing)	01	02
Other	02	02

Notes. ^†mean (SD). ^§Participants could select more than one ethnicity. ^‡Participants could select more than one cancer diagnosis. ^¦Three participants did not indicate their treatment status.

Six overarching themes capturing participants’ experiences within the yoga intervention were identified. Themes and subthemes are described below with representative quotes. Table 2 contains additional representative quotes for each theme and subtheme.

Table 2. Additional representative quotes for each theme and subtheme.

Theme	Subtheme(s)	Representative quotes
I was juggling a number of challenges and changes throughout the yoga intervention		- “I think when we first started [there] was a lot going on with work with me. Itt was just crazy times, and I was just switching off of night shifts so [my] sleep schedule was off and I was mentally in a pretty tough place. I was just aggravated about work and couldn’t relax and what not. […] It’s not only because of the yoga that I’m a little bit more calm now, but it definitely compounded my calmness because I was so uptight and tense all the time because I was just like, ugh, work was just so crappy at that moment when I first started.” YA10 (31 years old, off-treatment) - “When I signed up for the classes, I wasn’t working, and hadn’t gotten back to work yet. And then when I got back to work, I ended up working on [the same day as my class] so I found it was a bit of a tight crunch from finishing work and then attending.” YA11 (32 years old, off-treatment) - “I’ve been feeling pretty good, yeah. No, I mean I have two toddlers, I have two kids at home, and still actively doing treatments and appointments so, I’m tired because of that, but the yoga I did find me being tired it didn’t overexert me or do anything that could potentially be negative that’s for sure.” YA12 (38 years old, on-treatment) - “The one challenge [is that] I am physically changing [due to my disease progression] and getting new symptoms, particularly in my spine. It was very challenging to know what I should be trying to do and what I shouldn’t be trying to do because I just don’t know what I am able to do.”  YA13 (did not report age, on-treatment) - “Unrelated to the yoga [intervetion], I definitely had some oncology appointments and things like that that were very stressful. […] You know, there was still stressful stuff going on too.” YA29 (34 years old, on-treatment) - “[I have noticed] changes, but I’m not [fully] attributing it to the yoga [intervention], because in the background I’m working out in a gym every single day”. YA35 (37 years old, on-treatment) - “ […] And the isolation. I live by myself. Again, because of the isolation things going up even in [location] and not really having a circle [of friends]. […] So just that isolation. You’re trying to keep busy and positive, but there is some sadness for sure.” YA36 (37 years old, on-treatment)
I noticed some improvements in my mental and physical health	My mental health improved or was maintained during the yoga intervention	- “[Yoga] helped remind myself that it’s a process and I have to be patient with myself because for some reason, like in the movies, I thought that you’re done your chemo and you’re done [but there are side-effects and other concerns that continue]!” YA34 (33 years old, off-treatment) - “I’d say I’ve noticed I’m not as rushed or whatever. Like I said, [yoga] kind of decompressed me after work.” YA9 (39 years old, did not report treatment status) - “My stress load completely dove off [during the intervention]. Things that would usually stress me before the 8 weeks, I just kind of let slide now. It’s like ‘what do you do? We’re in lock down again. Am I gonna get mad about it? Am I gonna stress out about it? No.’ So, it went down quite a bit.” YA10 (31 years old, off-treatment) - “[The classes] helped me unwind on work days. […] I would [also] say my stress level was decreasing closer to the end [of the intervention anyways as] I was getting more used to being back at work part time.” YA11 (32 years old, on-treatment - “[I] think yoga has improved my quality of life, it’s given me a sense of physical ability to do things. […] [Yoga has] kind of carried me through a bit of a rough go. I found out I have disease progression, […] and I think yoga helped with that. Just practicing [yoga] made me a calmer person. There is no way to really quantify that.” YA13 (did not report age, on-treatment)
	My strength, flexibility, range of motion, and experience of pain improved	- “[My] fatigue has definitely improved. I have little to no fatigue other than when I’m dealing with headaches or what. When I first started [the yoga intervention], I was pretty tired.” YA10 (31 years old, off-treatment) - “I found [the yoga] very easy to do and hold and do what I needed to do. So, I think [yoga] helped a lot also with my progress, with my physio and everything because she says my mobility is good and that I’m doing well so I’m sure it has something to do with that as well, being able to move it and keep it going.” YA12 (38 years old, on-treatment) - “I was also able to reconnect with things like my balance, which I didn’t think I would have. The fact that I was able to balance on one leg for 45 s [in the physical assessment] was kind of neat. And just doing the [yoga] practice I would stand up taller. I awoke some of the muscles, versus sitting on my butt all day.” YA13 (did not report age, on-treatment) - “I’m finding a lot better range of motion more than anything else. […] I worked hard on my flexibility after my mastectomy, like really hard; I was doing exercises the next day. But I feel like I’ve gotten that much more range function back.” YA28 (44 years old, on-treatment) - “The core strengthening definitely helped with some of my back pain I have and the stretching and stuff also helped, I didn’t have to see my chiropractor as much and I’d been going every like week or two and [now] I’m up to three to four weeks now since starting this [intervention].” YA33 (35 years old, off-treatment)
I made time to discover new strategies to take care of myself	I learned how to practice self-care and self-compassion	- “[In the yoga intervention, there were] lots of good reminders with the mental piece with the mindfulness and the self-care and the relaxation and physically getting in that habit. Even last night I did a bit of yoga on my own, it just felt like I needed that to be present and focus on what I can control.” YA3 (34 years old, on-treatment) - “[…] I think yoga definitely helps me just take time for myself and feel more refreshed.” YA6 (22 years old, off-treatment) - “I think most of it was just more self-experience. Like, knowing that I can take that hour to do [yoga] for myself and to just kind of push things aside that are out of your control.” YA 12 (28 years old, on-treatment) - “It’s been really good, what was really interesting was on days where I was really struggling I wasn’t sure if I could do the class or not, even just showing up and participating was helpful for me to re-establish control of my day.” YA13 (did not report age, on-treatment) - “With respect to mental health I think mindfulness is definitely on my list of things [I noticed] but I think there’s also just a bit more self-care you know and whether that comes in a physical way or in a way that you know is more in a self-soothing or self-healing way.” YA15 (41 years old, off-treatment)
	I became more aware of my thoughts and feelings	- “I think the most important [aspect] for me […] was taking the time to slow down, like the mindfulness part was really important. [Life is] so busy, we just forget that we need to take time for ourselves as well.” YA6 (22 years old, off-treatment) - “ […] but I think like even when I’m at work and stuff like, I think with going through yoga and having that time to focus on breathing,I find myself in sticky situations outside of yoga but I’m able to slow myself down by my breathing which makes me a little more resilient in just everyday life .” YA10 (31 years old, off-treatment) “ I’m trying to [work on] letting go and the constant reminder of being in the moment [in the yoga class] has been a good reminder of how to do that.” YA11 (32 years old, on-treatment) - “I think [mindfulness and yoga] has helped with [my] stress level. There has been a lot of outside factors that have happened that you can’t do anything about but overall, I think it has definitely helped [with these feelings]. It puts your mind in a different space […] I think it does help to go back to those things, even the breathing exercises […] So, that’s awesome and beneficial I find if there’s a stressor, [it’s been helpful] sit back and do those deep breathing exercises and bring yourself back to a calming state.” YA12 (38 years old, on-treatment) - “[Mindfulness] was one of the big advantages of [the yoga intervention], again setting the intention at the beginning, allowing yourself to be mindful in that hour and just focus on yoga and your practice. It has allowed me to be more [present and mindful both in and out of yoga practice].” YA13 (did not report age, on-treatment) - “I’ve tried to be a bit more conscious of mindfulness, especially when it comes to completing tasks [in my day-to-day life] and staying focused at the task on hand.” YA15 (41 years old, off-treatment)
I was able to see what my body was capable of		- “I really liked how [the instructor] was offering different variations of poses we were doing so if there were some days when I was not feeling well and could not do everything, I could do something else. I think that really helps […] feeling [that] I can do something as well, even If I can’t do the hardest thing.” YA6 (22 years old, off-treatment) - “I really liked the modifications that [were] the baseline and if you [could] do more [there were options to] do more. So, I felt that was nice and it gave you an option. And if one day, it [was] like well, I can only do the first one but the next day, you [could] do the other one, it was a nice milestone.” YA11 (32 years old, on-treatment) - “Because of [the poses] you’re standing straighter, your core is engaged, you do feel better about yourself.” YA13 (did not report age, on-treatment) - “[…] I gained a better appreciation for what my body can do, improved what my body can do, I am sleeping better now, it motivated me to make better food choices, you know?” YA16 (38 years old, off-treatment) - “[The yoga interventiongave me] reassurance that [yoga] is something that I can do more of and continue with because I don’t think—had I not gone through it then I probably wouldn’t give yoga much more attention but I think I will now [now that I know I can do it].” YA31 (33 years old, did not report treatment status)
I was held accountable and I appreciated that		- “I think the steadiness of [the intervention] like those eight weeks, that anticipation, that structure and also I think that like the getting into my body part of it, was incredibly supportive for me at a time when I was just having a really hard time.” YA8 (35 years old, off-treatment) - “The whole [yoga intervention] was beneficial. Just to have a set time to be on my mat on a certain day, I think that was a benefit of creating a habit.” YA10 (31 years old, off-treatment) - “I find with these sessions, the accountability is kind of a big thing, right? Because you are needing to go every week so, if you feel if you have to, you know what I mean? It keeps you going but I really want to continue being able to do it just to stay active and just to do.” YA12 (38 years old, on-treatment) “I think it gave me a set time and date that I could schedule in, I knew that was my practice time. And because it felt so good when I did it, it inspired me to go on and I would do a practice here and there [on my own time] ‘cause my mat was already out, everything was all ready to go, so I could just go and do it again and it was easier to go back into it. I think that definitely made a big difference.” YA13 (did not report age, on-treatment) “[Participating in the yoga classes] definitely made me feel accomplished ‘cause it was doing something every week. I would go to it every week and like it felt good to do something and like accomplish that thing for myself. So, I would say [I experienced] a significant sense of [personal] growth.” YA20 (22 years old, off-treatment)
I was able to be around similar others in a safe (virtual) space		- “It felt really nice to be able to get together with everyone and kind of see everyone’s little set up at first and then just sharing our experience at the end. It was nice to get together with everyone even though it wasn’t in person. So, yeah it was good. It was nice.” YA10 (31 years old, off-treatment) - “In this particular setting you’re surrounded by people that are impacted by cancer and it created a much deeper space and for me knowing that I have experts in the video and also [moderators], it gave me a lot of confidence and allowed me to practice more. […] It just gives you something to do, really.” YA 13 (did not report age, on-treatment) - “Even though it was online, it still gave me that sense of belonging in a group or doing something that was productive or going out and doing something that was outside of my comfort zone because it certainly was a lot easier to do than if I had gone into an actual studio and actually done it in a group of people that I didn’t know, I found that this was a little bit nicer because you didn’t have to worry about, you know being in a kind of a bit of an introvert. It was easier for me to do it because I didn’t have to worry about throwing myself into a group of people that I didn’t know and you had that comfort of being home and being able to do it without having to feel like anyone’s, you know, like, you’re doing something wrong or you’re not doing a pose right.” YA12 (38 years old, on-treatment) - “I really felt like we’re working on something bigger here and being part of- knowing that there’s a study happening and that this can benefit other people who are living the same kind of experience that I’m living is like really powerful as well.” YA16 (38 years old, off-treatment) - “I liked how it is just cancer survivors in a group. YA22 (36 years old, did not report treatment status)

Theme one: I was juggling a number of challenges and changes throughout the yoga intervention

Without probing, participants in this sample shared detailed accounts of the challenges they were experiencing during their time in the yoga intervention, which may have impacted their experience and the benefits (or lack thereof) conferred. These details provide important context for the themes and subthemes to follow. Specifically, participants described navigating challenges related to cancer and its treatments (e.g. treatments, side effects), the COVID-19 pandemic (e.g. burnout from longer days spent online, isolation), and extant roles and responsibilities (e.g. work, parenthood), which placed a burden on their time and exacerbated feelings of stress, anxiety, and worry. These challenges were described as impacting how participants felt throughout the yoga intervention. Indeed, participant 8 (35 years old, off-treatment) captured this when they shared: “One of my friends died who had this [same cancer diagnosis], or a very similar, cancer to mine. […] There’s also been some family medical concerns, not COVID-19 related, but other [things that] have been stressful and anxiety provoking, and things that have happened in my own life […]. I don’t know whether it helps provide a little bit of context for some of the emotional struggles that I’ve been having in parallel to this [intervention] happening”. In addition, participants also described time constraints and difficulty managing busy schedules. During the intervention many returned to work and had to juggle the intervention alongside work, medical appointments, and their other responsibilities. Participant 16 (38 years old, off-treatment) said: “[I] definitely [experienced] the competing priorities with work and other medical appointments. There were certainly a couple sessions that conflicted with meetings and a couple of sessions that conflicted with medical appointments and once or twice [it was] just other social [commitments]”.

On the other hand, some participants shared that throughout the 8 weeks, they started to engage in other programming and resources (e.g. increased physical activity, therapy) which may have further supported or elicited the benefits they reported. This was exemplified when participant 33 (35 years old, off-treatment) shared: “[My] back [pain] really seemed to improve because I was focusing on sticking to the yoga [intervention] and I was doing some of the extra exercises that the chiropractor had given me, and I just feel like [with] those two things coupled I’ve been feeling so much better, I’m not having as much back pain”. Participants recognized that these challenges and changes likely impacted their experiences within the yoga intervention and responses to the questions to follow.

Theme two: I noticed some improvements in my mental and physical health

Participants described the improvements they saw in their mental and physical health over the 8-week yoga intervention, which are presented across two subthemes below.

My mental health improved or was maintained during the yoga intervention

Participants described feeling better overall post-intervention and commented that they saw improvements in their quality of life, capacity to bounce back and navigate challenging times, manage their stress, and accept things that were out of their control. Participants also shared they felt a stronger sense of self, improved mindfulness, lower levels of stress, and that they felt they had grown as a person over the 8-week intervention. Participant 6 (22 years old, off-treatment) captured this when they shared: “I think there is a lot of personal growth this year, [from being] involved in yoga [intervention] […]. I’ve been doing more emotional checks to make sure that I’m okay and being okay with how I feel. Then, coupled that with yoga to take the time to really accept my feelings and how I feel about this craziness that is going on around me [both personally and in the world] and accepting that. […] [I experienced a lot of] personal growth this year [being involved] in the yoga [intervention] and getting into more mindfulness [in and out of the intervention].” Participant 11 (32 years old, on-treatment) went on to say: “I found that after the classes I always felt less stressed […] I didn’t feel as stressed as I was before class.” Finally, some participants attributed the changes in their mental health to yoga. For example, participant 12 (38 years old, on-treatment) stated: “I think [yoga] has helped with [my] stress level. […] I think it has definitely helped because it puts your mind in a different space and gives you that calming time”.

My strength, flexibility, range of motion, and experience of pain improved

Participants described feeling stronger and more flexible and shared they felt less fatigued and were experiencing fewer symptoms of pain post-intervention. Participants appreciated feeling stronger, and many described a sense of regaining strength that they had lost during their treatment. Improved strength helped participants with more activities throughout their day and feel more autonomy with daily tasks. For example, participant 16 (38 years old, off-treatment) said: “I gained more strength, gained more flexibility, gained a better agency of my body.” Participant 11 (32 years old, on-treatment) went on to say: “[Yoga has] helped my physical [abilities] for sure because just even with practicing the breathing, when I’m doing things. I find it easier to pace my breath. I found that [yoga has] definitely helped with flexibility and even things like balance.” Beyond noticing these changes within themselves, some participants noted that close others (e.g. family, friends) recognized physical changes in participants. Participant 21 (40 years old, off-treatment) shared how individuals in her life remarked on the changes they noticed over the 8 weeks: “The yoga did help me. […] Everybody around me, my parents, my brother, my sister-in-law commented that I [appeared stronger]”.

Theme three: I made time to discover new strategies to take care of myself

Participants described learning self-care, self-compassion, and mindfulness strategies, which improved their ability to look after and care for themselves over the 8-weeks. These sentiments are presented across two subthemes below.

I learned how to practice self-care and self-compassion

Participants shared that throughout the yoga intervention they learned how to take better care of themselves and extend the same love and kindness to themselves that they do others. Participants appreciated the scheduled classes and dedicated time to take care of themselves. This was noted when participant 1 (38 years old, off-treatment) said: “[Yoga] was just some time for self-care and some time that was set aside each week to take time for myself to really focus on my body and making my body better so, I think that was what it really came down to; that time to take mentally and physically, to let everything else slide away”.

Participants found that they were able to take the strategies they learned during class off the mat and that they were engaging in greater self-care and self-compassion throughout their day. This was captured by Participant 10 (31 years old, off-treatment) who said: “Even when I’m at work and stuff , I think with going through yoga and having that time to focus on breathing, I find myself in sticky situations outside of yoga but I’m able to slow myself down by my breathing which makes me a little more resilient in just everyday life. Like, when things are really about to just set me [off] and I’m just like, ‘Ah relax, I’m OK. Like, things are alright. Bad things happen but you can keep moving.’ I like that I got my breath back, [I] like being more conscious about my breath and thoughts”.

I Became more aware of my thoughts and feelings

Participants described feeling more aware of their inner thoughts and emotions throughout the 8-week yoga intervention. For example, participant 3 (34 years old, on-treatment) said: “[The intervention] helped with [my] mindfulness and [helped me] look at what I can control, I think it’s been overall really beneficial”. Notably, participants also shared how they transferred their newfound awareness to other areas of their life (e.g. work, parenthood), which they found to be beneficial. Participant 6 (22 years old, off-treatment) captured this when they shared: “[I really liked] taking the time to slow down and reset for the day [before going into the rest of my evening. It was] really helpful, [because] you’re clearing your mind of all the stress for a while and it’s a very good feeling, it’s really relaxing [feeling]”.

Theme four: I was able to see what my body was capable of

Participants described that practicing yoga regularly helped them gain a deeper understanding of their physical capacity, which in turn helped them feel more confident and competent in their body. For example, Participant 12 (38 years old, on-treatment) shared: “I want to continue doing yoga now that I have an idea of what things I can [physically] do. It is nice to know that I can do it”. Some participants felt that the adaptable and progressive nature of the yoga intervention helped them learn how to meet themselves where they were (each class) and learn how to work within their limits, which allowed them to feel more confident with their current abilities. Participant 13 (did not report age, on-treatment) appreciated this and shared: “I think the instructors did a great job in providing options for us to do. Obviously in other times in my life I was doing a lot more complex yoga. The more restorative yoga has been really nice. It’s not as intimidating, maybe that’s not the right word but there is less opportunity for me to be frustrated with my body right now by doing the more restorative type of yoga. Whereas, if I was doing the more traditional full class, the inability to do things would be very frustrating for me”. This increased physical competence also helped participants feel more confident within and beyond the yoga classes. Participant 39 (32 years old, on-treatment) captured this when they stated: “[With the yoga intervention I valued] learning how my body is working and responding now [after treatment]. And [I have been] trying not to compare it to how it was before. So [with the yoga intervention I have been] learning what’s working for my body now. […] I liked being introduced to movements that I could do very comfortably […] and could use [outside of class]”. As a result of their increased feelings of competence and confidence, some participants sought out or planned to participate in other movement-based opportunities (including greater physical activity, planned exercise, and other yoga opportunities). For example, participant 21 (40 years old, off-treatment) shared: “[The yoga intervention] just kind of spurred me on to do more [yoga and activities], which was very helpful and very needed”.

Theme five: I was held accountable and I appreciated that

Participants shared that the 8-week yoga intervention provided a weekly routine. Regardless of whether participants were busy or not, the scheduled classes were nice and provided structure and a time and place to reprieve during the day. This thought was captured by participant 11 (32 years old, on-treatment) when they said: “I usually [sit] in front of a TV screen, because I’m tired and I don’t want to do anything so, it was nice to have that one hour designated [to] just sit there, just relax, and my husband [was] taking care of my child, and I [could] just be there and be in the moment. So, it was nice in that way for me I found”. Participant 6 (22 years old, off-treatment) also found the schedule class was something they looked forward to throughout the week: “Well, I [looked] forward to yoga on Thursdays, that [was] the one exciting thing marking the end of the week, that [was] really great. In general, it’s been a really crazy semester for me, so I’ve been really busy and really tired and so it was good, really good to have the yoga [classes] on Thursday I [was] like “yes!” my relaxed day, my saine day, and it worked really well with how fast everything else was”. This routine provided participants with a sense of accountability and was highly valued. This was evident when participant 1 said: “I liked that it was putting some accountability on me. It was a regular weekly thing. I did feel like it was a nice break in my day”. Participant 21 (40 years old, off-treatment) went on to share how the commitment they made to the 8-week intervention provided them with incentive to attend class, even when they were not feeling up for it: “Because of the commitment I made to the yoga, it did make me take time out for exercise whereas before I would always find an excuse: ‘no, I need to work on that paper; no, I need to go analyze that data.’ That stuff. Like, ‘no, I did this class, I committed’”. Other participants felt that although they were managing side effects from treatment, the accountability of the classes encouraged them to attend. Participant 34 (33 years old, off-treatment) shared their sentiments on this experience: “I look[ed] forward to [yoga] every week and even if I was really tired at night ‘cause I’m still dealing with long term side effects from chemo, it was nice to be held accountable [to the class]”.

Theme six: I was able to be around similar others in a safe (virtual) space

Participants appreciated that the yoga intervention was designed specifically for young adults affected by cancer. Being around similar others created a sense of comfort, which was captured by participant 31 (33 years old, did not report treatment status) who said: “I think being a part of that group, especially being amongst other cancer survivors and thrivers is super empowering, and [provided] a feeling of comfort almost”. Participants noted how this intervention differed from other programs and interventions they had been involved with in the past that were comprised primarily of middle- to older-aged adults. Within this intervention, participants felt that they were able to connect and relate to other participants, who they believed were facing similar challenges, life events, etc. Specifically, participant 24 (40 years old, on-treatment) said: “[…] You don’t get many opportunities to connect with other people who went through a similar experience. And I think a lot of things just have to do with our life circumstance, right? We’re younger, we’re still working, we’re gonna have to go back to work. Some people have young families that they’re taking care of. So, it’s just not the same as if you were a retired person and you have more time and energy”. Although being around similar others was viewed as important, some participants shared that they did not always feel personally connected to other participants in the in class. They felt this may have been due in part to the videoconference delivery of the yoga, which can make it harder to foster connections. For example, participant 35 (37 years old, on-treatment) said “I didn’t really feel a sense of relationship with any of the other participants, and I get Zoom is very hard to do that”. Despite this lack of personal connection, participants said that they valued the young adult nature of the intervention which in turn allowed them to feel more connected and gave them a sense of belonging to something bigger. This was captured by participant 13 (did not report age, on-treatment) who said: “In this particular setting you’re surrounded by people that are impacted by cancer and it created much of a deeper space and for me knowing that I have experts in the video and also [moderators], it gave me a lot of confidence and allowed me to practice more and I think that practice you something to do [and belong to], really”.

Discussion

This study sought to describe the experiences of young adults affected by cancer in an 8-week yoga intervention delivered by videoconference. Participants in this sample described the ways in which their participation may have enhanced their physical and mental health. Participants suggested that self-care, self-compassion, mindfulness practices, feeling a greater sense of competence, establishing a routine, and taking part in yoga with similar others were important elements of the intervention that may have contributed to the benefits conferred and transferred into participants’ day-to-day life.

Similar to findings from our pilot trial [28], participants in this sample described benefits spanning physical and mental health. However, these findings extend our pilot results and suggest additional benefits were realized in areas of self-care, self-compassion, mindfulness, physical competence, autonomy, and social support, which were not captured by quantitative measures. This highlights the importance of integrating different methodological approaches so as to better understand participants’ experiences within interventions. Further, when conducting research in an area with little available evidence, such as yoga for young adults affected by cancer, qualitative interviews can provide rich and in-depth data that may inform future directions, additional relevant considerations, and offer insights into the potential role of yoga for this cohort. Looking ahead, researchers should consider integrating qualitative interviews or other qualitative approaches (e.g. focus groups, photo elicitation) in their work with young adults so as to ensure their perspective is centred, which is something this population has shared they are interested in [36].

Participants in this sample also described improvements in their ability to practice self-care, self-compassion, and mindfulness both during and beyond their yoga classes. This is similar to findings reported by yoga practitioners (without a history of cancer) describing the transfer of skills gained in their yoga practice into their day-to-day life [37]. In addition to highlighting the transferable nature of the yoga intervention and potential to impact life beyond the mat, participants in our study shared that these elements may have contributed to some of the positive physical and mental health benefits they reported. Beyond self-care, self-compassion, and mindfulness, participants in this sample also described a greater sense of physical competence, with many sharing they were able to do more than they thought they were capable of. These sentiments are similar to those shared by young adults affected by cancer who participated in a 12-week community-based physical activity intervention [38]. Specifically, young adults indicated they felt more confident in their ability to engage in different types of physical activity, and that they were able to do more physical activity than they previous thought was possible [38]. Thus, it is plausible that yoga may confer similar benefits as more traditional physical activity. Exploring the role of self-care, self-compassion, and mindfulness, and perceptions of physical competence within yoga interventions for young adults will be important to better understand and identify factors that may underlie benefits (i.e. potential mechanisms) and further support participant accrual of the potential benefits from yoga participation.

Participants in our study described the importance of an intervention designed and delivered for young adults affected by cancer, aligning with prior research indicating the importance of tailored age-appropriate resources [39]. Participants also shared how they felt connected to others in their group-based class, despite very minimal interaction (as a function of the videoconference-based delivery). This suggests videoconference-based interventions may confer desired opportunities for young adults to connect with one another. However, it is also important to consider that this intervention was conducted during the COVID-19 pandemic (September 2020–April 2021), when physical distancing restrictions and isolation requirements were in place. This intervention may have therefore provided participants in our study with an opportunity to connect with others during a time when connecting with others was difficult. Finally, participants in our study explained how the yoga classes, although only once per week, provided them with more structure throughout their week and helped to establish a routine, regardless of how busy their week was. This underscores the necessity of available supportive care opportunities for this population.

Although this study provides important insights and advances knowledge, findings should be interpreted in light of the following considerations. First, this study included predominantly female and highly educated individuals. Looking ahead, recruitment techniques, such as referrals from healthcare providers, may help obtain insights from a more representative subset of the population of young adults affected by cancer; though unpaid social media (which were used herein) has been shown to be the top recruitment approach to physical activity research for young adults affected by cancer [40]. Second, questions in the interview guide (see Supplementary file 2) were structured according to the quantitative outcomes that were assessed (see [28] for more detail). Though probes were utilized, it is still possible that items were leading. Third, it is possible that one session/week was low frequency and that more yoga may have resulted in greater perceived benefits among participants. Notably, we have refined our protocol and are currently testing an intervention comprised of two sessions/week (clinicaltrials.gov identifier: NCT05314803). Fourth, the intervention delivered by videoconference could have systematically excluded young adults affected by cancer who did not want to engage in that delivery format, who had limited access to the technology required to participate, or who preferred in-person delivery of yoga. Thus, more work may be required to better understand delivery style preferences and influences of delivery style on benefits conferred among young adults affected by cancer. Finally, individuals who have conducted physical activity and yoga research and who believe in the benefits of movement conducted interviews and analyzed data. To temper this, the trial team actively and intentionally engaged in reflexivity practices and sought to continually come back to participants’ perspectives (see Supplementary file 3 for authors’ reflexivity statements).

Notwithstanding the considerations above, findings suggest that an 8-week yoga intervention may offer some benefits for young adults affected by cancer. Self-care, self-compassion, mindfulness, feelings of physical competence, establishing a routine, and being around similar others were viewed as important components of the intervention and may have contributed to the benefits experienced. Findings underscore the potential utility of yoga as a supportive care intervention for young adults affected by cancer. This study provides insight into experiences of young adults affected by cancer in a yoga intervention delivered by videoconference, and suggests yoga may be one strategy that can confer benefits on and off the mat.

Acknowledgements

The authors would like to thank the individuals who participated in the pilot trial and interviews for their time, the yoga instructors (Heather Molina and Lauren Cowley) and moderators (Delaney Duchek and Maximilian Eisele) who delivered and supported delivery of classes, respectively, and the organizations who aided with recruitment. The authors would also like to acknowledge funding from the University of the Fraser Valley (Initiate Grant; PI Wurz), which supported one of the authors (NA). Finally, the authors would like to thank the members of the Yoga for Young Adults Patient Advisory Board (Kaitlyn Quinn, Lisa Currey, Maria-Hélèna Pacelli, Melissa Coombs, and Sundas Shamshad) for their involvement on the Board and input on the manuscript

Authors’ contributions

Emma McLaughlin: developed study protocol and received ethics approval, participant recruitment, yoga intervention registration, study eligibility and informed consent, conducted physical activity assessments, moderated the yoga intervention, conducted interviews, analyzed qualitative data, analyzed quantitative data, writing – original draft, and writing – review and editing. Nafeel Arshad: analyzed qualitative data, writing – original draft, and writing – review and editing. Kelsey Ellis: conducted physical activity assessments, moderated the yoga intervention, conducted interviews, and writing – review and editing. Amy Chen: moderated the yoga intervention, transcribed interviews, and writing – review and editing. Kate Fougere: transcribed interviews, and writing – review and editing. S. Nicole Culos-Reed: conceptualization, writing – review and editing. Amanda Wurz: conceptualization, developed study protocol and received ethics approval, delivered the yoga intervention, analyzed qualitative data, analyzed quantitative data, writing – original draft, and writing – review and editing. Yoga for Young Adults Advisory Board Members: writing – review and editing

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

Disclosure statement

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

Data availability statement

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

Notes

1 Two participants from the larger pilot trial did not participate in the semi-structured interview due to time conflicts with work and medical appointments.

2 Three participants did not indicate their treatment status.