ORBIT Model Phase 1: Define and Refine Basic Elements

The purpose of phase 1 of the ORBIT model is to develop a hypothesized pathway through which behavioral intervention could impact health and determine components, duration, mode of delivery, and tailoring needs [18]. For our study, the intention for this phase was to identify and adapt an existing intervention or, if needed, develop a novel intervention using best practices. We approached this phase by (1) conducting literature searches and (2) engaging an advisory team of local stakeholders in a participatory development process.

We conducted a search of those listed in the National Cancer Institute’s (NCI) Research Testing Intervention/Program website [20] and through PubMed to identify existing behavioral interventions for cancer survivors. The identified interventions were reviewed during participatory processes.

This process was guided by a comprehensive participatory planning and evaluation process [21] (described below). It incorporated the Putting Public Health Evidence in Action training [22] and focused on the sessions related to identifying, selecting, and adapting evidence-based interventions.

To recruit advisory team members, the study was presented to all members of the Cancer Center Without Walls Southwest Virginia Community Advisory Board (CAB) during a quarterly CAB meeting. The CAB consists of representatives from local health care systems and other organizations that work on cancer-related issues, community members, and the UVA Cancer Center faculty and staff. The CAB members who were interested in joining the advisory team contacted the research team. The resulting advisory team consisted of 10 members: 6 community stakeholders, 1 UVA Cancer Center Outreach and Engagement staff member, and 3 interdisciplinary UVA faculty members with expertise in behavioral interventions, oncology, and community engagement. Community stakeholders represented local health systems (n=2), the social services sector (n=2), and higher education (n=2). The 3 members were cancer survivors.

The advisory team engaged in 6 meetings over 6 months, three 1-hour in-person meetings, and three 1-hour conference calls. The intention of these meetings was to identify key recommendations for what the intervention should address and to use these recommendations to identify and either adapt or develop a behavioral intervention. Planned activities included sharing previous experiences with behavioral interventions for cancer survivors and perceptions of needed and acceptable components, reviewing and commenting on existing behavioral interventions for cancer survivors, and deciding upon the intervention and identifying adaptations. Notes and reflection worksheets completed during meetings were reviewed, summarized, and used to identify key action steps between meetings. During this process and based on the literature review, it became evident that existing interventions did not meet local needs and that a novel intervention would need to be developed.

Through the participatory process, the advisory team identified 4 key recommendations that an ideal behavioral intervention for rural Appalachian cancer survivors would need to take into account: (1) incorporation of both in-person and telehealth components so that participants could engage even if they had barriers to one delivery mode; (2) utilization of strategies that promoted action planning and storytelling; (3) addressing multiple behaviors; and (4) opening the program to all adult cancer survivors regardless of gender or cancer type. A conceptual model and program design were developed using these recommendations and a review of the best practices (Figure 1).

weSurvive program conceptual model and component design. SCT: Social Cognitive Theory.

The resulting intervention, weSurvive, was rooted in Social Cognitive Theory (SCT) [23] and targeted improving participant quality of life (QoL) through the improvement of 11 health behaviors associated with better cancer survivorship outcomes, including dietary and physical activity (PA) behaviors (Figure 1) [4,5]. Participants self-selected 1 or 2 behaviors they wanted to focus on in the first in-person group class. To make this selection, participants engaged in a guided reflection through which they assessed their level of engagement with each healthy behavior, whether they wanted to improve upon it, and their confidence in making the improvements or changes.

Participants received 10 hours of contact over 13 weeks. There were 3 in-person group classes, 4 group telehealth calls, and 2 individualized telehealth calls. Telehealth activities were assessed using Zoom (Zoom Video Communications Inc) [24]. Each component was led by KP. The activities in each component addressed 6 SCT constructs: outcome expectations, behavioral capability, self-efficacy, goal intention, self-regulation, and supportive environment [23]. Behavior change techniques, including self-monitoring [25], that tapped into the theory constructs and addressed aspects of QoL were included in each component. To support the execution of the components and behavior change, participants received a physical workbook that included class and call content, action planning materials, and evidenced-based resources (eg, exercise DVDs). Group components also provided avenues for discussion about participants’ experiences as a cancer survivor to extend social networks to include other cancer survivors.