Introduction
Approximately 19.3 million people receive a cancer diagnosis annually worldwide (Sung et al. Reference Sung, Ferlay and Siegel2021), with cancer remaining the second leading cause of death globally (Mattiuzzi and Lippi Reference Mattiuzzi and Lippi2019). In the past decade, there has been a shift away from in-hospital cancer treatment, toward at-home care delivered by unpaid family caregivers (Kent et al. Reference Kent, Mollica and Buckenmaier2019). Caregivers are defined as unpaid individuals (often family members) who are most involved with supporting patients as they manage the physical and psychosocial challenges of cancer. Caregivers often take on this role without formal training, and while being unacknowledged and undervalued (Warth et al. Reference Warth, Zöller and Köhler2020). Taking on a caregiving role has been shown to increase levels of distress (Bining et al. Reference Bining, Wasserman and Brahim2022). Caregiving is particularly challenging for those caring for individuals with advanced cancer (van der Velden et al. Reference van der Velden, Smets and Hagedoorn2023; van Roij et al. Reference van Roij, Brom and Sommeijer2021).
Caregivers of those living with advanced cancer face unique challenges. These include considerations for end-of-life, palliative care planning, and care for more debilitating symptoms (van Roij et al. Reference van Roij, Brom and Youssef-El Soud2019). Due to these challenges, they report higher levels of anxiety, depression, and unmet needs than caregivers of those with early stages of cancer (Girgis et al. Reference Girgis, Lambert and Johnson2013; Lambert et al. Reference Lambert, Harrison and Smith2012b). Top unmet needs are managing feelings of anxiety, fear, and hopelessness; coping strategies to enhance quality of life (QoL); and learning to navigate the health care system (Wang et al. Reference Wang, Molassiotis and Chung2018). Given these unmet needs, patients and caregivers often seek information related to managing physical and psychological symptoms and improving their QoL (Warth et al. Reference Warth, Kessler and Koehler2019). Support for coping with these types of challenges can be provided by self-management interventions (Girgis et al. Reference Girgis, Lambert and Johnson2013).
Self-management interventions offer users the skills and confidence to manage the physical, emotional, and social aspects of their own health (Bartlett et al. Reference Bartlett, Lambert and McCusker2020). They are efficacious in addressing a number of unmet needs reported by patients with advanced cancer and their caregivers (Porter et al. Reference Porter, Steel and Fairclough2021) as well as to relieve their anxiety and improve QoL (Warth et al. Reference Warth, Kessler and Koehler2019). This especially rings true when the intervention is offered to both patients and caregivers, dyadically, due to the shared learning that occurs and synergistic benefits (Lambert et al. Reference Lambert, McElduff and Girgis2016b; Shaffer et al. Reference Shaffer, Tigershtrom and Badr2020). However, most caregiver interventions are led by nurses or a combination of clinicians and are time- and personnel-intensive, rendering them too costly for integration in routine cancer care (Lambert et al. Reference Lambert, Girgis and Turner2013b). Also, caregivers who might benefit from such interventions often do not access them, due to geographical or mobility barriers or they do not want to leave the patient (Lambert et al. Reference Lambert, Levesque and Girgis2016a). The urgency to find more sustainable and accessible modes to deliver caregiver interventions has contributed to an increased interest in the self-directed format (Lambert et al. Reference Lambert, Levesque and Girgis2016a).
Self-directed interventions offer more flexibility to patients and caregivers since they can be used at their own pace and with privacy (Wong and Kan Reference Wong and Kan2022). Self-directed interventions address barriers related to high costs and mobility constraints from having to seek guidance from healthcare professionals (Girgis et al. Reference Girgis, Lambert and Johnson2013). Reported benefits of self-directed, self-management interventions include improved QoL and psychological health outcomes (Warth et al. Reference Warth, Zöller and Köhler2020). Despite these benefits, adherence can be low often due to a lack of time and energy (Kubo et al. Reference Kubo, Kurtovich and McGinnis2019). Those coping with advanced cancer face additional barriers to accessing interventions due to the scarcity of research, support, and attention allocated toward this population (Lambert et al. Reference Lambert, Levesque and Girgis2016a). Few self-directed, self-management interventions have been developed for use by those coping with advanced cancer (Wang et al. Reference Wang, Molassiotis and Chung2018; Warth et al. Reference Warth, Zöller and Köhler2020). This emphasizes the urgent need for more sustainable and accessible resources for advanced cancer patients and their caregivers (Lambert et al. Reference Lambert, Levesque and Girgis2016a).
Coping-Together is a self-directed, self-management intervention for patients with early-stage cancer and their caregivers. Mainly, Coping-Together expands patients’ and caregivers’ repertoire of coping strategies (and confidence to use these), by providing strategies to optimize the management of cancer challenges (Lambert et al. Reference Lambert, Girgis and Turner2013b) (see Figure 1). This resource includes 6 booklets and 1 workbook. The booklets focus on coping strategies for: (1). Communication with your Healthcare Team, (2). Dealing with Stress and Worry, (3). Making your Treatment Decisions, (4). Getting on Top of Symptoms, (5). Getting the Support you Need, and (6). Supporting Each Other. The workbook focuses on developing a SMARTTER (specific, measurable, attainable, relevant, timely, and done together) self-management plan (see Table 1). Previous studies found that patients and caregivers facing early-stage cancer learned needed coping strategies from Coping-Together (Lambert et al. Reference Lambert, Girgis and McElduff2013a, Reference Lambert, McElduff and Girgis2016b). However, there is currently a lack of such interventions for use by those coping with advanced cancer (Warth et al. Reference Warth, Zöller and Köhler2020).
Figure 1. Expected impact of Coping-Together on patients’ and caregivers’ quality of life.
Table 1. Coping-Together intervention
This study aimed to evaluate the acceptability of Coping-Together for patients with advanced cancer and their caregivers, for the future adaptation of a comparable intervention for this population. Acceptability was defined as the users’ perception of the intervention’s suitability as it pertains to the uptake or initiation, application or use, and perceived benefits (Feeley et al. Reference Feeley, Cossette and Côté2009; Sidani and Braden Reference Sidani and Braden2011). As this is a qualitative study, acceptability benchmarks were not set. However, to enhance rigor we have added the specification that acceptability would be determined by overall positive feedback for most participants and that they felt the content was relevant to them and they could learn a new self-management skill.
Methods
Design
Coping-Together was evaluated using a qualitative descriptive design (Sandelowski Reference Sandelowski2000). Reporting was informed by the consolidated criteria for reporting qualitative research checklist (EQUATOR Network n.d.).
Sample
A purposive sample of 26 participants including 15 patients and 11 of their caregivers took part in this study (Figure 2). Patient inclusion criteria were: (a) being diagnosed with advanced cancer (stages III or IV, regardless of time since diagnosis and cancer type (Kleine et al. Reference Kleine, Hallensleben and Mehnert2019)), (b) identifying a caregiver (e.g., family member or significant other most involved in providing support), (c) self-reporting feeling well enough to participate in a study that will last 7 weeks, and (d) being relatively independent in daily activities as per the Karnofsky Performance Status Scale (Yates et al. Reference Yates, Chalmer and McKegney1980).
Figure 2. CONSORT diagram (EQUATOR Network., n.d.).
Setting and recruitment procedures
Recruitment primarily occurred across 2 cancer centers in Montreal, whereby clinicians introduced the study to patients and their caregivers and obtained their verbal permission for their contact information to be forwarded to the research assistant (RA). Patients participating in other studies who had agreed to be recontacted for relevant future studies were recruited by having an RA send them an email invitation. Recruitment was also done through online forums with collaborating community organizations who forwarded the study invite through their social media and listservs. Potentially interested individuals contacted the team directly by email. In all cases, an RA followed up to screen for eligibility by phone or email, based on potential participant preference.
When eligibility of a dyad was confirmed, they were given the option of receiving their consent forms by mail with a stamped, addressed return envelope, or by accessing a password protected consent form and baseline sociodemographic questionnaire online using Qualtrics, a secure web-based electronic data capture system. Ethics approval was obtainedacross centers.
The Coping-Together intervention was then mailed to participants who returned their consent forms to be used for 7 weeks. Each participant received the 6 booklets and workbook, as previously described.
Data collection
Strategies to enhance qualitative rigor are summarized in Table 2. Sociodemographic questionnaires were either completed online at baseline or over the phone after the first interview. As they used Coping-Together, patients and caregivers were invited to an initial 45–60-minute-long in-depth semi-structured interviews halfway through their study participation (i.e., 3 weeks) and then again at the end of the 7 weeks. Interviews focused on identifying facilitators and barriers to use, perceived usefulness, the intervention’s content/design, and highlighting any recommended changes. At the 7-week interview, there were questions about how their experienced with Coping-Together might have changed over time. All interviews were audio-recorded and conducted by a trained RA then transcribed verbatim by an independent professional transcribing company. Preferably, patients and caregivers were invited to participate in interviews as a dyad, though they were offered the choice to be interviewed separately.
Table 2. Maintaining methodological rigor
Data analysis
Interview transcripts were uploaded to NVIVO, a qualitative analysis software. The transcripts were analyzed using thematic analysis (Braun and Clarke Reference Braun and Clarke2022). Codes, which identified excerpts relevant to the objectives, were derived from the transcripts. As much as possible codes were labelled using words in the transcripts. Similar codes were combined into subcategories and then into larger categories. Categories were (1) approach to using Coping-Together and perceived ease of use; (2) reported usefulness and perceived benefits of Coping-Together; and (3) suggested improvements. Codes from all categories were then compared across interviews to identify similarities and differences, which led to the identification of themes.
Results
Sample
Ten patients and their caregivers participated as a dyad, and 5 patients and 1 caregiver participated as singletons, for a total of 26 individuals. Two dyads interviewed separately, whereas the other 8 interviewed together. All participants were either individuals living with advanced cancer (n = 15) or the caregiver of someone who identified as such (n = 11), with most participants identifying as women (n = 15). Participants’ ages ranged between 50 and 88 years old, with most participants having achieved higher education above postsecondary diplomas. Nine participants were interviewed before the COVID-19 pandemic and 17 from January 2021 to November 2023. Eighteen interviews were conducted at week 3 and 11 interviews at week 7, yielding a total of 29 transcripts. Those who did not complete the second interview at week 7 (n = 9) stopped participating mainly due to decreased function and increased illness severity. Full sociodemographic information can be seen in Table 3.
Table 3. Participant sociodemographic information
Reported usefulness and perceived benefits of Coping-Together
The main finding overall is that even if Coping-Together was not adapted for use among those facing advanced cancer, it had high-relevance for all participants (n = 26, 100%). An overview of findings is summarized in Table 4. The most used booklet was “Supporting Each Other,” which details strategies for communicating within the dyad and understanding each other’s perspectives. The other most used booklets were “Dealing with Stress and Worry” and “Getting the Support You Need.” While the top booklets used by patients were “Getting on Top of Symptoms” and “Getting the Support You Need,” caregivers used “Supporting Each Other” and “Dealing with Stress and Worry” the most.
Table 4. Summary of findings
The most common benefit of using the booklets, as they are, was learning coping and self-management strategies, as reported by most participants (n = 25, 96%). The top self-management strategies learned were related to skills to manage physical health (n = 20, 77%), emotional well-being (n = 21, 81%), as well as social well-being (n = 24, 92%). Examples of managing physical health included monitoring symptoms using the symptom diary. For example, in terms of managing physical symptoms, 1 patient used the skills to promote sleep hygiene (e.g., eating before bed and turning off electronics). The strategies for managing emotional well-being included reducing stress by reframing thoughts for a more positive outlook on life and illness, a more thoughtful approach to challenges, coping with difficult emotions such as fear and uncertainty and managing lifestyle changes. The skills for managing social well-being included methods for finding social support within the community, communicating with the healthcare team, and strategies to find financial support. Others emphasized what they had learned in terms of communicating with their healthcare team. One caregiver acknowledged that “There’s a lot of things, like, that are suggested in the booklets I could use with my [own doctor].” In terms of the dyadic benefits, the overall benefits included feeling connected through improved communication and normalizing cancer-related challenges. The booklets offered new skills to address participants’ existing challenges, while also acting as a reminder to the many who were already using similar strategies to manage their challenges.
All participants recognized that using a self-directed intervention offered them more autonomy over their health and contributed to their self-management of their illness in their own way, meaning at their own pace and readiness to learn. Participants reported that the self-directed format made them feel capable of implementing these coping skills in the long-term rather than only for the duration of this study.
Dyadic approach to using Coping-Together
More than half of participants read the booklets separately (n = 16, 62%), sometimes covering the same sections and other times covering different sections, then came together as a dyad to discuss the salient content they believed to reflect their shared needs. The dyads who used the booklets together (n = 10, 38%) felt it helped them understand the content. One patient mentioned: “[We] go through it together, so at least if one or the other doesn’t understand something at least we can help each other with it” – Patient (PID: A0304). Most used the booklets as a reference guide, rereading some of the parts deemed most pertinent by participants for retention of key strategies. It was noted that a few participants found the material to be more directed at patients, but still applicable to caregivers: “I mean this is more towards a person who has a condition, but at the same time, [managing psychosocial distress] does apply to caregivers” – Caregiver (PID: B0304). According to caregivers, the main strategy to address this was learning to take control over their own well-being from adopting better communication skills and stress management skills.
Barriers to use
The barriers to using the booklets were most commonly psychological across patients and caregivers. Several participants avoided the booklets because the quantity of material was overwhelming (n = 5, 19%). The emotional distress of reading the booklets and being reminded of acute challenges experienced in early stages also deterred a few participants (n = 3, 12%) from using the material, with 2 caregivers expressing that they were tempted not to use them at all because of this, though all participants ended up using them.
Participants also spoke of practical barriers. Some participants (n = 12, 46%) felt as though they were already prepared at this stage in their advanced cancer journey, having already established successful coping mechanisms: “A lot of it I’ve kind of already done – been there done that” – Caregiver (PID: B2012). Half of participants (n = 13, 50%) spoke to the timing of introduction of this intervention being more appropriate for early stages. However, most participants acknowledged that despite already knowing about some of the suggested coping skills, they appreciated the way the booklets were a reminder to practice them. In terms of physical barriers, all the patients recognized that cancer-related symptoms, such as fatigue, memory difficulties, and vision problems, made it difficult for them to use the booklets. More than half of caregivers (n = 7, 64%) mentioned that their caregiving tasks required time commitments that interfered with their ability to use the intervention. A few indicated that when the patient was medically unstable, it would be more difficult to find the time to read. Although less frequent, a few participants mentioned social barriers such as having stress from supporting their sick friends also living with cancer (outside of the dyad).
Facilitators to use
The most common facilitator was patients’ and caregivers’ desire to improve their coping skills to address specific challenges. Other facilitators included having a general interest in the material, being medically stable enough to find the time to read and wanting to support one another, as expressed by most participants (n = 17, 65%). These facilitators were more impactful than the barriers, resulting in all participants having used the booklets to some extent by the time of the first interview.
Despite their length, booklets were also deemed to be “user friendly” due to their consistency in formatting and structure: “The books followed a certain pattern, so you get into it almost as a flow. That worked for me” – Caregiver (PID: B1406). The flowcharts provided in each booklet were helpful for guiding users to the most salient topics to address their needs. The excerpts and quotes from real people motivated participants to continue to use the booklets, by offering an “authentic, human touch,” normalizing emotions, and making them feel less alone.
The exercises provided in the booklets offered participants a chance to put their skills into practice. A few participants specifically identified that the SMARTTER goal setting strategy made it easier to apply the self-management strategies.
Improvement suggestions for Coping-Together
Table 5 provides a list of the modifications requested by participanting patients and caregivers.
Table 5. Suggested adaptations for Coping-Together advanced
Missing information
Participants reported a lack of information about palliative care (e.g., planning for end-of-life, options for comfort care, and stopping treatment) and about resources available for advanced cancer. For example, some participants requested resources related to support for return to work, financial aid in late-stages, and government recognition and support. Furthermore, most participants addressed the need for more coping strategies for challenges related to their advanced cancer stage, such as fear of uncertainty, fear of death, and change of lifestyle and capacity. While many found ways to implement strategies from the booklets, this was made more difficult due challenges related to advanced cancer. For example, participants all defined their physical and emotional symptoms and challenges as being more debilitating than they were in early stages, with previous coping mechanisms no longer offering the same support.
Overall, most participants expressed facing challenges related to accessing sufficient social support. These challenges related to feeling like a burden by others, social isolation, limitations due to COVD-19, as well as the capacity, inaccessibility (e.g., distance, language), or cost of resources for social support. Other barriers to receiving support included that friends and family would not understand their current situation, or participants not wanting to burden others who are busy or living too far away to help. More information and strategies on social support was identified as a gap by all participants. The response from dyads was consistent with the premise that patients and caregivers rely on each other for physical and emotional support.
Many participants addressed the need for more information about connecting with others in similar situations. Participants wanted information to be adapted to the context of the COVID-19 pandemic: “Because some of the things most of us would do or could use coping strategies has also been impacted during this pandemic period” – Caregiver (PID: B1406). Infection control concerns related to COVID-19 were also expressed as being relevant beyond this pandemic. Another element that was determined to be missing from the Coping-Together booklets was content adapted to those coming from other countries. For instance, reliance on technology might be less common in other countries so some resources and suggestions were thought to be less universally relevant as they may not speak as accurately to the needs of immigrants. Participants also expressed the need for more positive coping strategies for everyday life, outside of the cancer-related symptoms: “Okay, you’ve got cancer. Now let’s move on. Yes, you’re dealing with it and everything, but give me tips on what I can do to feel better, to have a better outlook on life” – Patient (PID: A0304).
Another aspect participants reported could be improved was consideration for the “whole picture” – Patient (PID: A1406). While the booklets were reported by many as having addressed a wide variety of concerns, some noted that this “divided attention” approach to addressing challenges did not offer enough of a personalized touch and neglected to capture the whole picture holistically. To do so, participants suggested that more patient and caregiver testimonies could help in capturing this perspective.
Enhanced accessibility
Specific to this population, suggested changes to enhance learning in time of stress and illness include design changes to attend to the specific need for shorter sections in larger font given the increased severity of symptoms, such as fatigue, energy, attention, and memory problems. The main topics specific to advanced cancer that need to be added are palliative care treatment options, end-of-life planning, long-term financial aid, government recognition, and support for return to work, coping strategies for challenges such as fear of uncertainty, fear of death, and change of lifestyle and capacity. The dyads who had been patient-caregiver for longer periods of time tended to report having preestablished coping strategies. This led them to report not learning as much new information as compared to the newer dyads. This finding about learned coping skills rang true for those who had received their diagnosis longer ago as compared to more recently (Shaffer et al. Reference Shaffer, Tigershtrom and Badr2020). Many participants also reported the desire for a digitized version of this resource to enhance accessibility.
Discussion
The results support Coping-Together’s acceptability among both patients with advanced cancer and their caregivers. The results showed that participants found the booklets to be beneficial overall, with most expressing that the flowchart and the dyadic approach facilitated the self-directed process of achieving SMARTTER goals. The 4 key findings of this study are as follows: (a) changes are needed to further support learning new coping skills in terms of increased stress as well as including content specific to advanced cancer, (b) dyadic self-management does not mean that patients and caregivers use the same sections of Coping-Together, (c) learning, timing and readiness are key considerations that are acknowledged by the self-directed format for this self-management interventions, and (d) the main identified facilitators to using Coping-Together overcame the reported barriers. Each of these is discussed in turn.
While the overall impressions of Coping-Together were positive, the main barriers highlighted needed adaptations that were both general to increase accessibility and to enhance learning as well as those specific to the needs of patients with advanced cancer. Overall, most participants learned new coping skills and health behaviors despite the timing of diagnosis, which can be attributed to Coping-Together supporting behavior change techniques validated by experts, not yet typically integrated into usual care (Glidewell et al. Reference Glidewell, Willis and Petty2018). Key components of behavior change theory are: clear health goals, perceived barriers and facilitators to change, self-efficacy, self-regulatory skills, knowledge of benefits of health behaviors, and outcome expectations, all of which are established with the format of the SMARTTER approach to Coping-Together (Cuthbert et al. Reference Cuthbert, Farragher and Hemmelgarn2019).
The benefits of dyadic self-management interventions have been well established. When both the patient and caregiver are involved together, both of their individual needs as well as their collective needs in the relationship are addressed (Badr et al. Reference Badr, Bakhshaie and Chhabria2019). Interestingly, while patients and caregivers benefited from using the intervention together, they did not necessarily use the same booklets. Caregivers tended more toward the content related to social support and care planning, whereas patients focused on symptom management, with most improvement suggestions relating to the accessibility and ease of use of the booklets. Dyads referenced the importance of having a partner available to support them in using the booklets. While needs between patients and caregivers differed, their approach to using this self-management intervention showed that they complemented one another (Shaffer et al. Reference Shaffer, Tigershtrom and Badr2020).
The fact that all participants acknowledged the benefits of the self-directed format of this intervention is consistent with the literature that shows how people tend to prefer to follow self-management interventions at their own pace (Bamgboje-Ayodele et al. Reference Bamgboje-Ayodele, Smith and Short2021). This finding was further validated by the fact that participants who used the booklets during the COVID-19 pandemic recognized the importance of self-directed interventions that were not limited by physical accessibility restraints (Gonzalo-Encabo et al. Reference Gonzalo-Encabo, Wilson and Kang2022). Literature indicates that self-directed learning allows for a mastery and ownership of material that supports participants in regulating and becoming more accountable for their learning (Wong and Kan Reference Wong and Kan2022). To adopt behavior changes and achieve self-management goals, evidence shows that the consideration of timing and readiness are key factors that are prerequisites for effective learning (Gottlieb Reference Gottlieb2014). This aligns with the finding that participants would acknowledge the timing of introduction as being an important influence in whether they felt prepared to engage with the booklets.
While participants reported several barriers to using Coping-Together including feeling overwhelmed, being reminded of more acute challenges, having severe physical symptoms, there were more prominent facilitators that motivated their use of the intervention, which outweighed these barriers. The findings about facilitators from this study echo what has been found among other self-management interventions, with the most pertinent benefits from the literature being improved sense of control and empowerment, forming dynamic relationships and communication with healthcare providers, and facilitating treatment decision-making (McKenna et al. Reference McKenna, Sixsmith and Barry2020).
Clinical and research implications
This study has many clinical and research implications. Clinically, our results support that patients and caregivers may establish positive coping mechanisms for advanced cancer-related challenges to be undertaken together. Healthcare providers and researchers may also better understand the unique needs patients with advanced cancer and their caregivers’ experience (Porter et al. Reference Porter, Steel and Fairclough2021; Teo et al. Reference Teo, Krishnan and Lee2019). This study adds value to the existing Coping-Together intervention by offering more insight into its implications for practice with advanced cancer. These findings will directly contribute to the adaptation of the Coping-Together booklets for an advanced cancer population.
Study limitations
One limitation is that ethnicity was not measured in this study, given that it was less common to measure this variable when the sociodemographic sheet was first created and approved. However, previous studies have found that age and sex were the most important predictors for influence on adherence to self-management interventions (Xie et al. Reference Xie, Liu and Or2020). Nonetheless, future studies will consider ethnicity among sociodemographic data. Second, the narrow participant inclusion criteria made the feasibility for recruitment more difficult, which is consistent with other studies’ findings related to recruitment of dyads with advanced cancer (Edwards et al. Reference Edwards, Bennett and Blenkinsopp2019; Pii et al. Reference Pii, Schou and Piil2019). To enhance recruitment, singletons were accepted into the study to participate without the other member of their dyad. Five dyads stopped participating for reasons revolving around a lack of functionality related to illness progression. All participants were anglophone, and materials were only offered in English since the original Coping-Together intervention was developed in Australia (Lambert et al. Reference Lambert, Girgis and Turner2012a). The primary focus of this study was to evaluate acceptability, and as this was the first time Coping-Together was used in this subgroup of patients, we relied on qualitative interviews.
Conclusion
Patients with advanced cancer and caregivers in this study overall agreed that the Coping-Together intervention has great potential for supporting their physical, emotional, and psychosocial needs. They overall found the Coping-Together intervention was acceptable and had many perceived benefits. Despite the benefits, this population highlighted some key specifications that would make this intervention even more applicable to their unique needs. These suggested adaptations include having shorter booklets that also address additional information related to palliative care, end-of-life, long-term financial aid, government recognition, support for returning to work, and coping strategies for challenges such as fear of uncertainty, fear of death, and change of lifestyle and capacity. The future directions of this study will be to integrate patients’ and caregivers’ feedback in an adapted version of Coping-Together ready for pilot testing.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/S1478951524001755.
Acknowledgments
Contributions of individuals and supporting institutions: The primary author, Sydney Wasserman, conducted this study as a part of her master’s in advanced nursing at McGill University, under the co-supervision of 2 other coauthors, Dr. Sylvie Lambert and Dr. Andrea Laizner. All other listed authors contributed significantly to the development of the Coping-Together intervention or the adoption of this study.
Funding
This work was supported by funding, primarily from Réseau de recherche en interventions en sciences infirmières du Québec (RRISIQ). Additional funding has been received from Canadian Institute of Health Research (CIHR) Canada Research Chair for Dr. Sylvie Lambert. Sydney Wasserman was also funded by a CIHR Canada Graduate Scholarship – Master’s program (CGS-m) as well as the Bureau de cooperation interuniversitaire (BCI) - end of Master’s studies award. The second author acknowledges funding from the Fonds de recherche santé Québec (FRQS), Réseau de recherche portant sur les interventions en sciences infirmières du Québec (RRISIQ), and the Bureau de coopération interuniversitaire (BCI).
Competing interests
No conflict of interest to disclose.
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