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The impact of motivational interviewing on behavioural change and health outcomes in cancer patients and survivors. A systematic review and meta-analysis

  • Katherine Harkin
    Affiliations
    Institute for Health and Sport, Victoria University, Melbourne, Australia

    First Year College, Victoria University, Melbourne, Australia
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  • Vasso Apostolopoulos
    Affiliations
    Institute for Health and Sport, Victoria University, Melbourne, Australia

    Australian Institute for Musculoskeletal Science (AIMSS), Victoria University, The University of Melbourne and Western Health, St. Albans, Australia
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  • Kathy Tangalakis
    Affiliations
    First Year College, Victoria University, Melbourne, Australia

    Institute for Sustainable Industries & Liveable Cities, Victoria University, Melbourne, Australia
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  • Susan Irvine
    Affiliations
    First Year College, Victoria University, Melbourne, Australia
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  • Author Footnotes
    1 These authors contributed equally to the manuscript.
    Nicholas Tripodi
    Correspondence
    Correspondence to: N. Tripodi, Institute for Health and Sport, Victoria University, Melbourne, Australia.
    Footnotes
    1 These authors contributed equally to the manuscript.
    Affiliations
    Institute for Health and Sport, Victoria University, Melbourne, Australia

    Australian Institute for Musculoskeletal Science (AIMSS), Victoria University, The University of Melbourne and Western Health, St. Albans, Australia

    First Year College, Victoria University, Melbourne, Australia
    Search for articles by this author
  • Author Footnotes
    1 These authors contributed equally to the manuscript.
    Jack Feehan
    Correspondence
    Correspondence to: J. Feehan, Australian Institute for Musculoskeletal Science (AIMSS), Victoria University, The University of Melbourne and Western Health, St. Albans, Australia.
    Footnotes
    1 These authors contributed equally to the manuscript.
    Affiliations
    Institute for Health and Sport, Victoria University, Melbourne, Australia

    Australian Institute for Musculoskeletal Science (AIMSS), Victoria University, The University of Melbourne and Western Health, St. Albans, Australia
    Search for articles by this author
  • Author Footnotes
    1 These authors contributed equally to the manuscript.
Open AccessPublished:January 19, 2023DOI:https://doi.org/10.1016/j.maturitas.2023.01.004

      Highlights

      • Motivational interviewing impacts on levels of physical activity in cancer patients and survivors.
      • Motivational interviewing has a positive impact on depression, functional tasks and body mass index in cancer patients and survivors.
      • Motivational interviewing has a positive impact on self-efficacy in cancer patients and survivors.
      • Achievement of minimum physical activity thresholds and motivational interviewing that contained an element of self-efficacy in the management of symptoms had more favourable health and behaviour outcomes.

      Abstract

      Background

      Cancer patients and survivors commonly have poorer health behaviours and subsequent outcomes, often as a result of negative impacts of diagnosis and treatment. Motivational interviewing is reported to be an effective psychological tool to produce a shift in one's behaviour resulting in improved outcomes. However, there is a lack of analyses investigating this tool's impact on healthy behaviours and health outcomes in cancer populations.

      Objective

      To investigate the effect of motivational interviewing on behaviours and health outcomes in cancer populations.

      Methods

      The studies were identified from four databases using variations of the terms “cancer” and “motivational interviewing”. Randomised trials, non-randomised trials and quasi-experimental studies which contained control (or usual care) comparators were included. Risk of bias was assessed using the Cochrane Risk of Bias Version 5.1.0 and the Risk of Bias In Non-Randomised Studies of Interventions tools. The quality of evidence was assessed using the GRADE framework. Means difference and standardised mean differences and 95 % confidence intervals were used to report the pooled effects using a random effects model.

      Results

      Twenty-one studies were included in the review and 17 studies were included in the meta-analysis. A total of 1752 cancer patients and survivors received MI as an intervention (or part thereof). Quality of life, anxiety, depression, functional tasks (6-minute walk test), body mass index and body weight (BMI/BW), physical activity (PA), self-efficacy and fatigue were outcomes measured in the selected studies. Effects were seen in functional tasks, physical activity, BMI/BW, depression and self-efficacy. All of these outcomes were from studies that were classed as very low-quality evidence except for BMI/BW and PA, which were from moderate-quality evidence.

      Conclusion

      Motivational interviewing had positive effects on functional tasks, PA, BMI/BW, depression and self-efficacy in people diagnosed with cancer. However, more higher-quality studies need to be conducted to further ascertain the effect of this intervention.

      Keywords

      1. Introduction

      The prevalence of cancer is steadily increasing each year, with an estimated 151,000 new cancer diagnoses in Australia in 2021 [
      • Welfare A.I.o.H.a.
      Cancer in Australia 2021.
      ]. Many patients suffer from adverse effects of cancer diagnosis or treatment including fatigue [
      • Schmitz K.H.
      • et al.
      American College of Sports Medicine roundtable on exercise guidelines for cancer survivors.
      ], depression [
      • Niedzwiedz C.L.
      • et al.
      Depression and anxiety among people living with and beyond cancer: a growing clinical and research priority.
      ], pain [
      • Mokhatri-Hesari P.
      • Montazeri A.
      Health-related quality of life in breast cancer patients: review of reviews from 2008 to 2018.
      ], financial challenges and social isolation [
      • Koch L.
      • et al.
      Quality of life in long-term breast cancer survivors - a 10-year longitudinal population-based study.
      ] both during active treatment and well into longer-term survivorship periods. Consequently, an individual's motivation and ability to engage in recommended levels of healthy behaviours can become limited [
      • Avancini A.
      • et al.
      "Running with cancer": a qualitative study to evaluate barriers and motivations in running for female oncological patients.
      ,
      • Eng L.
      • et al.
      Patterns, perceptions, and perceived barriers to physical activity in adult cancer survivors.
      ]. Only 10 % of female breast cancer survivors (fBCS) achieve recommended physical activity (PA) levels [
      • Bluethmann S.M.
      • et al.
      Taking the next step: a systematic review and meta-analysis of physical activity and behavior change interventions in recent post-treatment breast cancer survivors.
      ], whilst approximately 15 % of cancer survivors are cigarette smokers [
      • Underwood J.M.
      • et al.
      Surveillance of demographic characteristics and health behaviors among adult cancer survivors–Behavioral risk factor surveillance system, United States, 2009.
      ]. Unhealthy behaviours such as these are disadvantageous as maintaining healthy behaviours can help to ameliorate many adverse effects of treatment [
      • Campbell K.L.
      • et al.
      Exercise guidelines for cancer survivors: consensus statement from international multidisciplinary roundtable.
      ], improve cancer survival and reduce further cancer risk [
      • Underwood J.M.
      • et al.
      Surveillance of demographic characteristics and health behaviors among adult cancer survivors–Behavioral risk factor surveillance system, United States, 2009.
      ,
      • Welfare A.I.o.H.a.
      ]. The time of initial diagnosis and treatment is proposed by Denmark-Wahnefried et al., to be a ‘teachable moment’, which presents a unique opportunity for oncologists to advise and motivate cancer patients to engage in behavioural change [
      • Demark-Wahnefried W.
      • et al.
      Riding the crest of the teachable moment: promoting long-term health after the diagnosis of cancer.
      ]. Paradoxically, this is when adverse effects can maximally impact the capacity to maintain or improve health behaviour. The importance of behavioural change strategies in boosting adherence to desired behaviour in cancer populations is well recognised. Evidence supports the use of motivational tools such as pedometers, print materials and counselling to significantly improve self-directed PA levels in fBCS [
      • Pudkasam S.
      • et al.
      Motivational strategies to improve adherence to physical activity in breast cancer survivors: a systematic review and meta-analysis.
      ] and increased adherence to PA and nutritional recommendations in mixed cancer survivor populations [
      • Stacey F.G.
      • et al.
      A systematic review and meta-analysis of social cognitive theory-based physical activity and/or nutrition behavior change interventions for cancer survivors.
      ].
      Motivational interviewing (MI) is a psychological motivational tool primarily designed to resolve an individual's ambivalence to behavioural change [
      • Miller W.R.
      • Rollnick S.
      Motivational interviewing : preparing people for change.
      ]. MI has specific hallmarks that ensure its overall effectiveness, including collaboration between practitioner and patient, showing empathy, identifying reasons for ambivalence, being flexible with resistance to change and reinforcing a patient's confidence in their capacity for change. Therefore, MI can be useful in achieving particular goals, such as eating a healthy diet (behavioural change), or managing pain (perception and attitudes to symptoms) in a specific population or context. A large meta-analysis of 48 studies (9618 participants) investigated the effects of MI in a medical setting and showed a statistically significant improvement in a range of health outcomes such as blood pressure, body weight, cholesterol level, death rate, dental caries, HIV viral load, body weight, physical strength, quality of life (QoL) and healthy behaviours such as substance abuse, sedentary behaviour, treatment adherence, self-efficacy and intention to change [
      • Lundahl B.
      • et al.
      Motivational interviewing in medical care settings: a systematic review and meta-analysis of randomized controlled trials.
      ]. Additionally, in a systematic review, common features of MI including conducting the interview over the phone with a trained nurse, the use of worksheets or diaries and strategies targeting improving PA behaviour were all associated with improved behavioural outcomes in cancer populations [
      • Spencer J.C.
      • Wheeler S.B.
      A systematic review of motivational interviewing interventions in cancer patients and survivors.
      ].
      As previous studies of MI have not focused on cancer survivors, who have a unique set of needs and circumstances which effect adherence, this systematic review and meta-analysis investigated the impact of MI on healthy behaviours and related behavioural health outcomes in mixed-cancer populations. We aimed to identify the effect of MI on healthy PA behaviours and health outcomes such as QoL, anxiety, depression, functional tasks, self-efficacy, BMI and fatigue were determined in cancer patients and survivors. Findings from this review will help to inform future research in methods that can improve the well-being of cancer patients and survivors.

      2. Methods

      2.1 Protocol and registration

      A protocol was written according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA 2020) [
      • Page M.J.
      • et al.
      PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews.
      ]. The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42022315725).

      2.2 Eligibility criteria

      2.2.1 Participants

      Studies were included if participants were: (1) 18 years or older; (2) had a previous or current cancer diagnosis; and (3) human subjects.

      2.2.2 Intervention

      The systematic review included studies that used MI as the solitary intervention or combined with other components, such as primary exercise or diet interventions. For the purpose of this review, MI was defined as an intervention that was in ‘real-time’ either in-person or over the phone (inclusive of associated terms such as ‘counselling’ or ‘coaching’) that was underpinned by MI principles. Interventions that were passively delivered such as an educational video or print materials alone were excluded given the interactive dynamic nature of MI.

      2.2.3 Comparator

      Studies included in this review were randomised controlled trials (RCTs) and quasi-experimental studies which involved using one or more comparators, or a control group within the design. Those with a mixed-methods design were included if the relevant quantitative data could be extracted. In three-arm studies involving two interventions (one with and one without MI) and one control group, two comparisons were conducted. Studies were considered eligible if the control group received either no intervention or ‘usual care’, so long as it did not involve any components of MI.

      2.2.4 Outcome

      Studies that measured either health behaviours or health outcomes were included.

      2.2.5 Report characteristics

      This systematic review and meta-analysis included articles that were peer-reviewed, with full-text availability and in English. Exclusions were book chapters, conference abstracts and review articles.

      2.3 Information sources and search strategy

      The search was conducted in September 2022. The databases: PubMed, PsychINFO (EBSCOhost), SPORTDiscus with full text (EBSCOhost), and Cumulative Index to Nursing and Allied Health Literature (CINAHL) with full text (EBSCOhost), were searched for articles published since 1980 (based on development of MI). The terms used within each database during the final search are presented in Supplementary Table 1.
      Search results from each of the four databases were imported into EndNote X9 and duplicates removed. All articles were then exported into the ©2022 Covidence software, with two co-authors independently screening the titles and abstracts according to the eligibility criteria, prior to full-text review. Inconsistencies or disagreements were resolved by a third reviewer (JF). A summary of article inclusion and exclusion at each stage was conducted using the Preferred Reporting of Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of identification, screening, eligibility and inclusion of studies template [
      • Haddaway N.R.
      • Pritchard C.C.
      • McGuinness L.A.
      PRISMA2020: R Package and ShinyApp for Producing PRISMA 2020 Compliant Flow Diagrams (Version 0.0.2).
      ].

      2.4 Data extraction

      Data from the included studies were extracted and manually entered into a Microsoft Excel spreadsheet by a reviewer (KH). Authors of studies where data was inconsistent or not reported were contacted via email, and if no response was received, then the study was excluded.
      The following data were extracted from each study: publication details (author and year), type of study design (RCT, quasi-experimental), sample size, demographic details of participants (mean age, cancer type, patient stage such as active or survivorship), intervention characteristics (the aim of MI, duration and number of MI sessions; delivery mode of MI: combined, in-person or phone; and other components such as pedometer or print materials), outcome details (outcomes measured and measurement follow-up time-points) and additional comments such as financial reimbursement and if intervention fidelity measures were undertaken.

      2.5 Assessment of risk of bias

      The two independent reviewers (KH and NT) assessed the risk of bias in the included studies, with a randomised controlled study methodology, using a modified version of the Cochrane Collaboration's tool assessing the risk of bias Version 5.1.0. (RoB 5.1.0) [
      • Higgins J.P.T.
      • Green S.
      Cochrane Handbook for Systematic Reviews of Interventions.
      ]. As blinding participants to MI and any other components of the intervention was impossible, the third domain of performance bias was modified to be defined as blinding of personnel only [
      • Sweegers M.G.
      • et al.
      Which exercise prescriptions improve quality of life and physical function in patients with cancer during and following treatment? A systematic review and meta-analysis of randomised controlled trials.
      ]. Furthermore, the reporting bias domain was defined as being specific to the reporting of outcomes by the authors and researchers, and not reporting bias associated with self-reporting of outcomes by participants, such as medication adherence and PA levels. If there was a suspected reporting bias due to participant self-reporting measures, it was included as a high risk within the seventh domain. Each of the domains were then be assigned either ‘low risk’, ‘high risk’ or ‘unclear risk’ [
      • Higgins J.P.T.
      • Green S.
      Cochrane Handbook for Systematic Reviews of Interventions.
      ]. The methodological quality of studies that were either quasi-experimental or non-randomised were assessed using the Cochrane Risk of Bias In Non-Randomised Studies of Interventions (ROBINS-I) tool [
      • Higgins J.P.T.
      • et al.
      Cochrane Handbook for Systematic Reviews of Interventions.
      ]. Disagreements were resolved by a third reviewer (JF).

      2.6 Synthesis of results

      Two reviewers (KH and NT) conducted the meta-analysis using Review Manager (RevMan) Version 5.4.1 (The Cochrane Collaboration, Denmark). For continuous outcome data, mean change from baseline or post-intervention and standard deviation, were calculated for each study. Functional task (6 minute walk test) data were analysed using the mean difference (MD) statistic as all included studies utilised the same outcome measuring tool. QoL, anxiety, depression, BMI, PA, self-efficacy and fatigue were analysed using the standardised mean difference (SMD) statistic given the heterogeneity between outcome assessment tools. The effect score of SMD or MD was considered as either; small (<0.20), moderate (0.20–0.80) or large (>0.80).
      The I2 statistic was used to identify heterogeneity between studies using the following ranges: 0–30 % no relevant heterogeneity, 31–60 % moderate heterogeneity, 61–90 % substantial heterogeneity and 91–100 %.
      The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework was used to assess the quality of evidence across five criteria [
      • Schunemann H.
      • et al.
      GRADE Handbook for Grading Quality of Evidence and Strength of Recommendations.
      ]. The five criteria were modified and based upon those in other similar meta-analyses of MI [
      • O’Halloran P.D.
      • et al.
      Motivational interviewing to increase physical activity in people with chronic health conditions: a systematic review and meta-analysis.
      ]:
      • 1.
        Risk of Bias: Assigned ‘Yes’ if >25 % of studies included within the outcome analysis were classified as ‘high’ or ‘serious’ risk
      • 2.
        Inconsistency (unexplained heterogeneity): Assigned ‘Yes’ if I2 value was >50 %
      • 3.
        Indirectness: Assigned ‘Yes’ if there were any of the following: a) Indirect comparison between MI and the comparator group; or b) specifics of the MI mode delivery were difficult to ascertain
      • 4.
        Imprecision (wide CIs): Assigned ‘Yes’ if The CI for the SMD was >0.8 (a large effect according to Cohen [
        • Cohen J.
        Statistical power analysis.
        ]).
      • 5.
        Publication Bias: Assigned ‘Yes’ if funnel plot was used to evaluate when >10 studies within the same outcome.
      For every ‘Yes’ assigned to each criterion there was one point deduction (downgrading of quality of evidence) from a starting total figure of five. Reporting bias was evaluated by visual analysis of the funnel plot, if there were adequate studies. Overall quality criteria were assigned a classification of: High if no ‘Yes’ responses, Moderate if one ‘Yes’ response, Low if two ‘Yes’ responses, Very Low if three or more ‘Yes’ responses. See Table 2 for results.

      3. Results

      3.1 Study selection

      The four databases yielded a resultant total of 13,607 articles: PubMed (10,806), CINAHL (2319), APA PsychInfo (101) and SPORTDiscus (381), with 9263 unique records following duplicate removal. Of these, 8959 studies were excluded after title and abstract screening for relevance and eligibility. Full texts of ten of the remaining 304 studies could not be retrieved. Full-text screening on the remaining 294 studies led to the ultimate inclusion of 21 studies for the literature review and 17 studies for data extraction used within the meta-analysis. This process is illustrated in Fig. 1 [
      • Page M.J.
      • et al.
      PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews.
      ].
      Fig. 1
      Fig. 1Literature search summary according to PRISMA guidelines.

      3.2 Study characteristics

      Study characteristics are summarised in Table 1.
      Table 1Study characteristics.
      Study detailsDemographic characteristicsInterventionComparatorOutcomeAdditional comments
      Author (year), study designSample sizeMean age (years)Cancer typeCancer stageAimDuration, number, and modeOther componentsComparator groupOutcomes, measurement toolsFU (wks)
      Bennett (2007)
      • Bennett J.A.
      • et al.
      Motivational interviewing to increase physical activity in long-term cancer survivors: a randomized controlled trial.


      RCT
      56IG = 55.5, CG = 60.1Mixed CaSurvivors, mean time 42 M since completion of tmt^PA Behaviour3 × 30 min sessions, CPedometerReceived two social phone calls without MI content. No pedometer received
      • 1)
        PA
      • 2)
        Self-efficacy
      • 3)
        Aerobic fitness
      • 4)
        QoL
      • 5)
        Fatigue
      12, 24Received financial reimbursement
      Ҫakmak (2021)
      • Çakmak H.S.G.
      • Kapucu S.
      The effect of educational follow-up with the motivational interview technique on self-efficacy and drug adherence in cancer patients using oral chemotherapy treatment: a randomized controlled trial.


      RCT
      80IG = 57, CG = 62Mixed CaActive tmt^Adherence to oral medication5 × 15-20 min sessions, CPrint materialsPrinted general health information and standard health advice
      • 1)
        Self-efficacy
      • 2)
        Medication adherence
      12
      Coolbrandt (2018)
      • Coolbrandt A.
      • et al.
      A nursing intervention for reducing symptom burden during chemotherapy.


      Quasi-experimental
      142IG = 62 (median), CG = 65 (median)Mixed CaActive tmt^Self-efficacy, healthy behaviours and symptom managementMinimum of 2 × 10–60 min sessions, CPrint materialsPrinted general health information and standard health advice
      • 1)
        Overall Symptom Distress & Severity
      • 2)
        Self-efficacy
      3, 6, 12Using TTM to inform the MI design. Measures taken for MI fidelity
      Dennett (2018)
      • Dennett A.M.
      • et al.
      Motivational interviewing added to oncology rehabilitation did not improve moderate-intensity physical activity in cancer survivors: a randomised trial.


      RCT
      46IG = 57, CG = 60Mixed cancerCombined during and post active tmt, mean time since tmt 4.4 M^PA behaviour7 × 20 min sessions, PGroup education, supervised and home-based exercise sessions and print materialsSupervised and home-based PA sessions, group education sessions and print materials
      • 1)
        PA
      • 2)
        Physical function
      • 3)
        Self-efficacy
      • 4)
        Fatigue
      • 5)
        QoL
      • 6)
        Mental health
      • 7)
        Blood analysis
      8Measures taken for MI fidelity
      Djuric (2011)
      • Djuric Z.
      • et al.
      A diet and exercise intervention during chemotherapy for breast cancer.


      RCT
      40Combined 52.3Breast CaPre-active tmt^Adherence to dietary goals19 × sessions, PPrint materials, pedometerPrint materials and pedometer
      • 1)
        Anthropometrics
      • 2)
        PA
      • 3)
        QoL
      • 4)
        Dietary intake
      • 5)
        Blood analysis
      24, 52Measures taken for MI fidelity. Received financial reimbursement
      Frawley (2020)
      • Frawley H.C.
      • et al.
      An allied health rehabilitation program for patients following surgery for abdomino-pelvic cancer: a feasibility and pilot clinical study.


      Non-randomised, controlled before and after study
      188IG = 66.1, CG = 67.1Abdomino-pelvic CaCompleted surgical tmt, mean time since surgery 70.5 days^Adherence to PA and dietary recommendations + emotional management16 × 1 h group sessions, CHome-based ex program, print materials and pedometerNothing received
      • 1)
        Feasibility
      • 2)
        Physical function (IG only)
      • 3)
        PA
      • 4)
        Mental health
      • 5)
        QoL
      • 6)
        Self-efficacy
      • 7)
        Pelvic floor symptoms
      8, 24
      Hartman (2018)
      • Hartman S.J.
      • et al.
      Randomized controlled trial of increasing physical activity on objectively measured and self-reported cognitive functioning among breast cancer survivors: the memory & motion study.


      RCT
      87IG = 58.2, CG = 56.2Breast CaSurvivors, mean time since surgery 30.1 M^PA Behaviour3 × sessions, CIndividualised PA recommendations and pedometerPrinted general health advice
      • 1)
        PA
      • 2)
        Objective neurocognitive functioning
      • 3)
        Self-reported cognition
      • 4)
        Anthropometrics
      12
      Hoy (2009)
      • Hoy M.K.
      • et al.
      Implementing a low-fat eating plan in the women's intervention nutrition study.


      RCT
      2437IG = 58.6, CG = 58.5Breast CaSurvivors, within 365 days of active tmt^Adherence to dietary goals34 × 60 min sessions, CPrint materialsPrint materials only
      • 1)
        Dietary intake
      • 2)
        Anthropometrics
      12, 24, 36, 48, 60, 72Measures taken for MI fidelity. TTM informing MI
      Huang (2018)
      • Huang F.F.
      • et al.
      A self-efficacy enhancing intervention for pulmonary rehabilitation based on motivational interviewing for postoperative lung cancers patients: modeling and randomized exploratory trial.


      RCT
      30IG = 57, CG = 61.1Lung CaImmediately post-surgery^Self-efficacy, healthy behaviours and symptom management6 × 15-40 min sessions, CPrint materialsPrint materials and four general follow up phone calls
      • 1)
        Feasibility
      • 2)
        Acceptability
      • 3)
        Self-efficacy
      • 4)
        QoL
      • 5)
        Mental health
      • 6)
        Social support
      • 7)
        Subjective wellbeing
      • 8)
        Coping styles
      • 9)
        Post-traumatic growth
      • 10)
        Pulmonary rehabilitation effect
      12Measures taken for MI fidelity.
      Kvale (2016)
      • Kvale E.A.
      • et al.
      Patient-centered support in the survivorship care transition: outcomes from the patient-owned survivorship care plan intervention.


      RCT
      79IG = 57 CG = 59Breast CaSurvivors, mean time since tmt 115 days^Healthy behaviour + symptom management1 × 75 min session, IPUsual care (no detail given)
      • 1)
        QoL
      • 2)
        Self-reported health
      • 3)
        Depression
      • 4)
        Limitations in Social roles and activities
      • 5)
        Self-Management
      • 6)
        Self-efficacy
      • 7)
        Care co-ordination
      12Measures taken for MI fidelity.
      Lahart (2018)
      • Lahart I.M.
      • et al.
      The effects of a home-based physical activity intervention on cardiorespiratory fitness in breast cancer survivors; a randomised controlled trial.


      RCT
      32IG = 52.5, CG = 52Breast CaSurvivors, mean time since tmt 10.9 wks^Healthy Behaviour4: 1 × 30-45 min sessions, CPrint materials, DVD, reminder emails and exercise diariesPrint materials on general health advice
      • 1)
        Cardio-vascular fitness
      • 2)
        Exercise tolerance
      • 3)
        PA
      • 4)
        Anthropometrics
      24
      Pollak (2018)
      • Pollak K.I.
      • et al.
      A smoking cessation and pain management program for cancer survivors.


      RCT
      30IG = 60, CG = 54Mixed CaSurvivors, within 5 yrs of diagnosis^Smoking cessation + pain management4 × 60 min sessions, PNRT, print materials and workbookNothing received
      • 1)
        Feasibility
      • 2)
        Acceptability
      • 3)
        Abstinence
      • 4)
        Mental health
      • 5)
        Coping
      • 6)
        QoL
      8
      Ream (2015)
      • Ream E.
      • et al.
      Management of cancer-related fatigue during chemotherapy through telephone motivational interviewing: modeling and randomized exploratory trial.


      RCT
      44IG = 52, CG = 55Mixed CaActive tmtSymptom management (mostly fatigue)3 × sessions, PPrint materials (information handbook and fatigue diary)Nothing received
      • 1)
        Global Fatigue
      • 2)
        Fatigue DISTRESS
      • 3)
        Self-efficacy
      • 4)
        Mental health
      3 treatment cyclesMeasures taken for MI fidelity.
      Sheppard (2016)
      • Sheppard V.B.
      • et al.
      The feasibility and acceptability of a diet and exercise trial in overweight and obese black breast cancer survivors: the stepping STONE study.


      RCT
      31Combined 54.7Breast CaSurvivors, mean time since tmt 1.7 yrs^Adherence to PA and dietary recommendations + emotional management6 × 60 min + 6 × 15 min sessions, CPrint materials, supervised exercise sessions, pedometersPrint materials
      • 1)
        PA
      • 2)
        Anthropometrics
      • 3)
        Cardio-vascular fitness
      • 4)
        Self-efficacy
      • 5)
        Dietary intake
      • 6)
        Intervention satisfaction
      12Some interviewers were fBCS. MI informed by the TPB and SCT. Financial reimbursement
      Thomas (2012)
      • Thomas M.L.
      • et al.
      A randomized, clinical trial of education or motivational-interviewing-based coaching compared to usual care to improve cancer pain management.


      3 arm RCT: 2 × IG (1 × MI + education, 1 × education only) + 1 × CG
      317IG (MI) = 61.8, IG (non-MI) = 62.5, CG = 58.7Mixed CaSurvivors, mean time since diagnosis: MI group 30 M, non-MI group 37.5 MSymptom management (pain)4 × 30 min sessions, PInformation video on management of symptoms + print materialsInformation video on cancer
      • 1)
        Pain
      • 2)
        Physical Function
      • 3)
        Attitudinal barriers
      • 4)
        QoL
      12Measures taken for MI fidelity.
      Tsianakas (2017)
      • Tsianakas V.
      • et al.
      CanWalk: a feasibility study with embedded randomised controlled trial pilot of a walking intervention for people with recurrent or metastatic cancer.


      RCT (mixed methods)
      42IG: Male = 65, female = 60

      CG: Male = 66.2, female = 58
      Mixed CaAdvanced, meantime since diagnosis: 25 % < 1 yr, 35 % 1-2 yrs, 10 % 3-4 yrs, 20 % 5-9 yrs, 10 % 10+ yrs^PA behaviour1 × 15 min sessions, IPPrint material (PA promotion)Advised to continue on current PA levels
      • 1)
        QoL
      • 2)
        Health status
      • 3)
        PA
      • 4)
        Fatigue
      • 5)
        Mental health
      • 6)
        Self-efficacy
      • 7)
        Feasibility
      6, 12, 24Measures taken for MI fidelity.
      Turner (2019)
      • Turner J.
      • et al.
      The ENHANCES study: a randomised controlled trial of a nurse-led survivorship intervention for patients treated for head and neck cancer.


      3 arm RCT: 2 × IG (1 × MI, 1 × information) + 1 × CG
      109Combined IG and CG: <60 years = 49.1 %, >60 years = 50.9 %Head and neck CaSurvivors, time since tmt within 1 M^Self-efficacy, healthy behaviours and symptom management1 × 60 min sessions, IPPrint material (information on survivorship issues)Usual clinical care (no information resource)
      • 1)
        QoL
      • 2)
        Mental health
      • 3)
        Self-efficacy
      12, 24
      Vallance (2020)
      • Vallance J.K.
      • et al.
      Effects of the ACTIVity And TEchnology (ACTIVATE) intervention on health-related quality of life and fatigue outcomes in breast cancer survivors.
      (Lynch, 2019 for PA outcomes
      • Lynch B.M.
      • et al.
      A randomized controlled trial of a wearable technology-based intervention for increasing moderate to vigorous physical activity and reducing sedentary behavior in breast cancer survivors: the ACTIVATE trial.
      )

      RCT
      83IG = 61.3, CG = 61.9Breast CaSurvivors, completed primary tmt (no values given)^PA behaviour6 × sessions, CPedometer and log bookReceived a pedometer at wk 12 time-point
      • 1)
        Fatigue
      • 2)
        QoL
      • 3)
        PA
      12, 24
      Yang (2020)
      • Yang S.-Y.
      • Wang J.-D.
      • Chang J.-H.
      Occupational therapy to improve quality of life for colorectal cancer survivors: a randomized clinical trial.


      RCT
      68IG = 59.97, CG = 63.62Colorectal CaSurvivors, immediately post surgery^Healthy behaviour + symptom management3 × sessions, IPPrint materials (colorectal cancer education handbook)Print materials (colorectal cancer education handbook)
      • 1)
        QoL
      • 2)
        Mental health
      • 3)
        Functional status
      • 4)
        Healthy lifestyle
      4, 12
      Zangeneh (2019)
      • Zangeneh F.
      • et al.
      The effect of motivational interviewing-based counseling on women's sexual satisfaction and body image.


      RCT
      60IG = 43.7, CG = 45.9Breast CaSurvivors, completed mastectomy (no values given)^Sexual behaviour and body image5 × 45 min sessions, IPGroup educational sessionsNothing received
      • 1)
        Sexual satisfaction
      • 2)
        Body image
      5
      Zuniga (2018)
      • Zuniga K.E.
      • et al.
      Dietary intervention among breast cancer survivors increased adherence to a Mediterranean-style, anti-inflammatory dietary pattern: the Rx for better breast health randomized controlled trial.


      RCT
      153IG = 55.3, CG = 58.4Breast CaSurvivors, mean time since tmt; <6 M: IG = 13.3 % CG = 12.3 %

      6 M–24 M: IG = 21.7 % CG = 26.2 %

      >24 M: IG = 65 % CG = 61.5 %
      ^Adherence to dietary goals6 × sessions, PGroup education sessions, individualised print materials and workbookMonthly general health dietary information brochures
      • 1)
        Adherence to diet
      • 2)
        Spices and herbs intake
      • 3)
        Nutrient analysis
      24
      ^ = increase/improve, BMI = body mass index, C = combined, Ca = cancer, CG = control group, Chemo = chemotherapy, FU = follow up measurement time points (baseline time point assumed), IG = intervention group, Info = information, IP = in-person, M = months, min = minutes, NRT = nicotine replacement therapy, P = phone, PA = physical activity, QoL = quality of life, RCT = randomised controlled trial, SCT = social cognitive theory, T0 = baseline, TPB = theory of planned behaviour, Tmt = treatment, TTM = trans-theoretical model, Wkly = weekly, Wks = weeks, Yrs = years.

      3.3 Study details

      There were a total of 17 two-arm [
      • Bennett J.A.
      • et al.
      Motivational interviewing to increase physical activity in long-term cancer survivors: a randomized controlled trial.
      ,
      • Çakmak H.S.G.
      • Kapucu S.
      The effect of educational follow-up with the motivational interview technique on self-efficacy and drug adherence in cancer patients using oral chemotherapy treatment: a randomized controlled trial.
      ,
      • Dennett A.M.
      • et al.
      Motivational interviewing added to oncology rehabilitation did not improve moderate-intensity physical activity in cancer survivors: a randomised trial.
      ,
      • Djuric Z.
      • et al.
      A diet and exercise intervention during chemotherapy for breast cancer.
      ,
      • Hartman S.J.
      • et al.
      Randomized controlled trial of increasing physical activity on objectively measured and self-reported cognitive functioning among breast cancer survivors: the memory & motion study.
      ,
      • Hoy M.K.
      • et al.
      Implementing a low-fat eating plan in the women's intervention nutrition study.
      ,
      • Huang F.F.
      • et al.
      A self-efficacy enhancing intervention for pulmonary rehabilitation based on motivational interviewing for postoperative lung cancers patients: modeling and randomized exploratory trial.
      ,
      • Kvale E.A.
      • et al.
      Patient-centered support in the survivorship care transition: outcomes from the patient-owned survivorship care plan intervention.
      ,
      • Lahart I.M.
      • et al.
      The effects of a home-based physical activity intervention on cardiorespiratory fitness in breast cancer survivors; a randomised controlled trial.
      ,
      • Pollak K.I.
      • et al.
      A smoking cessation and pain management program for cancer survivors.
      ,
      • Ream E.
      • et al.
      Management of cancer-related fatigue during chemotherapy through telephone motivational interviewing: modeling and randomized exploratory trial.
      ,
      • Sheppard V.B.
      • et al.
      The feasibility and acceptability of a diet and exercise trial in overweight and obese black breast cancer survivors: the stepping STONE study.
      ,
      • Tsianakas V.
      • et al.
      CanWalk: a feasibility study with embedded randomised controlled trial pilot of a walking intervention for people with recurrent or metastatic cancer.
      ,
      • Vallance J.K.
      • et al.
      Effects of the ACTIVity And TEchnology (ACTIVATE) intervention on health-related quality of life and fatigue outcomes in breast cancer survivors.
      ,
      • Zangeneh F.
      • et al.
      The effect of motivational interviewing-based counseling on women's sexual satisfaction and body image.
      ,
      • Zuniga K.E.
      • et al.
      Dietary intervention among breast cancer survivors increased adherence to a Mediterranean-style, anti-inflammatory dietary pattern: the Rx for better breast health randomized controlled trial.
      ,
      • Turner J.
      • et al.
      The ENHANCES study: a randomised controlled trial of a nurse-led survivorship intervention for patients treated for head and neck cancer.
      ] and 2 three-arm RCT [
      • Turner J.
      • et al.
      The ENHANCES study: a randomised controlled trial of a nurse-led survivorship intervention for patients treated for head and neck cancer.
      ,
      • Thomas M.L.
      • et al.
      A randomized, clinical trial of education or motivational-interviewing-based coaching compared to usual care to improve cancer pain management.
      ], one quasi-experimental [
      • Coolbrandt A.
      • et al.
      A nursing intervention for reducing symptom burden during chemotherapy.
      ] and one non-randomised controlled study [
      • Frawley H.C.
      • et al.
      An allied health rehabilitation program for patients following surgery for abdomino-pelvic cancer: a feasibility and pilot clinical study.
      ]. The 21 included studies had 4154 participants (1752 intervention and 2402 control or non-MI intervention) with a mean age range from 43.7 to 67.1 years of age.

      3.3.1 Demographic characteristics of participants

      There were several cancer types that constituted the participant population with eight studies in mixed cancer [
      • Bennett J.A.
      • et al.
      Motivational interviewing to increase physical activity in long-term cancer survivors: a randomized controlled trial.
      ,
      • Çakmak H.S.G.
      • Kapucu S.
      The effect of educational follow-up with the motivational interview technique on self-efficacy and drug adherence in cancer patients using oral chemotherapy treatment: a randomized controlled trial.
      ,
      • Dennett A.M.
      • et al.
      Motivational interviewing added to oncology rehabilitation did not improve moderate-intensity physical activity in cancer survivors: a randomised trial.
      ,
      • Pollak K.I.
      • et al.
      A smoking cessation and pain management program for cancer survivors.
      ,
      • Ream E.
      • et al.
      Management of cancer-related fatigue during chemotherapy through telephone motivational interviewing: modeling and randomized exploratory trial.
      ,
      • Tsianakas V.
      • et al.
      CanWalk: a feasibility study with embedded randomised controlled trial pilot of a walking intervention for people with recurrent or metastatic cancer.
      ,
      • Thomas M.L.
      • et al.
      A randomized, clinical trial of education or motivational-interviewing-based coaching compared to usual care to improve cancer pain management.
      ,
      • Coolbrandt A.
      • et al.
      A nursing intervention for reducing symptom burden during chemotherapy.
      ], nine in breast cancer [
      • Djuric Z.
      • et al.
      A diet and exercise intervention during chemotherapy for breast cancer.
      ,
      • Hartman S.J.
      • et al.
      Randomized controlled trial of increasing physical activity on objectively measured and self-reported cognitive functioning among breast cancer survivors: the memory & motion study.
      ,
      • Hoy M.K.
      • et al.
      Implementing a low-fat eating plan in the women's intervention nutrition study.
      ,
      • Kvale E.A.
      • et al.
      Patient-centered support in the survivorship care transition: outcomes from the patient-owned survivorship care plan intervention.
      ,
      • Lahart I.M.
      • et al.
      The effects of a home-based physical activity intervention on cardiorespiratory fitness in breast cancer survivors; a randomised controlled trial.
      ,
      • Sheppard V.B.
      • et al.
      The feasibility and acceptability of a diet and exercise trial in overweight and obese black breast cancer survivors: the stepping STONE study.
      ,
      • Vallance J.K.
      • et al.
      Effects of the ACTIVity And TEchnology (ACTIVATE) intervention on health-related quality of life and fatigue outcomes in breast cancer survivors.
      ,
      • Zangeneh F.
      • et al.
      The effect of motivational interviewing-based counseling on women's sexual satisfaction and body image.
      ,
      • Zuniga K.E.
      • et al.
      Dietary intervention among breast cancer survivors increased adherence to a Mediterranean-style, anti-inflammatory dietary pattern: the Rx for better breast health randomized controlled trial.
      ], one study in each of abdomino-pelvic [
      • Frawley H.C.
      • et al.
      An allied health rehabilitation program for patients following surgery for abdomino-pelvic cancer: a feasibility and pilot clinical study.
      ], head and neck [
      • Turner J.
      • et al.
      The ENHANCES study: a randomised controlled trial of a nurse-led survivorship intervention for patients treated for head and neck cancer.
      ], lung [
      • Huang F.F.
      • et al.
      A self-efficacy enhancing intervention for pulmonary rehabilitation based on motivational interviewing for postoperative lung cancers patients: modeling and randomized exploratory trial.
      ] and colorectal cancer [
      • Yang S.-Y.
      • Wang J.-D.
      • Chang J.-H.
      Occupational therapy to improve quality of life for colorectal cancer survivors: a randomized clinical trial.
      ] populations. The point within the cancer continuum that participants were at varied with the meantime since the end of treatment or diagnosis being: one year or more in eight studies, between ten weeks and one year in five studies, between hospital discharge and one month in four studies, during the active phase of treatment in three studies and during pre-treatment phase in one study.

      3.4 Intervention characteristics

      The focus of the MI differed across the 21 included studies. Five studies used a MI intervention that was aimed at increasing or achievement of recommended PA levels [
      • Bennett J.A.
      • et al.
      Motivational interviewing to increase physical activity in long-term cancer survivors: a randomized controlled trial.
      ,
      • Dennett A.M.
      • et al.
      Motivational interviewing added to oncology rehabilitation did not improve moderate-intensity physical activity in cancer survivors: a randomised trial.
      ,
      • Hartman S.J.
      • et al.
      Randomized controlled trial of increasing physical activity on objectively measured and self-reported cognitive functioning among breast cancer survivors: the memory & motion study.
      ,
      • Tsianakas V.
      • et al.
      CanWalk: a feasibility study with embedded randomised controlled trial pilot of a walking intervention for people with recurrent or metastatic cancer.
      ,
      • Vallance J.K.
      • et al.
      Effects of the ACTIVity And TEchnology (ACTIVATE) intervention on health-related quality of life and fatigue outcomes in breast cancer survivors.
      ]. Four studies focused at improving general health behaviour (diet and PA) and symptom management combined [
      • Kvale E.A.
      • et al.
      Patient-centered support in the survivorship care transition: outcomes from the patient-owned survivorship care plan intervention.
      ,
      • Sheppard V.B.
      • et al.
      The feasibility and acceptability of a diet and exercise trial in overweight and obese black breast cancer survivors: the stepping STONE study.
      ,
      • Frawley H.C.
      • et al.
      An allied health rehabilitation program for patients following surgery for abdomino-pelvic cancer: a feasibility and pilot clinical study.
      ,
      • Yang S.-Y.
      • Wang J.-D.
      • Chang J.-H.
      Occupational therapy to improve quality of life for colorectal cancer survivors: a randomized clinical trial.
      ], whilst three studies used MI targeting general health behaviour (diet and PA), symptom management and self-efficacy combined [
      • Huang F.F.
      • et al.
      A self-efficacy enhancing intervention for pulmonary rehabilitation based on motivational interviewing for postoperative lung cancers patients: modeling and randomized exploratory trial.
      ,
      • Turner J.
      • et al.
      The ENHANCES study: a randomised controlled trial of a nurse-led survivorship intervention for patients treated for head and neck cancer.
      ,
      • Coolbrandt A.
      • et al.
      A nursing intervention for reducing symptom burden during chemotherapy.
      ]. Only one study aimed at improving only general health behaviour (diet and PA) [
      • Lahart I.M.
      • et al.
      The effects of a home-based physical activity intervention on cardiorespiratory fitness in breast cancer survivors; a randomised controlled trial.
      ]. Two studies focused on symptom management only; one primarily aimed at improving fatigue [
      • Ream E.
      • et al.
      Management of cancer-related fatigue during chemotherapy through telephone motivational interviewing: modeling and randomized exploratory trial.
      ] and one aimed at pain [
      • Thomas M.L.
      • et al.
      A randomized, clinical trial of education or motivational-interviewing-based coaching compared to usual care to improve cancer pain management.
      ]. Adherence to dietary goals was the focus in three studies [
      • Djuric Z.
      • et al.
      A diet and exercise intervention during chemotherapy for breast cancer.
      ,
      • Hoy M.K.
      • et al.
      Implementing a low-fat eating plan in the women's intervention nutrition study.
      ,
      • Zuniga K.E.
      • et al.
      Dietary intervention among breast cancer survivors increased adherence to a Mediterranean-style, anti-inflammatory dietary pattern: the Rx for better breast health randomized controlled trial.
      ] and adherence to oral medication was the focus in one study [
      • Çakmak H.S.G.
      • Kapucu S.
      The effect of educational follow-up with the motivational interview technique on self-efficacy and drug adherence in cancer patients using oral chemotherapy treatment: a randomized controlled trial.
      ]. One study aimed their MI at improving smoking cessation and pain management [
      • Pollak K.I.
      • et al.
      A smoking cessation and pain management program for cancer survivors.
      ] and one study used MI that was targeting improving sexual behaviour and body image [
      • Zangeneh F.
      • et al.
      The effect of motivational interviewing-based counseling on women's sexual satisfaction and body image.
      ].
      Five studies delivered the MI in-person [
      • Kvale E.A.
      • et al.
      Patient-centered support in the survivorship care transition: outcomes from the patient-owned survivorship care plan intervention.
      ,
      • Tsianakas V.
      • et al.
      CanWalk: a feasibility study with embedded randomised controlled trial pilot of a walking intervention for people with recurrent or metastatic cancer.
      ,
      • Zangeneh F.
      • et al.
      The effect of motivational interviewing-based counseling on women's sexual satisfaction and body image.
      ,
      • Turner J.
      • et al.
      The ENHANCES study: a randomised controlled trial of a nurse-led survivorship intervention for patients treated for head and neck cancer.
      ,
      • Yang S.-Y.
      • Wang J.-D.
      • Chang J.-H.
      Occupational therapy to improve quality of life for colorectal cancer survivors: a randomized clinical trial.
      ], six were over the phone [
      • Dennett A.M.
      • et al.
      Motivational interviewing added to oncology rehabilitation did not improve moderate-intensity physical activity in cancer survivors: a randomised trial.
      ,
      • Djuric Z.
      • et al.
      A diet and exercise intervention during chemotherapy for breast cancer.
      ,
      • Pollak K.I.
      • et al.
      A smoking cessation and pain management program for cancer survivors.
      ,
      • Ream E.
      • et al.
      Management of cancer-related fatigue during chemotherapy through telephone motivational interviewing: modeling and randomized exploratory trial.
      ,
      • Zuniga K.E.
      • et al.
      Dietary intervention among breast cancer survivors increased adherence to a Mediterranean-style, anti-inflammatory dietary pattern: the Rx for better breast health randomized controlled trial.
      ,
      • Thomas M.L.
      • et al.
      A randomized, clinical trial of education or motivational-interviewing-based coaching compared to usual care to improve cancer pain management.
      ] and ten were a combination of both in-person and over the phone [
      • Bennett J.A.
      • et al.
      Motivational interviewing to increase physical activity in long-term cancer survivors: a randomized controlled trial.
      ,
      • Çakmak H.S.G.
      • Kapucu S.
      The effect of educational follow-up with the motivational interview technique on self-efficacy and drug adherence in cancer patients using oral chemotherapy treatment: a randomized controlled trial.
      ,
      • Hartman S.J.
      • et al.
      Randomized controlled trial of increasing physical activity on objectively measured and self-reported cognitive functioning among breast cancer survivors: the memory & motion study.
      ,
      • Hoy M.K.
      • et al.
      Implementing a low-fat eating plan in the women's intervention nutrition study.
      ,
      • Huang F.F.
      • et al.
      A self-efficacy enhancing intervention for pulmonary rehabilitation based on motivational interviewing for postoperative lung cancers patients: modeling and randomized exploratory trial.
      ,
      • Lahart I.M.
      • et al.
      The effects of a home-based physical activity intervention on cardiorespiratory fitness in breast cancer survivors; a randomised controlled trial.
      ,
      • Sheppard V.B.
      • et al.
      The feasibility and acceptability of a diet and exercise trial in overweight and obese black breast cancer survivors: the stepping STONE study.
      ,
      • Vallance J.K.
      • et al.
      Effects of the ACTIVity And TEchnology (ACTIVATE) intervention on health-related quality of life and fatigue outcomes in breast cancer survivors.
      ,
      • Coolbrandt A.
      • et al.
      A nursing intervention for reducing symptom burden during chemotherapy.
      ,
      • Frawley H.C.
      • et al.
      An allied health rehabilitation program for patients following surgery for abdomino-pelvic cancer: a feasibility and pilot clinical study.
      ]. There was great heterogeneity between the number, duration and frequency of MI sessions ranging from 1 to 32 sessions, 10 to 75 min in duration and between a few days to 6 months apart.
      Many studies utilised other components (in addition to MI) within their intervention such as; pedometers [
      • Bennett J.A.
      • et al.
      Motivational interviewing to increase physical activity in long-term cancer survivors: a randomized controlled trial.
      ,
      • Djuric Z.
      • et al.
      A diet and exercise intervention during chemotherapy for breast cancer.
      ,
      • Hartman S.J.
      • et al.
      Randomized controlled trial of increasing physical activity on objectively measured and self-reported cognitive functioning among breast cancer survivors: the memory & motion study.
      ,
      • Sheppard V.B.
      • et al.
      The feasibility and acceptability of a diet and exercise trial in overweight and obese black breast cancer survivors: the stepping STONE study.
      ,
      • Vallance J.K.
      • et al.
      Effects of the ACTIVity And TEchnology (ACTIVATE) intervention on health-related quality of life and fatigue outcomes in breast cancer survivors.
      ,
      • Frawley H.C.
      • et al.
      An allied health rehabilitation program for patients following surgery for abdomino-pelvic cancer: a feasibility and pilot clinical study.
      ], supervised PA sessions [
      • Dennett A.M.
      • et al.
      Motivational interviewing added to oncology rehabilitation did not improve moderate-intensity physical activity in cancer survivors: a randomised trial.
      ,
      • Sheppard V.B.
      • et al.
      The feasibility and acceptability of a diet and exercise trial in overweight and obese black breast cancer survivors: the stepping STONE study.
      ], group education sessions [
      • Dennett A.M.
      • et al.
      Motivational interviewing added to oncology rehabilitation did not improve moderate-intensity physical activity in cancer survivors: a randomised trial.
      ,
      • Sheppard V.B.
      • et al.
      The feasibility and acceptability of a diet and exercise trial in overweight and obese black breast cancer survivors: the stepping STONE study.
      ,
      • Zuniga K.E.
      • et al.
      Dietary intervention among breast cancer survivors increased adherence to a Mediterranean-style, anti-inflammatory dietary pattern: the Rx for better breast health randomized controlled trial.
      ], workbook or diary [
      • Dennett A.M.
      • et al.
      Motivational interviewing added to oncology rehabilitation did not improve moderate-intensity physical activity in cancer survivors: a randomised trial.
      ,
      • Lahart I.M.
      • et al.
      The effects of a home-based physical activity intervention on cardiorespiratory fitness in breast cancer survivors; a randomised controlled trial.
      ,
      • Pollak K.I.
      • et al.
      A smoking cessation and pain management program for cancer survivors.
      ,
      • Ream E.
      • et al.
      Management of cancer-related fatigue during chemotherapy through telephone motivational interviewing: modeling and randomized exploratory trial.
      ,
      • Sheppard V.B.
      • et al.
      The feasibility and acceptability of a diet and exercise trial in overweight and obese black breast cancer survivors: the stepping STONE study.
      ,
      • Zuniga K.E.
      • et al.
      Dietary intervention among breast cancer survivors increased adherence to a Mediterranean-style, anti-inflammatory dietary pattern: the Rx for better breast health randomized controlled trial.
      ,
      • Frawley H.C.
      • et al.
      An allied health rehabilitation program for patients following surgery for abdomino-pelvic cancer: a feasibility and pilot clinical study.
      ] and information booklets [
      • Çakmak H.S.G.
      • Kapucu S.
      The effect of educational follow-up with the motivational interview technique on self-efficacy and drug adherence in cancer patients using oral chemotherapy treatment: a randomized controlled trial.
      ,
      • Djuric Z.
      • et al.
      A diet and exercise intervention during chemotherapy for breast cancer.
      ,
      • Hartman S.J.
      • et al.
      Randomized controlled trial of increasing physical activity on objectively measured and self-reported cognitive functioning among breast cancer survivors: the memory & motion study.
      ,
      • Hoy M.K.
      • et al.
      Implementing a low-fat eating plan in the women's intervention nutrition study.
      ,
      • Huang F.F.
      • et al.
      A self-efficacy enhancing intervention for pulmonary rehabilitation based on motivational interviewing for postoperative lung cancers patients: modeling and randomized exploratory trial.
      ,
      • Lahart I.M.
      • et al.
      The effects of a home-based physical activity intervention on cardiorespiratory fitness in breast cancer survivors; a randomised controlled trial.
      ,
      • Pollak K.I.
      • et al.
      A smoking cessation and pain management program for cancer survivors.
      ,
      • Ream E.
      • et al.
      Management of cancer-related fatigue during chemotherapy through telephone motivational interviewing: modeling and randomized exploratory trial.
      ,
      • Sheppard V.B.
      • et al.
      The feasibility and acceptability of a diet and exercise trial in overweight and obese black breast cancer survivors: the stepping STONE study.
      ,
      • Tsianakas V.
      • et al.
      CanWalk: a feasibility study with embedded randomised controlled trial pilot of a walking intervention for people with recurrent or metastatic cancer.
      ,
      • Zangeneh F.
      • et al.
      The effect of motivational interviewing-based counseling on women's sexual satisfaction and body image.
      ,
      • Thomas M.L.
      • et al.
      A randomized, clinical trial of education or motivational-interviewing-based coaching compared to usual care to improve cancer pain management.
      ,
      • Coolbrandt A.
      • et al.
      A nursing intervention for reducing symptom burden during chemotherapy.
      ,
      • Frawley H.C.
      • et al.
      An allied health rehabilitation program for patients following surgery for abdomino-pelvic cancer: a feasibility and pilot clinical study.
      ,
      • Yang S.-Y.
      • Wang J.-D.
      • Chang J.-H.
      Occupational therapy to improve quality of life for colorectal cancer survivors: a randomized clinical trial.
      ]. Nine studies contained methods that were taken to ensure fidelity of the MI intervention [
      • Dennett A.M.
      • et al.
      Motivational interviewing added to oncology rehabilitation did not improve moderate-intensity physical activity in cancer survivors: a randomised trial.
      ,
      • Djuric Z.
      • et al.
      A diet and exercise intervention during chemotherapy for breast cancer.
      ,
      • Hoy M.K.
      • et al.
      Implementing a low-fat eating plan in the women's intervention nutrition study.
      ,
      • Huang F.F.
      • et al.
      A self-efficacy enhancing intervention for pulmonary rehabilitation based on motivational interviewing for postoperative lung cancers patients: modeling and randomized exploratory trial.
      ,
      • Kvale E.A.
      • et al.
      Patient-centered support in the survivorship care transition: outcomes from the patient-owned survivorship care plan intervention.
      ,
      • Ream E.
      • et al.
      Management of cancer-related fatigue during chemotherapy through telephone motivational interviewing: modeling and randomized exploratory trial.
      ,
      • Tsianakas V.
      • et al.
      CanWalk: a feasibility study with embedded randomised controlled trial pilot of a walking intervention for people with recurrent or metastatic cancer.
      ,
      • Thomas M.L.
      • et al.
      A randomized, clinical trial of education or motivational-interviewing-based coaching compared to usual care to improve cancer pain management.
      ,
      • Coolbrandt A.
      • et al.
      A nursing intervention for reducing symptom burden during chemotherapy.
      ].

      3.5 Outcomes

      All studies measured at least one outcome with a mixture of both health behaviour and health outcomes. Nine studies measured PA behaviour [
      • Bennett J.A.
      • et al.
      Motivational interviewing to increase physical activity in long-term cancer survivors: a randomized controlled trial.
      ,
      • Dennett A.M.
      • et al.
      Motivational interviewing added to oncology rehabilitation did not improve moderate-intensity physical activity in cancer survivors: a randomised trial.
      ,
      • Djuric Z.
      • et al.
      A diet and exercise intervention during chemotherapy for breast cancer.
      ,
      • Hartman S.J.
      • et al.
      Randomized controlled trial of increasing physical activity on objectively measured and self-reported cognitive functioning among breast cancer survivors: the memory & motion study.
      ,
      • Lahart I.M.
      • et al.
      The effects of a home-based physical activity intervention on cardiorespiratory fitness in breast cancer survivors; a randomised controlled trial.
      ,
      • Sheppard V.B.
      • et al.
      The feasibility and acceptability of a diet and exercise trial in overweight and obese black breast cancer survivors: the stepping STONE study.
      ,
      • Tsianakas V.
      • et al.
      CanWalk: a feasibility study with embedded randomised controlled trial pilot of a walking intervention for people with recurrent or metastatic cancer.
      ,
      • Vallance J.K.
      • et al.
      Effects of the ACTIVity And TEchnology (ACTIVATE) intervention on health-related quality of life and fatigue outcomes in breast cancer survivors.
      ,
      • Frawley H.C.
      • et al.
      An allied health rehabilitation program for patients following surgery for abdomino-pelvic cancer: a feasibility and pilot clinical study.
      ], four assessed dietary behaviour [
      • Djuric Z.
      • et al.
      A diet and exercise intervention during chemotherapy for breast cancer.
      ,
      • Hoy M.K.
      • et al.
      Implementing a low-fat eating plan in the women's intervention nutrition study.
      ,
      • Sheppard V.B.
      • et al.
      The feasibility and acceptability of a diet and exercise trial in overweight and obese black breast cancer survivors: the stepping STONE study.
      ,
      • Zuniga K.E.
      • et al.
      Dietary intervention among breast cancer survivors increased adherence to a Mediterranean-style, anti-inflammatory dietary pattern: the Rx for better breast health randomized controlled trial.
      ], one measured adherence to oral medication [
      • Çakmak H.S.G.
      • Kapucu S.
      The effect of educational follow-up with the motivational interview technique on self-efficacy and drug adherence in cancer patients using oral chemotherapy treatment: a randomized controlled trial.
      ], and one measured smoking cessation [
      • Pollak K.I.
      • et al.
      A smoking cessation and pain management program for cancer survivors.
      ]. Many studies measured specific health outcomes such as: QoL [
      • Bennett J.A.
      • et al.
      Motivational interviewing to increase physical activity in long-term cancer survivors: a randomized controlled trial.
      ,
      • Dennett A.M.
      • et al.
      Motivational interviewing added to oncology rehabilitation did not improve moderate-intensity physical activity in cancer survivors: a randomised trial.
      ,
      • Djuric Z.
      • et al.
      A diet and exercise intervention during chemotherapy for breast cancer.
      ,
      • Huang F.F.
      • et al.
      A self-efficacy enhancing intervention for pulmonary rehabilitation based on motivational interviewing for postoperative lung cancers patients: modeling and randomized exploratory trial.
      ,
      • Kvale E.A.
      • et al.
      Patient-centered support in the survivorship care transition: outcomes from the patient-owned survivorship care plan intervention.
      ,
      • Pollak K.I.
      • et al.
      A smoking cessation and pain management program for cancer survivors.
      ,
      • Vallance J.K.
      • et al.
      Effects of the ACTIVity And TEchnology (ACTIVATE) intervention on health-related quality of life and fatigue outcomes in breast cancer survivors.
      ,
      • Turner J.
      • et al.
      The ENHANCES study: a randomised controlled trial of a nurse-led survivorship intervention for patients treated for head and neck cancer.
      ,
      • Thomas M.L.
      • et al.
      A randomized, clinical trial of education or motivational-interviewing-based coaching compared to usual care to improve cancer pain management.
      ,
      • Frawley H.C.
      • et al.
      An allied health rehabilitation program for patients following surgery for abdomino-pelvic cancer: a feasibility and pilot clinical study.
      ,
      • Yang S.-Y.
      • Wang J.-D.
      • Chang J.-H.
      Occupational therapy to improve quality of life for colorectal cancer survivors: a randomized clinical trial.
      ], fatigue [
      • Bennett J.A.
      • et al.
      Motivational interviewing to increase physical activity in long-term cancer survivors: a randomized controlled trial.
      ,
      • Dennett A.M.
      • et al.
      Motivational interviewing added to oncology rehabilitation did not improve moderate-intensity physical activity in cancer survivors: a randomised trial.
      ,
      • Ream E.
      • et al.
      Management of cancer-related fatigue during chemotherapy through telephone motivational interviewing: modeling and randomized exploratory trial.
      ,
      • Tsianakas V.
      • et al.
      CanWalk: a feasibility study with embedded randomised controlled trial pilot of a walking intervention for people with recurrent or metastatic cancer.
      ,
      • Vallance J.K.
      • et al.
      Effects of the ACTIVity And TEchnology (ACTIVATE) intervention on health-related quality of life and fatigue outcomes in breast cancer survivors.
      ], anthropometric measures [
      • Djuric Z.
      • et al.
      A diet and exercise intervention during chemotherapy for breast cancer.
      ,
      • Hartman S.J.
      • et al.
      Randomized controlled trial of increasing physical activity on objectively measured and self-reported cognitive functioning among breast cancer survivors: the memory & motion study.
      ,
      • Lahart I.M.
      • et al.
      The effects of a home-based physical activity intervention on cardiorespiratory fitness in breast cancer survivors; a randomised controlled trial.
      ,
      • Sheppard V.B.
      • et al.
      The feasibility and acceptability of a diet and exercise trial in overweight and obese black breast cancer survivors: the stepping STONE study.
      ], functional and fitness measures [
      • Bennett J.A.
      • et al.
      Motivational interviewing to increase physical activity in long-term cancer survivors: a randomized controlled trial.
      ,
      • Dennett A.M.
      • et al.
      Motivational interviewing added to oncology rehabilitation did not improve moderate-intensity physical activity in cancer survivors: a randomised trial.
      ,
      • Hartman S.J.
      • et al.
      Randomized controlled trial of increasing physical activity on objectively measured and self-reported cognitive functioning among breast cancer survivors: the memory & motion study.
      ,
      • Huang F.F.
      • et al.
      A self-efficacy enhancing intervention for pulmonary rehabilitation based on motivational interviewing for postoperative lung cancers patients: modeling and randomized exploratory trial.
      ,
      • Lahart I.M.
      • et al.
      The effects of a home-based physical activity intervention on cardiorespiratory fitness in breast cancer survivors; a randomised controlled trial.
      ,
      • Thomas M.L.
      • et al.
      A randomized, clinical trial of education or motivational-interviewing-based coaching compared to usual care to improve cancer pain management.
      ,
      • Frawley H.C.
      • et al.
      An allied health rehabilitation program for patients following surgery for abdomino-pelvic cancer: a feasibility and pilot clinical study.
      ,
      • Yang S.-Y.
      • Wang J.-D.
      • Chang J.-H.
      Occupational therapy to improve quality of life for colorectal cancer survivors: a randomized clinical trial.
      ] and mental health [
      • Dennett A.M.
      • et al.
      Motivational interviewing added to oncology rehabilitation did not improve moderate-intensity physical activity in cancer survivors: a randomised trial.
      ,
      • Huang F.F.
      • et al.
      A self-efficacy enhancing intervention for pulmonary rehabilitation based on motivational interviewing for postoperative lung cancers patients: modeling and randomized exploratory trial.
      ,
      • Kvale E.A.
      • et al.
      Patient-centered support in the survivorship care transition: outcomes from the patient-owned survivorship care plan intervention.
      ,
      • Pollak K.I.
      • et al.
      A smoking cessation and pain management program for cancer survivors.
      ,
      • Ream E.
      • et al.
      Management of cancer-related fatigue during chemotherapy through telephone motivational interviewing: modeling and randomized exploratory trial.
      ,
      • Tsianakas V.
      • et al.
      CanWalk: a feasibility study with embedded randomised controlled trial pilot of a walking intervention for people with recurrent or metastatic cancer.
      ,
      • Turner J.
      • et al.
      The ENHANCES study: a randomised controlled trial of a nurse-led survivorship intervention for patients treated for head and neck cancer.
      ,
      • Frawley H.C.
      • et al.
      An allied health rehabilitation program for patients following surgery for abdomino-pelvic cancer: a feasibility and pilot clinical study.
      ,
      • Yang S.-Y.
      • Wang J.-D.
      • Chang J.-H.
      Occupational therapy to improve quality of life for colorectal cancer survivors: a randomized clinical trial.
      ]. Finally, self-efficacy was investigated in eleven studies [
      • Bennett J.A.
      • et al.
      Motivational interviewing to increase physical activity in long-term cancer survivors: a randomized controlled trial.
      ,
      • Çakmak H.S.G.
      • Kapucu S.
      The effect of educational follow-up with the motivational interview technique on self-efficacy and drug adherence in cancer patients using oral chemotherapy treatment: a randomized controlled trial.
      ,
      • Dennett A.M.
      • et al.
      Motivational interviewing added to oncology rehabilitation did not improve moderate-intensity physical activity in cancer survivors: a randomised trial.
      ,
      • Huang F.F.
      • et al.
      A self-efficacy enhancing intervention for pulmonary rehabilitation based on motivational interviewing for postoperative lung cancers patients: modeling and randomized exploratory trial.
      ,
      • Kvale E.A.
      • et al.
      Patient-centered support in the survivorship care transition: outcomes from the patient-owned survivorship care plan intervention.
      ,
      • Ream E.
      • et al.
      Management of cancer-related fatigue during chemotherapy through telephone motivational interviewing: modeling and randomized exploratory trial.
      ,
      • Sheppard V.B.
      • et al.
      The feasibility and acceptability of a diet and exercise trial in overweight and obese black breast cancer survivors: the stepping STONE study.
      ,
      • Tsianakas V.
      • et al.
      CanWalk: a feasibility study with embedded randomised controlled trial pilot of a walking intervention for people with recurrent or metastatic cancer.
      ,
      • Turner J.
      • et al.
      The ENHANCES study: a randomised controlled trial of a nurse-led survivorship intervention for patients treated for head and neck cancer.
      ,
      • Coolbrandt A.
      • et al.
      A nursing intervention for reducing symptom burden during chemotherapy.
      ,
      • Frawley H.C.
      • et al.
      An allied health rehabilitation program for patients following surgery for abdomino-pelvic cancer: a feasibility and pilot clinical study.
      ].

      3.6 Risk of bias within the studies

      The randomisation (or lack thereof) and concealment of allocation into groups were reported by most studies. Due to the inherent nature of the intervention being delivered by personnel, all studies were deemed ‘high risk’ in the criteria of performance bias or ‘serious risk’ in the criteria of bias due to deviations from intended interventions. However, with regards to the reporting of blinding of assessors to the participant allocation (bias in measurement of outcomes in the ROBINS-I tool), two clearly stated the assessors were not blinded [
      • Zangeneh F.
      • et al.
      The effect of motivational interviewing-based counseling on women's sexual satisfaction and body image.
      ,
      • Yang S.-Y.
      • Wang J.-D.
      • Chang J.-H.
      Occupational therapy to improve quality of life for colorectal cancer survivors: a randomized clinical trial.
      ] and 11 studies didn't report if the assessors were different to those delivering the intervention, and were therefore deemed either ‘unclear risk’ or ‘no information’ for that criteria. The reporting on management of missing data was poor with more than half either not reported [
      • Djuric Z.
      • et al.
      A diet and exercise intervention during chemotherapy for breast cancer.
      ,
      • Hoy M.K.
      • et al.
      Implementing a low-fat eating plan in the women's intervention nutrition study.
      ,
      • Huang F.F.
      • et al.
      A self-efficacy enhancing intervention for pulmonary rehabilitation based on motivational interviewing for postoperative lung cancers patients: modeling and randomized exploratory trial.
      ,
      • Kvale E.A.
      • et al.
      Patient-centered support in the survivorship care transition: outcomes from the patient-owned survivorship care plan intervention.
      ,
      • Sheppard V.B.
      • et al.
      The feasibility and acceptability of a diet and exercise trial in overweight and obese black breast cancer survivors: the stepping STONE study.
      ,
      • Tsianakas V.
      • et al.
      CanWalk: a feasibility study with embedded randomised controlled trial pilot of a walking intervention for people with recurrent or metastatic cancer.
      ,
      • Vallance J.K.
      • et al.
      Effects of the ACTIVity And TEchnology (ACTIVATE) intervention on health-related quality of life and fatigue outcomes in breast cancer survivors.
      ,
      • Zangeneh F.
      • et al.
      The effect of motivational interviewing-based counseling on women's sexual satisfaction and body image.
      ,
      • Turner J.
      • et al.
      The ENHANCES study: a randomised controlled trial of a nurse-led survivorship intervention for patients treated for head and neck cancer.
      ] or showing missing data in the outcomes, without outlining accommodation methods [
      • Çakmak H.S.G.
      • Kapucu S.
      The effect of educational follow-up with the motivational interview technique on self-efficacy and drug adherence in cancer patients using oral chemotherapy treatment: a randomized controlled trial.
      ,
      • Ream E.
      • et al.
      Management of cancer-related fatigue during chemotherapy through telephone motivational interviewing: modeling and randomized exploratory trial.
      ,
      • Frawley H.C.
      • et al.
      An allied health rehabilitation program for patients following surgery for abdomino-pelvic cancer: a feasibility and pilot clinical study.
      ], thus deemed ‘unclear risk’ or ‘no information’ by the reviewers. One study was deemed high risk as the authors made the assumption that surveys non-responders were ongoing smokers (in a study assessing smoking cessation rates) [
      • Pollak K.I.
      • et al.
      A smoking cessation and pain management program for cancer survivors.
      ]. Another study was deemed high risk for reporting bias where not all domains within the QoL outcome were reported [
      • Thomas M.L.
      • et al.
      A randomized, clinical trial of education or motivational-interviewing-based coaching compared to usual care to improve cancer pain management.
      ]. Finally, seven studies were deemed high risk of ‘other’ bias (or serious risk in bias in selection of the reported result in the ROBINS-I tool) which included: possible between group contamination during an outcome assessment [
      • Bennett J.A.
      • et al.
      Motivational interviewing to increase physical activity in long-term cancer survivors: a randomized controlled trial.
      ,
      • Tsianakas V.
      • et al.
      CanWalk: a feasibility study with embedded randomised controlled trial pilot of a walking intervention for people with recurrent or metastatic cancer.
      ], contamination between groups during intervention delivery of the exercise component (which both groups received) [
      • Dennett A.M.
      • et al.
      Motivational interviewing added to oncology rehabilitation did not improve moderate-intensity physical activity in cancer survivors: a randomised trial.
      ], bias in reporting due to self-reported outcome measures that could otherwise be measured with objective methods, such as PA and medication adherence or smoking cessation [
      • Bennett J.A.
      • et al.
      Motivational interviewing to increase physical activity in long-term cancer survivors: a randomized controlled trial.
      ,
      • Çakmak H.S.G.
      • Kapucu S.
      The effect of educational follow-up with the motivational interview technique on self-efficacy and drug adherence in cancer patients using oral chemotherapy treatment: a randomized controlled trial.
      ,
      • Djuric Z.
      • et al.
      A diet and exercise intervention during chemotherapy for breast cancer.
      ,
      • Lahart I.M.
      • et al.
      The effects of a home-based physical activity intervention on cardiorespiratory fitness in breast cancer survivors; a randomised controlled trial.
      ,
      • Pollak K.I.
      • et al.
      A smoking cessation and pain management program for cancer survivors.
      ,
      • Sheppard V.B.
      • et al.
      The feasibility and acceptability of a diet and exercise trial in overweight and obese black breast cancer survivors: the stepping STONE study.
      ,
      • Tsianakas V.
      • et al.
      CanWalk: a feasibility study with embedded randomised controlled trial pilot of a walking intervention for people with recurrent or metastatic cancer.
      ,
      • Frawley H.C.
      • et al.
      An allied health rehabilitation program for patients following surgery for abdomino-pelvic cancer: a feasibility and pilot clinical study.
      ], control groups which were ‘wait-list’ rather than pure controls as stated [
      • Pollak K.I.
      • et al.
      A smoking cessation and pain management program for cancer survivors.
      ], non-assessment of components of physical and mental health [
      • Vallance J.K.
      • et al.
      Effects of the ACTIVity And TEchnology (ACTIVATE) intervention on health-related quality of life and fatigue outcomes in breast cancer survivors.
      ] or subject expectancy (with respect to group allocation) [
      • Yang S.-Y.
      • Wang J.-D.
      • Chang J.-H.
      Occupational therapy to improve quality of life for colorectal cancer survivors: a randomized clinical trial.
      ]. The risk of bias using the RoB 5.1.0 tool is summarised in Fig. 2 and using the ROBINS-I tool in Table 2.
      Fig. 2
      Fig. 2The risk of bias assessment of randomised controlled studies using the RoB 5.1.0 tool summary.
      Table 2The risk of bias assessment of included studies using the ROBINS-I tool summary.
      Table thumbnail fx1

      3.7 Synthesis of results

      3.7.1 Quality of life

      When investigating the impact of MI on QoL outcomes, using the data from eight studies (with ten comparisons), there was no effect of MI on QoL compared to control groups (Fig. 3: SMD 0.09; 95 % confidence interval (CI) -0.05 to 0.23, p = 0.22, I2 = 69 %, n = 789). The studies in this outcome were downgraded to low-quality due to risk of bias and inconsistency (Table 3).
      Fig. 3
      Fig. 3Forest plot of the effects of MI on QoL.
      Table 3Quality of evidence classification.
      OutcomeRisk of biasInconsistencyIndirectnessImprecisionPublication biasOverall quality
      Quality of lifeYesYesNoNoNoLow
      AnxietyYesNoNoNoNoModerate
      DepressionYesYesYesNoNoVery low
      Functional tasksYesYesNoYesNoVery low
      Body mass index and body weightYesNoNoNoNoModerate
      Physical activity - TotalYesNoNoNoNoModerate
      Physical activity - Step countYesNoNoNoNoModerate
      Physical activity - overallYesNoNoNoNoModerate
      Self-efficacyYesYesYesNoNoVery low
      FatigueYesYesYesNoNoVery low

      3.7.2 Anxiety

      There was no effect of MI on levels of anxiety, using the data from five studies (with six comparisons), compared to control groups (Fig. 4: SMD 0.09; 95 % CI -0.12 to 0.29, p = 0.23, I2 = 28 %, n = 365). The five studies within this outcome were downgraded to a moderate quality of evidence due to risk of bias (Table 3).
      Fig. 4
      Fig. 4Forest plot of the effects of MI on anxiety.

      3.7.3 Depression

      There was a moderate effect of MI on levels of depression compared to control groups using the data from seven studies (with eight comparisons) (Fig. 5: SMD 0.38; 95 % CI 0.20 to 0.56, p < 0.0001, I2 = 72 %, n = 502). The studies in this outcome were downgraded to very low-quality due to risk of bias, inconsistency and indirectness (Table 3).
      Fig. 5
      Fig. 5Forest plot of the effects of MI on depression.

      3.7.4 Functional tasks

      There was a large effect of MI on functional task (6 minute walk test) outcomes compared to control groups using the data from three studies (Fig. 6: MD 50.24; 95 % CI 22.04 to 78.44, p = 0.0005, I2 = 83 %, n = 111). The studies in this outcome were downgraded to very low-quality due to risk of bias, inconsistency and imprecision (Table 3).
      Fig. 6
      Fig. 6Forest plot of the effects of MI on functional tasks.

      3.7.5 Body mass index and body weight

      MI had a moderate effect on BMI and body weight outcomes compared to control groups using the data from six studies (with seven comparisons) (Fig. 7: SMD 0.25; 95 % CI 0.14 to 0.37, p < 0.0001, I2 = 0 %, n = 1241). The studies in this outcome were downgraded to moderate-quality due to risk of bias (Table 3).
      Fig. 7
      Fig. 7Forest plot of the effects of MI on body mass index and body weight.

      3.7.6 Physical activity

      There was a moderate effect of MI on total PA outcomes compared to control groups (Fig. 8, 6.1.1: SMD 0.35; 95 % CI 0.12 to 0.58, p = 0.003, I2 = 42 %, n = 304). There was a moderate effect of MI on step count compared to control groups (Fig. 8, 6.1.2: SMD 0.62, 95 % CI 0.25 to 0.99, p = 0.001, I2 = 0 %, n = 119).
      Fig. 8
      Fig. 8Forest plot of the effects of MI on physical activity.
      Combined, there was a moderate effect of MI on overall PA compared to control groups (Fig. 8: SMD 0.42; 95 % CI 0.23 to 0.62, p < 0.0001, I2 = 32 %, n = 423). The studies in this outcome (both sub-categories and overall) were downgraded to moderate-quality due to risk of bias (Table 3).

      3.7.7 Self-efficacy

      MI had a moderate effect on self-efficacy outcomes compared to control groups from a total of eight studies (ten comparisons) (Fig. 9: SMD 0.33; 95 % CI 0.19 to 0.48, p < 0.0001, I2 = 78 %, n = 746). The studies in this outcome were downgraded to very low-quality due to risk of bias, inconsistency and indirectness (Table 3).
      Fig. 9
      Fig. 9Forest plot of the effects of MI on self-efficacy.

      3.7.8 Fatigue

      There was no effect of MI on fatigue outcomes compared to control groups from a total of five studies (Fig. 10: SMD 0.25; 95 % CI -0.01 to 0.52, p = 0.06, I2 = 66 %, n = 233). The studies in this outcome were downgraded to very low-quality due to risk of bias, inconsistency, and indirectness (Table 3).
      Fig. 10
      Fig. 10Forest plot of the effects of MI on fatigue.

      4. Discussion

      This review and meta-analysis provides new evidence that MI can positively impact, to varying degrees, the levels of PA, depression, functional tasks, BMI and self-efficacy, in populations of cancer patients and survivors. These results are somewhat reflected in other comparable analyses. In one meta-analysis of eight RCT's, there was a statistically significant improvement in PA levels, following an MI intervention, in populations with chronic diseases (multiple sclerosis, cardiovascular disease and obesity) immediately post-intervention however not sustained at longer term (three months post-intervention) [
      • O’Halloran P.D.
      • et al.
      Motivational interviewing to increase physical activity in people with chronic health conditions: a systematic review and meta-analysis.
      ]. However, the analysis (using data from two studies) did not show a significant improvement in functional tasks (using the same measure as in this analysis) and cardiovascular fitness. The authors reported that these results could be due to either; overestimation of PA levels whereby only two of the eight studies used objective measures or the improvements in PA levels were not great enough to produce an improvement in functional and fitness outcomes [
      • O’Halloran P.D.
      • et al.
      Motivational interviewing to increase physical activity in people with chronic health conditions: a systematic review and meta-analysis.
      ]. This may be a rational explanation for the PA and functional tasks results in this analysis as five of the six studies included in the analysis for PA outcomes included exercise sessions (or recommendations) that achieved the minimum required threshold (<150 min of moderate intensity PA per week) required to achieve significant improvements in health outcomes in healthy [
      • Organisation W.H.
      WHO Guidelines on Physical Activity and Sedentary Behaviour.
      ] and cancer [
      • Campbell K.L.
      • et al.
      Exercise guidelines for cancer survivors: consensus statement from international multidisciplinary roundtable.
      ] adult populations. In contrast, a meta-analysis that used data from two RCT's found that there whilst there was a significant improvement in PA levels, they failed to achieve the recommended PA levels (as described previously) in populations of overweight and hypertensive patients [
      • VanBuskirk K.A.
      • Wetherell J.L.
      Motivational interviewing with primary care populations: a systematic review and meta-analysis.
      ]. However, there was a significant improvement in BMI outcomes in both studies which was explained by the inclusion of dietary components within the intervention [
      • VanBuskirk K.A.
      • Wetherell J.L.
      Motivational interviewing with primary care populations: a systematic review and meta-analysis.
      ]. Again, this rationale aligns with the significant improvements in BMI that were seen in this analysis whereby five of the six included studies contained a dietary component to the intervention.
      Significant improvements in self-efficacy, as a result of MI, were also illustrated in the outcomes of the analysis of seven studies of populations of patients with various conditions such as cancer, diabetes or cardiovascular disease when approaching changes in behaviour such as smoking, diet and exercise [
      • Lundahl B.
      • et al.
      Motivational interviewing in medical care settings: a systematic review and meta-analysis of randomized controlled trials.
      ]. It is suggested that whilst this finding may be a direct result of the MI process itself, which enhances an individual's sense of control over their approach to change, it also may be due to the associated positive changes that are made [
      • Lundahl B.W.
      • et al.
      A meta-analysis of motivational interviewing: twenty-five years of empirical studies.
      ].
      In objectively measured health factors, such as BMI and functional tasks, there is a clearer link between motivation and outcomes, mediated by PA, compared to the impact of MI on subjectively measured health outcomes such as QoL, mental health and fatigue, is not as clearly defined [
      • Campbell K.L.
      • et al.
      Exercise guidelines for cancer survivors: consensus statement from international multidisciplinary roundtable.
      ,
      • Spencer J.C.
      • Wheeler S.B.
      A systematic review of motivational interviewing interventions in cancer patients and survivors.
      ]. An analysis of data from six RCT's showed significant improvements in worry, anxiety, depression, pain and global QoL outcomes as a result of interventions with combined dietary, exercise and healthy lifestyle programs in a mixed population of adults with diagnoses of diabetes, stroke and chronic heart failure [
      • Lundahl B.
      • et al.
      Motivational interviewing in medical care settings: a systematic review and meta-analysis of randomized controlled trials.
      ]. A more recent systematic review in cancer populations found that there were improvements in certain health outcomes such as fatigue, symptom distress and pain in studies when MI was focused on management of the specific outcome such as how to manage pain levels [
      • Spencer J.C.
      • Wheeler S.B.
      A systematic review of motivational interviewing interventions in cancer patients and survivors.
      ]. However, the results of this analysis suggested that the particular focus of the MI did not seem to influence the effects. For example, the only study included in this analysis which contained an MI intervention specifically targeting management of fatigue symptoms produced a significant improvement [
      • Ream E.
      • et al.
      Management of cancer-related fatigue during chemotherapy through telephone motivational interviewing: modeling and randomized exploratory trial.
      ]. However, the study that produced the greatest effect size of MI on fatigue outcomes was a study using MI focused on improving PA behaviour [
      • Vallance J.K.
      • et al.
      Effects of the ACTIVity And TEchnology (ACTIVATE) intervention on health-related quality of life and fatigue outcomes in breast cancer survivors.
      ]. Research has shown that improving self-efficacy is key to predicting successful PA behavioural change in cancer survivors [
      • Hirschey R.
      • et al.
      Predicting physical activity among cancer survivors: meta-analytic path modeling of longitudinal studies.
      ] and a major factor in management of adverse symptoms [
      • Heitzmann C.A.
      • et al.
      Assessing self-efficacy for coping with cancer: development and psychometric analysis of the brief version of the Cancer Behavior Inventory (CBI-B).
      ]. This suggests that MI may be more likely to generate improvements in subjectively measured health outcomes if: 1) there is an element of self-efficacy to symptom management within the MI; and 2) PA levels achieve a minimum threshold enough to produce changes.
      Three meta-analyses reported that measures taken within studies to ensure fidelity of the delivery of the MI intervention was a moderator of improved outcomes [
      • Lundahl B.
      • et al.
      Motivational interviewing in medical care settings: a systematic review and meta-analysis of randomized controlled trials.
      ,
      • O’Halloran P.D.
      • et al.
      Motivational interviewing to increase physical activity in people with chronic health conditions: a systematic review and meta-analysis.
      ,
      • VanBuskirk K.A.
      • Wetherell J.L.
      Motivational interviewing with primary care populations: a systematic review and meta-analysis.
      ]. However, this was not shown to be a potential influential factor within our results as the nine studies included within our analysis that incorporated methods to ensure fidelity of the MI intervention, [
      • Dennett A.M.
      • et al.
      Motivational interviewing added to oncology rehabilitation did not improve moderate-intensity physical activity in cancer survivors: a randomised trial.
      ,
      • Djuric Z.
      • et al.
      A diet and exercise intervention during chemotherapy for breast cancer.
      ,
      • Hoy M.K.
      • et al.
      Implementing a low-fat eating plan in the women's intervention nutrition study.
      ,
      • Huang F.F.
      • et al.
      A self-efficacy enhancing intervention for pulmonary rehabilitation based on motivational interviewing for postoperative lung cancers patients: modeling and randomized exploratory trial.
      ,
      • Kvale E.A.
      • et al.
      Patient-centered support in the survivorship care transition: outcomes from the patient-owned survivorship care plan intervention.
      ,
      • Ream E.
      • et al.
      Management of cancer-related fatigue during chemotherapy through telephone motivational interviewing: modeling and randomized exploratory trial.
      ,
      • Tsianakas V.
      • et al.
      CanWalk: a feasibility study with embedded randomised controlled trial pilot of a walking intervention for people with recurrent or metastatic cancer.
      ,
      • Thomas M.L.
      • et al.
      A randomized, clinical trial of education or motivational-interviewing-based coaching compared to usual care to improve cancer pain management.
      ,
      • Coolbrandt A.
      • et al.
      A nursing intervention for reducing symptom burden during chemotherapy.
      ] showed varying effects in a range of outcomes. Other proposed moderating factors shown to increase the MI effect are: higher number of sessions [
      • Lundahl B.W.
      • et al.
      A meta-analysis of motivational interviewing: twenty-five years of empirical studies.
      ], higher qualification of the interviewer [
      • VanBuskirk K.A.
      • Wetherell J.L.
      Motivational interviewing with primary care populations: a systematic review and meta-analysis.
      ], self-reporting outcome measures [
      • Lundahl B.
      • et al.
      Motivational interviewing in medical care settings: a systematic review and meta-analysis of randomized controlled trials.
      ] and use of other additional motivational strategies, such as pedometers and print materials [
      • Pudkasam S.
      • et al.
      Motivational strategies to improve adherence to physical activity in breast cancer survivors: a systematic review and meta-analysis.
      ], which may have positive impacts on outcomes.
      Whilst the aim of this review was to evaluate mixed cancer populations, its findings may require adaptation in specific oncological settings. The majority of the studies included in this review were in either mixed populations, or breast cancer survivors. Importantly, the largest component of the mixed population work was also breast cancer, making the results particularly applicable to that setting. The use of mixed cancer populations allows broad applicability to many oncological settings, however it is likely that for maximal impact, the interventions should be tailored to patient specifics, as factors such as symptoms of the cancer, and effects of the gold standard treatment are likely to have an effect on outcomes. MI delivered to patients should be practically focused on the individual and their physical and psychological condition, in order to increase efficacy and adherence.
      The quality of evidence for four of the eight outcomes within this analysis was from very low-quality studies, and so results should be interpreted with care. All studies suffered from the inability to blind personnel, an unavoidable bias for studies that incorporate behavioural and psychological interventions, and so it has been suggested that this does not indicate low quality research in these fields [
      • Hong F.
      • et al.
      Exercise intervention improves clinical outcomes, but the "time of session" is crucial for better quality of life in breast cancer survivors: a systematic review and meta-analysis.
      ]. In our analysis, removal of this criteria from overall risk of bias assessment, would upgrade five studies to low risk of bias [
      • Hoy M.K.
      • et al.
      Implementing a low-fat eating plan in the women's intervention nutrition study.
      ,
      • Kvale E.A.
      • et al.
      Patient-centered support in the survivorship care transition: outcomes from the patient-owned survivorship care plan intervention.
      ,
      • Ream E.
      • et al.
      Management of cancer-related fatigue during chemotherapy through telephone motivational interviewing: modeling and randomized exploratory trial.
      ,
      • Zuniga K.E.
      • et al.
      Dietary intervention among breast cancer survivors increased adherence to a Mediterranean-style, anti-inflammatory dietary pattern: the Rx for better breast health randomized controlled trial.
      ,
      • Turner J.
      • et al.
      The ENHANCES study: a randomised controlled trial of a nurse-led survivorship intervention for patients treated for head and neck cancer.
      ]. However, this did not result in a difference to the overall quality of evidence for any of the outcomes.
      A strength of this review is its focus on cancer populations which can reduce the heterogeneity between literature as highlighted in other research [
      • Lundahl B.
      • et al.
      Motivational interviewing in medical care settings: a systematic review and meta-analysis of randomized controlled trials.
      ,
      • VanBuskirk K.A.
      • Wetherell J.L.
      Motivational interviewing with primary care populations: a systematic review and meta-analysis.
      ]. In addition, included studies within this review have not been included in previous analyses which may shed new light on the improved refinement and application of MI interventions in research.
      Limitations include the small numbers of studies, low sample sizes and low quality of evidence; these mean that the findings should be interpreted with caution. Additionally, a large majority of these studies were feasibility studies or studies that were not adequately powered to detect a response to the intervention. Publication bias was another limitation with the use of four databases and selecting studies that are only published in English. Furthermore, several studies did not publish outcome data in the format that could be used within the meta-analysis and authors did not respond with requests for further information.
      Whilst this review had a focus on cancer populations, future research may benefit from further focus into the effect of MI on behavioural change and associated health outcomes within specific cancer types and stages as well as identification of potential moderators via regression analyses.

      5. Conclusion

      This systematic review and meta-analysis found that MI has positive effects on various health behaviours and health outcomes including PA behaviour, BMI, depression, functional tasks and self-efficacy in cancer populations. Given the unique barriers and health challenges these individuals face as a result of diagnosis and treatment, MI is a feasible intervention that can be used by various health professionals to optimise clinical outcomes in cancer patients and survivors. Implementing routine MI into care of cancer survivors could significantly improve both QoL, and clinical outcomes. Further research into specific populations and moderating factors of MI, or any adjunct methods, that ensure its success in producing improved outcomes, will help to inform clinical guidelines and study design.
      The following is the supplementary data related to this article.

      Contributors

      Katherine Harkin contributed to the conceptualisation, formal analysis, methodology, writing of the original draft and review and editing of the paper.
      Vasso Apostolopoulos contributed to supervision, review and editing of the paper.
      Kathy Tangalakis contributed to supervision, review and editing of the paper.
      Susan Irvine contributed to supervision, review and editing of the paper.
      Nicholas Tripodi contributed to supervision, formal analysis, methodology, review and editing of the paper.
      Jack Feehan contributed to supervision, methodology, formal analysis, review and editing of the paper.
      All authors read and agreed to the published version of the manuscript.

      Funding

      This systematic review and meta-analysis was supported by a Masters of Research study from Victoria University, Melbourne, Australia for ©2022 Covidence software purchasing. No funding was received for the study itself.

      Provenance and peer review

      This article was not commissioned and was externally peer reviewed.

      Declaration of competing interest

      The authors declare that they have no competing interest.

      Acknowledgements

      We thank the librarians within the College of Health and Biomedicine, Victoria University for their guidance and advice in development of search strategies. KH would like to thank the Victoria University Institute for Health and Sport for student research support funds. KH and NT were supported by Victoria University Postgraduate Research Scholarship. JF and VA were supported by the Victoria University Institute for Health and Sport, KT by the Institute for Sustainable Industries and Liveable Cities and VU Research Fellowship, and, KT, NT, SI, KH by the first-year college.

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