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Our data have indicated that minority breast cancer survivors are receptive to participating in lifestyle interventions delivered via email or the Web, yet few Web-based studies exist in this population.
The aim of this study was to examine the feasibility and preliminary results of an email-delivered diet and activity intervention program, “A Lifestyle Intervention Via Email (ALIVE),” delivered to a sample of racial and ethnic minority breast cancer survivors.
Survivors (mean age: 52 years, 83% [59/71] African American) were recruited and randomized to receive either the ALIVE program’s 3-month physical activity track or its 3-month dietary track. The fully automated system provided tools for self-monitoring and goal setting, tailored content, and automated phone calls. Descriptive statistics and mixed-effects models were computed to examine the outcomes of the study.
Upon completion, 44 of 71 survivors completed the study. Our “intention-to-treat” analysis revealed that participants in the physical activity track made greater improvements in moderate to vigorous activity than those in the dietary track (+97 vs. +49 min/week,
ALIVE appears to be feasible for racial and ethnic minority cancer survivors and showed promising results for larger implementation. Although survivors favored the educational content, a mobile phone app and interactive emails that work on multiple email domains may help to boost adherence rates and to improve satisfaction with the Web-based platform.
ClinicalTrials.gov NCT02722850; https://clinicaltrials.gov/ct2/show/NCT02722850 (Archived by WebCite at http://www.webcitation.org/6tHN9VsPh)
Breast cancer survivors suffer from high rates of overweight or obesity and often do not meet current guidelines for physical activity and intake of fruits and vegetables [
Comprehensive reviews and meta-analytic studies have indicated that clinic-based or in-person studies intended to improve diet, exercise, and HRQoL in cancer survivors have had promising results [
Despite the recent surge in Web-based interventions among cancer survivors, few studies have focused on minority cancer survivors [
Minority cancer survivors were recruited using nonprobability sampling techniques. Survivors were identified via word of mouth, existing relationships with community-based organizations, and cases ascertained from tumor registries in the North Texas metropolitan area. Eligibility criteria included (1) a previous diagnosis of breast cancer, (2) being at least 18 years old at study enrollment, (3) having completed treatment (except hormonal therapy) at least 6 months before study enrollment, and (4) receptivity to participating in a Web-based intervention study. Also, those who self-identified as African American, Hispanic, or of mixed ethnicity (ie, Asian and African American or African American and non-Hispanic white) were eligible for this study. We used a rolling recruitment process for screening and consenting participants. Survivors completed the screening and consent process from June 2014 to October 2015 using a multi-gated approach. All identified survivors were screened with Web-based surveys that assessed prior history of cancer, lifestyle factors (ie, diet and exercise), and physical activity readiness. The Physical Activity Readiness Questionnaire (PAR-Q) was used to identify contraindications to physical activity[
After participants completed the screening and consent process, a random number generator was used to randomize survivors to either a 3-month physical activity or a 3-month dietary track. Survivors were then sent track-specific enrollment links (ie, physical activity or dietary intake) to begin the ALIVE intervention. Participants in the dietary track could further choose between changing their dietary fat and added sugar intake or their fruit and vegetable intake. Data from participants working on both dietary behaviors were treated as one diet track for this analysis. A total of 71 minority survivors were randomized with equal probability to each track. Survivors received a US $20 incentive for completing each assessment. Thus, if they completed the baseline and follow-up assessment, they received a total of US $40.
Survivors in the physical activity track were encouraged to meet or exceed current federal recommendations for physical activity (eg, ≥150 min of moderate to vigorous physical activity per week). Survivors in the fruit and vegetable subtrack were encouraged to meet or exceed current recommendations for fruit and vegetable intake (eg, ≥3.5 cup servings of fruit and vegetable consumption). Survivors in the fats and added sugar track were encouraged to decrease intake of saturated and trans fats, decrease added sugars, and increase the intake of “good” fats and carbohydrates to meet or exceed these health recommendations (ie, ≤50 g/day of added sugars and ≤10% of calories from saturated fat) [
ALIVE was developed in collaboration between the Kaiser Permanente of Northern California Division of Research and NutritionQuest. No tailoring or modifications were made to the original program for this study. ALIVE was a theory-based coaching system derived from the principles of various theoretical models including the social cognitive theory [
The Physical Activity Questionnaire (PAQ) was adapted from the Cross-Cultural Activity Participation Study (CAPS) Questionnaire [
The dietary questionnaire queried participants on the intake of 35 commonly consumed foods identified as significant contributors to the intake of fruits and vegetables, added sugars, and saturated and trans fats in the National Health and Nutrition Examination Survey [
Survivors were asked to report on their satisfaction with components of the ALIVE system in a separate Web-based survey. Satisfaction was rated on a 5-point Likert-type response scale ranging from 1 (very dissatisfied) to 5 (very satisfied). We also included a separate overall satisfaction question. We used one question to assess the perceived effectiveness of ALIVE to change health behaviors and another question to assess whether they would recommend ALIVE to other cancer survivors (yes or no). Finally, we included open-ended questions that provided survivors with the opportunity to report on three likes and three dislikes about the ALIVE program. Our process evaluation facilitated our ability to assess the following components of feasibility: acceptability (ie, satisfaction), demand (ie, adherence to website usage), implementation and practicality (ie, success or failure of execution reported in the qualitative responses), and limited efficacy (ie, change scores and effect sizes) [
These self-report data were collected during the screening survey. The data included items related to age, education, employment status, age at diagnosis, disease stage at diagnosis, and comorbid conditions. We summed the number of comorbid conditions (ie, arthritis, diabetes, high blood pressure, heart disease, and high cholesterol) to create a single continuous variable.
Components of the ALIVE (A Lifestyle Intervention Via Email) program by study track.
Features | Physical activity | Dietary intake |
Individual tailoring: Information used to tailor content was based on the baseline diet and physical activity survey. | Preference for facility-based or home-based exercises Stage of physical activity readiness Social support for exercise Physical activity barriers Suggestions to reduce sedentary behavior User home page |
Habits related to cooking and eating out Stage of dietary readiness Specific foods consumed Social support for healthy eating Dietary barriers Suggestions to reduce the top three sources of problematic nutrients User home page |
Tailored goal setting: Content encouraging progress toward goal attainment. New goals were set once old ones were accomplished. | Weekly emails suggesting four to six small-step goals tailored to characteristics mentioned above (eg, I will walk 5 min at lunch time today) Queries about physical activity goal achievement |
Weekly emails suggesting four to six small-step goals tailored to characteristics mentioned above (eg, I will have a salad at lunch one day this week) Queries about dietary goal achievement |
Midweek reminders | Reminded survivors of their physical activity goals |
Reminded participants of their dietary goals |
Tips: Tips sent out weekly. | Tips provided information related to achieving physical activity goals and overcoming specific physical activity barriers |
Tips provided information related to achieving dietary goals and overcoming specific dietary barriers |
Goal tracker: Tracks which goals survivors achieve. | Tracked goals related to the frequency, type, and duration of physical activity |
Tracked goals related to the frequency, type, and quantity of dietary nutrients |
Simulation tool: An interactive feature of the ALIVE website for simulating effects of recommended goals | Allowed the participant to simulate how changing the frequency, quantity, or type of specific activities impacts total physical activity levels |
Allowed the participant to simulate how changing the frequency, quantity, or type of specific foods or beverages impacts total nutrient levels |
Health notes: Each week, a different topic was discussed. | Topics included research on the relationship between physical activity and various health outcomes |
Topics included research on the relationship between a healthy diet and various health outcomes |
Provisions for social support: Weekly goals and tips encouraging survivors to build a support systems with friends and family members. Chat rooms were available for participants to discuss problems and offer solutions to each other. | Provided suggestions such as walks with colleagues at lunch time Allowed survivors to engage and troubleshoot physical activity barriers and solutions. |
Provided suggestions to eat healthy meals with friends and family Allowed survivors to engage and troubleshoot dietary barriers and solutions. |
Automated phone calls: 3- to 5-min calls that facilitated goal setting, provided positive words of encouragement, and emphasized stage specific processes of change. Survivors also queried about personal barriers and goals. | Calls encouraged: Scheduling physical activity Overcoming physical activity barriers Making public commitments to be active Identifying a workout partner Reporting your physical activity achievements to others Encouraging friends to hold you accountable to activity goals |
Calls encouraged: Planning healthy meals Overcoming dietary barriers Making public commitments to consume a healthy diet Identifying a friend who would go out and consume a healthy meal with you Reporting your dietary achievements to others Encouraging friends to hold you accountable to your dietary goals |
Descriptive statistics were computed to describe the study population. Chi-square tests for independence and Fisher exact tests were used to determine whether there were categorical differences in the sociodemographic and medical variables between study tracks. Subsequent nonparametric Wilcoxon rank-sum tests were computed to determine whether there were mean or median differences in the continuous outcomes at baseline. Generalized mixed-effects models (PROC GLIMMIX) were used to estimate within and between-group changes in study outcomes over time. Given that many of the outcomes were nonnormal, log-normal or Poisson distributions were specified. The effects in the model comprised time, track, time by track interaction, and significant covariates identified in the initial analyses. Furthermore, survivors nested within study tracks were treated as a random effect. Cohen
In total, 162 minority survivors expressed interest in participating in the study, but only 71 of them (43.8%, 71/162) received the allocated intervention materials (see
Consolidated standards of reporting trials (CONSORT) diagram.
Descriptive statistics comparing completers and noncompleters at baseline.
Variables | Total sample |
Completers |
Noncompleters |
||
52.2 (8.6) | 52.0 (7.8) | 52.6 (9.9) | .62 | ||
Median and range of age | 53 (26-72) | 52 (32-69) | 54 (26-72) | - | |
Mean age at diagnosis (SD) | 43.9 (8.9) | 43.3 (7.2) | 44.8 (11.2) | .21 | |
Mean years out from diagnosis (SD) | 8.4 (6.5) | 8.8 (6.9) | 7.7 (5.8) | .57 | |
.86 | |||||
African American | 59 (83) | 36 (61) | 23 (39) | ||
Hispanic | 8 (11) | 5 (63) | 3 (37) | ||
Mixed | 4 (6) | 3 (75) | 1 (25) | ||
Currently employed, n (%) | 51 (72) | 33 (75) | 18 (67) | .45 | |
.20 | |||||
College graduate | 46 (65) | 31 (70) | 15 (56) | ||
.60 | |||||
Localized | 14 (20) | 9 (21) | 5 (19) | ||
Regional | 38 (54) | 23 (52) | 15 (56) | ||
Distant | 19 (26) | 12 (27) | 7 (25) | ||
Surgery | 67 (94) | 41 (93) | 26 (96) | .37 | |
Radiation | 49 (69) | 30 (68) | 19 (70) | .85 | |
Chemotherapy | 53 (75) | 33 (75) | 20 (74) | .93 | |
Hormone | 31 (44) | 19 (43) | 12 (44) | .92 | |
0.8 (0.9) | 0.8 (1.1) | 0.7 (0.7) | .93 | ||
Median and range of comorbidities | 1 (0-4) | 1 (0-4) | 1 (0-2) | - | |
Body mass index | 30.8 (6.0) | 30.5 (5.8) | 31.3 (6.6) | .66 | |
Fruit and vegetable intake in cup servings | 2.8 (1.6) | 2.7 (1.6) | 3.0 (1.6) | .48 | |
Fiber intake in g/day | 16.4 (8.1) | 16.2 (7.9) | 16.7 (8.6) | .84 | |
Saturated fat in % calories | 11.8 (7.7) | 11.8 (7.7) | 11.7 (7.9) | .84 | |
Minutes of moderate to vigorous physical activity/week | 222 (272) | 240 (233) | 194 (329) | .19 | |
Total sedentary minutes/week | 1462 (886) | 1412 (853) | 1554 (949) | .65 |
aCategorical
bSD: standard deviation.
Attrition at the 3-month assessment was 38% (27/71), with no differences in attrition observed between completers and noncompleters on lifestyle, treatment-related variables, and sociodemographic characteristics (all
At the baseline assessment, Hispanic survivors were more likely to be randomized to the physical activity track, and mixed race individuals were more likely to be randomized to the dietary track (
Descriptive statistics of participants enrolled in ALIVE (A Lifestyle Intervention Via Email) by study tracks at baseline.
Variables | Physical activity |
Diet |
||
Dropout, n (%) | 14 (41) | 13 (35) | .60 | |
Mean age (SDb) | 52.7 (8.4) | 51.8 (8.9) | .70 | |
Mean age at diagnosis (SD) | 44.6 (7.8) | 43.3 (9.9) | .52 | |
Mean years out from diagnosis (SD) | 8.2 (5.6) | 8.5 (7.1) | .96 | |
.02 | ||||
African American | 27 (79) | 32 (86) | ||
Hispanic | 7 (21) | 1 (3) | ||
Mixed or other | 0 (0) | 4 (11) | ||
Employment, n (%) | 26 (76) | 25 (68) | .41 | |
College graduate | 25 (74) | 21 (57) | .14 | |
Number of comorbidities, mean (SD) | 0.8 (0.8) | 0.8 (1.1) | .57 | |
.16 | ||||
Localized | 10 (29) | 4 (11) | ||
Regional | 16 (47) | 22 (59) | ||
Distant | 8 (24) | 11 (30) | ||
Surgery | 31 (91) | 36 (97) | .34 | |
Radiation | 23 (68) | 26 (70) | .81 | |
Chemotherapy | 22 (65) | 31 (84) | .07 | |
Hormone | 15 (44) | 16 (43) | .94 | |
Body mass index | 29.8 (25.8-34.1) | 31.0 (25.8-35.8) | .50 | |
Fruit and vegetable intake in cup servings | 2.5 (1.4-4.1) | 2.8 (1.5-3.6) | .80 | |
Fiber intake in g/day | 15.8 (10.7-19.7) | 15.4 (10.2-21.6) | .86 | |
Sugar in g/day | 14.8 (7.2-44.5) | 24.5 (14.1-51.3) | .19 | |
Carbohydrates in g/day | 113.7 (84.8-197.5) | 142.2 (106.6-186.0) | .28 | |
Trans fat in % calories | 0.4 (0.2-0.8) | 0.5 (0.3-0.9) | .21 | |
Saturated fat in % calories | 8.8 (5.6-13.4) | 11.2 (6.7-15.1) | .14 | |
Minutes of moderate to vigorous physical activity/week | 138 (0-390) | 150 (0-390) | >.99 | |
Discretionary minutes of sedentary time/week | 1095 (660-1680) | 1170 (510-1860) | .93 | |
Other minutes of sedentary time/week | 210 (150-720) | 360 (120-720) | .70 | |
Television viewing time/week | 840 (420-1260) | 720 (360-1200) | .62 | |
Total sedentary minutes/week | 1410 (750-2040) | 1380 (630-1890) | .53 |
aCategorical
bSD: standard deviation.
cThe median and 25% and 75% CIs were reported for the lifestyle variables.
Our “completers only” and ITT analyses are reported in
Our analyses indicated that both groups made reductions in discretionary, television-related, and total sedentary time (all
Our completers case analysis indicates that only the dietary track made improvements in the intake of fiber (+4.4 g/day;
Change scores for the study outcomes in the completers case analysis (N=44).
Outcomes | Physical activity changea (SEb) |
Dietary intake changea (SE) |
Effect size | |
Minutes of moderate to vigorous physical activity/week | +165 (68)d | +75 (62)d | 0.30 | <.001 |
Discretionary minutes of sedentary time/week | −309 (138)d | −125 (126)d | 0.30 | <.001 |
Other minutes of sedentary time/week | −93 (75)d | +23 (68)d | 0.35 | <.001 |
Television viewing time/week | −216 (114)d | −103 (104)d | 0.22 | <.001 |
Total sedentary minutes/week | −517 (148)d | −91 (135)d | 0.64 | <.001 |
Sugar in g/day | +6.6 (4.4) | −2.3 (4.0) | 0.45 | .43 |
Fiber in g/day | +1.9 (1.7) | +4.4 (1.6)e | 0.32 | .40 |
Fruits and vegetables in cup equivalents/day | +0.6 (0.3) | +1.0 (0.3)d | 0.28 | .35 |
Saturated fat in g/day | −1.0 (1.3) | −0.8 (1.2)e | 0.31 | .46 |
Trans fat in g/day | +0.0 (0.2) | −0.3 (0.1)e | 0.51 | .99 |
Carbohydrates in g/day | +14.2 (11.3) | +17.6 (10.3) | 0.07 | .68 |
aAll values represent within-group mean changes for the variables between baseline and follow-up periods.
bSE: standard error.
cMixed-effects models were adjusted for race or ethnicity.
d
e
Change scores for the study outcomes in the intention-to-treat analysis (N=71). An intention-to-treat protocol was applied where the last observations were carried forward.
Outcomes | Physical activity changea (SEb) |
Dietary intake changea (SE) |
Effect size | |
Minutes of moderate to vigorous physical activity/week | +97 (42)d | +49 (40)d | 0.20 | <.001 |
Discretionary minutes of sedentary time/week | −182 (85)d | −81 (81)d | 0.20 | <.001 |
Other minutes of sedentary time/week | −55 (45)d | −15 (43)e | 0.15 | <.001 |
Television viewing time/week | −127 (69)d | −66 (67)d | 0.15 | <.001 |
Total sedentary minutes/week | −304 (94)d | −59 (90)d | 0.45 | <.001 |
Sugar in g/day | +3.9 (2.7) | −1.5 (2.5) | 0.35 | .42 |
Fiber in g/day | +1.1 (1.1) | +2.9 (1.1) | 0.27 | .35 |
Fruits and vegetables in cup equivalents/day | +0.3 (0.2) | +0.7 (0.2)e | 0.34 | .29 |
Saturated fat in g/day | −0.6 (0.8) | −1.8 (0.8) | 0.25 | .40 |
Trans fat in g/day | −0.0 (0.1) | −0.2 (0.1) | 0.30 | .90 |
Carbohydrates in g/day | +8.3 (6.9) | +11.4 (6.6) | 0.08 | .61 |
aAll values represent within-group mean changes for the variables between baseline and follow-up periods.
bSE: standard error.
cMixed-effects models were adjusted for race or ethnicity.
d
e
Website usage did not differ between study intervention conditions. Survivors in the physical activity track visited the website on an average of 9.6 of the 12 weeks, whereas survivors in the diet track visited the website on an average of 10.7 of the 12 weeks (
Survivors in both tracks were mostly satisfied with the following components: tips for overcoming barriers, tips for achieving goals, goal-setting tools, and health notes. Additionally, most (97%) who completed the follow-up assessment indicated that they would recommend the ALIVE program to other cancer survivors. No statistically significant differences were observed between tracks. However, mean scores for the tracking tools were marginally lower in the physical activity track (
This component of feasibility was assessed via the qualitative responses obtained during our process evaluation. “Likes” reported by survivors could be grouped into six main themes: educational information (36%), email reminders (14%), goal-setting tools (12%), ease of use (9%), and motivation or encouragement (9%). The most commonly reported theme related to the educational information presented by the ALIVE program. For example, survivors indicated they liked the “information and tips,” and the “Did you know section.”
Components of ALIVE that survivors did not like could be grouped into the following themes: Functionality (48%), information (31%), tools (14%), and time (7%). For functionality, survivors indicated that they “could not enter goals,” that “links were not supported” or that they “got stuck” at some point while using the website. Examples of comments pertaining to information were “too much information” and “no relevant patient information.”
The effect sizes measuring changes in dietary intake between tracks were mostly medium in size. In the completers case analysis (see
Process evaluation data for study participants.
Satisfaction (1=not at all, 5=very satisfied) | Total | Physical activity | Diet | |
Tips for overcoming barriers | 4.2 (0.6) | 4.1 (0.7) | 4.2 (0.6) | .63 |
Tips for achieving goals | 4.2 (0.6) | 4.2 (0.7) | 4.3 (0.6) | .78 |
Tracker of daily habits | 3.7 (0.8) | 3.4 (0.8) | 4.0 (0.8) | .05 |
Progress tools—tracks current and past goals | 3.9 (0.9) | 3.6 (1.0) | 4.2 (0.7) | .08 |
Simulator tools—tool to help you visualize success | 4.0 (0.7) | 4.0 (0.7) | 4.0 (0.6) | .99 |
Goal-setting tools | 4.2 (0.7) | 4.3 (0.7) | 4.1 (0.8) | .46 |
Automated phone coaching | 3.5 (1.3) | 3.4 (1.2) | 3.6 (1.3) | .68 |
Tailored newsletters | 4.0 (0.9) | 4.1 (0.8) | 3.9 (1.0) | .57 |
Health note—articles to increase knowledge and skills | 4.2 (0.9) | 4.2 (0.8) | 4.1 (1.0) | .85 |
Overall satisfaction | 4.1 (0.9) | 3.9 (1.0) | 4.3 (0.7) | .24 |
Effectiveness in changing behavior (1=not at all, 5=very effective) | 3.8 (0.9) | 3.7 (1.1) | 3.8 (0.7) | .67 |
Recommend ALIVEb to other survivors, % yes | 97 | 95 | 100 | .47 |
a
bALIVE: A Lifestyle Intervention Via Email.
In this randomized parallel-group study, we observed that survivors randomized to the physical activity track made greater improvements in physical activity and greater reductions in sedentary behavior than those randomized to the dietary track. Despite the improvements in our activity-related constructs, these data only partially support our initial hypotheses, given that changes in the dietary variables did not differ significantly between tracks. Our process evaluation indicated that survivors were mostly satisfied with ALIVE and would recommend it to other survivors. However, concerns about ALIVE were noted. Overall, these data demonstrate that Web-based interventions such as ALIVE are feasible for racial and ethnic minority breast cancer survivors, but challenges must be addressed to improve the end user experience. The Alive program developers have recently developed and tested an updated version of the program that addresses some of the concerns identified in this study.
This is one of the first studies to examine the feasibility of a fully automated Web-based intervention in a sample of underserved breast cancer survivors. Our feasibility data were favorable, but attrition rates were high. The study’s attrition rate was comparable to previous Web-based intervention studies [
ALIVE was associated with significant improvements in physical activity for both tracks. Prior Web-based interventions among cancer survivors have observed significant improvements in physical activity [
To our knowledge, this is one of the first Web-based studies among cancer survivors to observe significant changes in sedentary time. ALIVE was not designed to be a sedentary behavior intervention, yet reductions in sedentary time were observed among our physical activity track. In discussions with NutritionQuest to inquire about the sedentary behavior curriculum, we were informed that educational materials discussing sedentary behaviors were minimal. Observed improvements in sedentary activity could be the result of this minimal sedentary behavior program content. Alternatively, it could be a transfer effect, similar to what was observed in dietary track. More research is needed to determine how, when, and for whom transfer effects occur.
Few Web-based interventions for cancer survivors have intervened on dietary intake. Our completers case analysis indicated significant improvements in the intake of fiber, fruits and vegetables intake, and saturated fat for the dietary track. These data support the results found in the original ALIVE study [
Our study has limitations. Our team used a convenient sampling strategy to maximize our recruitment efforts, and our sample consisted mostly of African American survivors who were college educated. It should also be noted that eligibility was not based on baseline physical activity or dietary behaviors. In particular, some participants were meeting guidelines for physical activity or dietary intake before joining the study. This may have lowered our estimated effect size between study tracks. Prior studies have observed stronger effects among survivors not meeting guidelines to lifestyle behaviors at the baseline assessment [
ALIVE appears to be feasible for racial and ethnic minority breast cancer survivors and capable of improving multiple lifestyle behaviors. Although we observed favorable ratings for ALIVE, improvements to functionality and a tailoring to cancer survivors are warranted. Web-based programs should be created to minimize challenges that the end user would encounter. Since the time our study concluded, the developers of ALIVE have released an updated version of the program that includes features to increase engagement and reduce attrition. In particular, the newest version of ALIVE was designed to operate on phones, tablets, and computers; includes a stand-alone mobile phone app; and uses gamification, a points system, and other strategies to increase adherence [
CONSORT-EHEALTH checklist (v1.6.1).
A Lifestyle Intervention Via Email
Cross-Cultural Activity Participation Study
health-related quality of life
intention-to-treat
Statistical Analysis System
standard error
standard deviation
Physical Activity Readiness Qestionnaire
Physical Activity Questionnaire
The authors would like to thank several community-based organizations, including the Sisters Network Inc, Army of Women, Bridge Breast Network, and Cancer Care Services for assisting us in recruiting racial and ethnic minority breast cancer survivors. Importantly, they would like to thank the women who continue to fight against breast cancer; may this work help the struggle. The authors would also like to thank Ms Susan Page for providing editorial assistance. This research was supported, in part, by National Cancer Institute grants K01CA158000 (RJP).
RP, RH, and PN spearhead recruitment efforts and IRB protocols at the respective institutions. RP, WC, SC, LJ, and KC conceived the study. RP, SB, and MD participated in tracking and tracing participants and entering data. All authors participated in drafting and editing the manuscript.
GB and TB hold the copyright on ALIVE and have financial interest in ALIVE.