Skip to main content

Advertisement

SpringerLink
Log in

Mindfulness-based stress reduction for breast cancer survivors (MBSR(BC)): evaluating mediators of psychological and physical outcomes in a large randomized controlled trial

  • Published:
Journal of Behavioral Medicine Aims and scope Submit manuscript

Abstract

MBSR(BC) is known to have a positive impact on psychological and physical symptoms among breast cancer survivors (BCS). The cognitive mechanisms of “how” MBSR(BC) works was addressed in a recent study that found that there was strong consistent evidence that reduced emotional reactivity is a mediator and moderate consistent evidence that mindfulness, rumination, and worry were mediators. The purpose of this study, as part of a larger R01 trial, was to test whether positive effects achieved from the MBSR(BC) program were mediated through changes in increased mindfulness, decreased fear of breast cancer recurrence, and perceived stress. Female BCS > 21 years diagnosed with Stage 0-III breast cancer were randomly assigned to a 6-week MBSR(BC) or a Usual Care (UC)regimen. Potential mediators of 6- and 12-week outcomes were identified by analysis of covariance (ANCOVA), followed by formal mediational analyses of main effects of MBSR(BC) on 6- and 12-week outcomes, including percentage of total effects explained. Among 322 BCS (167 MBSR(BC) and 155 UC), fear of recurrence and perceived stress, but not mindfulness, mediated reductions in anxiety and fatigue at weeks 6 and 12, partially supporting our hypothesis of cognitive mechanisms of MBSR(BC).

Trial Registration

Registration Number: NCT01177124 http://www.ClinicalTrials.gov

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Data availability

Data will be archived in accordance with the NIH Data Sharing Plan, a national data repository.

References

  • American Cancer Society (2019). Cancer Facts & Figures. In American Cancer Society (Ed.). Atlanta.

  • American Cancer Society (2020). Survival Rates for Breast Cancer Retrieved from https://www.cancer.org/cancer/breast-cancer/understanding-a-breast-cancer-diagnosis/breast-cancer-survival-rates.html

  • Baer, R. A. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and Practice, 10(2), 125–143. https://doi.org/10.1093/clipsy/bpg015

    Article  Google Scholar 

  • Baer, R. A., Lykins, E., & Peters, J. R. (2012). Mindfulness and self-compassion as predictors of psychological wellbeing in long-term meditators and matched nonmeditators. The Journal of Positive Psychology, 7, 230–238.

    Article  Google Scholar 

  • Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report assessment methods to explore facets of mindfulness. Assessment, 13, 27–45.

    Article  PubMed  Google Scholar 

  • Baer, R. A., Smith, G. T., Lykins, E., Button, D., Krietemeyer, J., Sauer, S., & Williams, J. M. (2008). Construct validity of the five facet mindfulness questionnaire in meditating and nonmeditating samples. Assessment, 15, 329–342.

    Article  PubMed  Google Scholar 

  • Bishop, S. R. (2002). What do we really know about mindfulness-based stress reduction? Psychosomatic Medicine 64(1), 71–83. Retrieved from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=11818588

  • Bishop, S. R., Lau, M., Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J., & Devins, G. (2004). Mindfulness: A proposed operational definition. Clinical Psychology Science and Practice, 11, 230–241.

    Article  Google Scholar 

  • Boden, M. T., Bernstein, A., Walser, R. D., Bui, L., Alvarez, J., & Bonn-Miller, M. O. (2012). Changes in facets of mindfulness and posttraumatic stress disorder treatment outcome. Psychiatry Research, 200(2–3), 609–613.

    Article  Google Scholar 

  • Boyle, C. C., Stanton, A. L., Ganz, P. A., Crespi, C. M., & Bower, J. E. (2017). Improvements in emotion regulation following mindfulness meditation: Effects on depressive symptoms and perceived stress in younger breast cancer survivors. Journal of Consulting and Clinical Psychology, 85, 397.

    Article  PubMed  PubMed Central  Google Scholar 

  • Bränström, R., Kvillemo, P., Brandberg, Y., & Moskowitz, J. T. (2010). Self-report mindfulness as a mediator of psychological well-being in a stress reduction intervention for cancer patients- A randomized study. Annals of Behavioral Medicine, 39, 151–161.

    Article  PubMed  Google Scholar 

  • Bränström, R., Kvillemo, P., & Moskowitz, J. T. (2012). A randomized study of the effects of mindfulness training on psychological well-being and symptoms of stress in patients treated for cancer at 6-month follow-up. International journal of behavioral medicine, 19, 535–542.

    Article  PubMed  PubMed Central  Google Scholar 

  • Brown, K. W., & Cordon, S. (2009). Toward a Phenomenology of Mindfulness: Subjective Experience and Emotional Correlates. In F. Didonna (Ed.), Clinical Handbook of Mindfulness. New York: Springer Science.

    Google Scholar 

  • Brown, K. W., Ryan, R. A., & Creswell, J. D. (2007). Mindfulness: Theoretical foundations and evidence for its salutary effects. Psychological Inquiry, 18(4), 211–237. Retrieved from <Go to ISI>://000250865000001

  • Butow, P. N., Turner, J., Gilchrist, J., Sharpe, L., Smith, A. B., Fardell, J. E., & Gebski, V. J. (2017). Randomized trial of ConquerFear: A novel, theoretically based psychosocial intervention for fear of cancer recurrence. Journal of Clinical Oncology, 35, 4066–4077.

    Article  PubMed  Google Scholar 

  • Campbell, T. S., Labelle, L. E., Bacon, S. L., Faris, P., & Carlson, L. E. (2012). Impact of mindfulness-based stress reduction (MBSR) on attention, rumination and resting blood pressure in women with cancer: A waitlist-controlled study. Journal of Behavioral Medicine, 35, 262–271.

    Article  PubMed  Google Scholar 

  • Carlson, L. E., Doll, R., Stephen, J., Faris, P., Tamagawa, R., Drysdale, E., & Speca, M. (2013). Randomized controlled trial of mindfulness-based cancer recovery versus supportive expressive group therapy for distressed survivors of breast cancer (MINDSET). Journal of Clinical Oncology, 31, 3119–3126. https://doi.org/10.1200/jco.2012.47.5210.

    Article  PubMed  Google Scholar 

  • Carpenter, J. S., & Andrykowski, M. A. (1998). Psychometric evaluation of the Pittsburgh Sleep Quality Index. Journal of Psychosomatic Research, 45(1 Spec No), 5–13. Retrieved from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=9720850

  • Cheli, S., Caligiani, L., Martella, F., De Bartolo, P., Mancini, F., & Fioretto, L. (2019). Mindfulness and metacognition in facing with fear of recurrence: A proof-of-concept study with breast-cancer women. Psycho-oncology, 28, 600–606.

    PubMed  Google Scholar 

  • Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24(4), 385–396. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/6668417

  • Compen, F., Bisseling, E., Schellekens, M., Donders, R., Carlson, L., van der Lee, M., & Speckens, A. (2018). Face-to-face and internet-based mindfulness-based cognitive therapy compared with treatment as usual in reducing psychological distress in patients with cancer: A multicenter randomized controlled trial. Journal of Clinical Oncology, 36, 2413–2421.

    Article  PubMed  Google Scholar 

  • Crane-Okada, R., Kiger, H., Sugerman, F., Uman, G. C., Shapiro, S. L., Wyman-McGinty, W., & Anderson, N. L. (2012). Mindful movement program for older breast cancer survivors: A pilot study. Cancer Nursing, 35, E1–E13.

    PubMed  Google Scholar 

  • DeSantis, C. E., Ma, J., Gaudet, M. M., Newman, L. A., Miller, K. D., Goding Sauer, A., & Siegel, R. L. (2019). Breast cancer statistics. CA A Cancer J Clin, 69, 438–451.

    Article  Google Scholar 

  • Feldman, G., Hayes, A., Kumar, S., Greeson, J., & Laurenceau, J. (2007). Mindfulness and emotion regulation: The development and initial validation of the cognitive and affective mindfulness scale-revised (CAMS-R). Journal of Psychopathology and Behavioral Assessment, 29, 177–190.

    Article  Google Scholar 

  • Garland, S. N., Carlson, L. E., Stephens, A. J., Antle, M. C., Samuels, C., & Campbell, T. S. (2014). Mindfulness-based stress reduction compared with cognitive behavioral therapy for the treatment of insomnia comorbid with cancer: a randomized, partially blinded, noninferiority trial. Journal of Clinical Oncology, 32, 449–457.

    Article  PubMed  Google Scholar 

  • Gu, J., Strauss, C., Bond, R., & Cavanagh, K. (2015). How do mindfulness-based cognitive therapy and mindfulness-based stress reduction improve mental health and wellbeing? A systematic review and meta-analysis of mediation studies. Clinical Psychology Review, 37, 1–12.

    Article  CAS  PubMed  Google Scholar 

  • Hall, D. L., Luberto, C. M., Philpotts, L. L., Song, R., Park, E. R., & Yeh, G. Y. (2018). Mind-body interventions for fear of cancer recurrence: A systematic review and meta-analysis. Psycho-oncology, 27, 2546–2558.

    Article  PubMed  PubMed Central  Google Scholar 

  • Hamilton, N. A., Kitzman, H., & Guyotte, S. (2006). Enhancing health and emotion: Mindfulness as a missing link between cognitive therapy and positive psychology. Journal of Cognitive Psychotherapy, 20, 123–134.

    Article  Google Scholar 

  • Hann, D. M., Jacobsen, P., Martin, S., Azzarello, L., & Greenberg, H. (1998). Fatigue and quality of life following radiotherapy for breast cancer: A comparative study. Journal of Clinical Psychology in Medical Settings, 5, 19–33.

    Article  Google Scholar 

  • Hayes, S., Luoma, J., Bond, F., Masuda, A., & Lillis, J. (2006). Behaviour research and therapy. Behaviour Research and Therapy, 44, 1–25.

    Article  PubMed  Google Scholar 

  • Hicks, R., & Tingley, D. (2011). Causal mediation analysis. Stata J, 11, 605.

    Article  Google Scholar 

  • Hölzel, B. K., Lazar, S. W., Gard, T., Schuman-Olivier, Z., Vago, D. R., & Ott, U. (2011). How does mindfulness meditation work? Proposing mechanisms of action from a conceptual and neural perspective. Perspectives on Psychological Science, 6, 537–559.

    Article  PubMed  Google Scholar 

  • Imai, K., Keele, L., & Tingley, D. (2010). A general approach to causal mediation analysis. Psychological Methods, 15, 309–334. https://doi.org/10.1037/a0020761.

    Article  PubMed  Google Scholar 

  • Jain, S., Shapiro, S. L., Swanick, S., Roesch, S. C., Mills, P. J., Bell, I., & Schwartz, G. E. (2007). A randomized controlled trial of mindfulness meditation versus relaxation training: Effects on distress, positive states of mind, rumination, and distraction. Annuals of Behavioral Medicine, 33, 11–21. https://doi.org/10.1207/s15324796abm3301_2.

    Article  Google Scholar 

  • Johns, S. A., Brown, L. F., Beck-Coon, K., Monahan, P. O., Tong, Y., & Kroenke, K. (2015). Randomized controlled pilot study of mindfulness-based stress reduction for persistently fatigued cancer survivors. Psycho-Oncology, 24, 885–893.

    Article  PubMed  Google Scholar 

  • Josefsson, T., Larsman, P., Broberg, A., & Lundh, L.-G. (2011). Self-reported mindfulness mediates the relation between meditation experience and psychological well-being. Mindfulness, 2, 49–58.

    Article  Google Scholar 

  • Kabat-Zinn, J. (1990). Full-catastrophe living: Using the wisdom of your body and mind to face stress, pain and illness. . Bantam Doubleday Dell Publishing.

    Google Scholar 

  • Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future. Clinical Psychology-Science and Practice, 10, 144–156.

    Article  Google Scholar 

  • Kabat-Zinn, J., Lipworth, L., & Burney, R. (1985). The clinical use of mindfulness meditation for the self-regulation of chronic pain. Journal of Behavioral Medicine, 8(2), 163–190. Retrieved from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=3897551

  • Kabat-Zinn, J., Massion, A. O., Kristeller, J., Peterson, L. G., Fletcher, K. E., Pbert, L., . . . Santorelli, S. F. (1992). Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. American Journal of Psychiatry, 149(7), 936–943. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/1609875

  • Kazdin, A. E. (2006). Mechanisms of Change in Psychotherapy: Advances, Breakthroughs, and Cutting-Edge Research (Do Not Yet Exist).

  • Kazdin, A. E. (2007). Mediators and Mechanisms of Change in Psychotherapy Research. Annual Review of Clinical Psychology, 3(1), 1. Retrieved from http://ezproxy.lib.usf.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=edb&AN=53344843&site=eds-live

  • Keller, S., Bann, C. M., Dodd, S. L., Schein, J., Mendoza, T. R., & Cleeland, C. S. (2004). Validity of the brief pain inventory for use in documenting the outcomes of patients with noncancer pain. Clinical Journal of Pain, 20(5), 309–318. Retrieved from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15322437

  • Kim, M. K., Lee, K. S., Kim, B., Choi, T. K., & Lee, S.-H. (2016). Impact of mindfulness-based cognitive therapy on intolerance of uncertainty in patients with panic disorder. Psychiatry investigation, 13, 196.

    Article  PubMed  PubMed Central  Google Scholar 

  • Kraemer, H., Wilson, T., Fairburn, C. C. G., & Agras, W. S. (2002). Mediators and moderators of treatment effects in randomized clinical trials. Archives of General Psychiatry, 59, 877–883.

    Article  PubMed  Google Scholar 

  • Labelle, L. E., Campbell, T. S., & Carlson, L. E. (2010). Mindfulness-based stress reduction in oncology: Evaluating mindfulness and rumination as mediators of change in depressive symptoms. Mindfulness, 1, 28–40.

    Article  Google Scholar 

  • Labelle, L. E., Lawlor-Savage, L., Campbell, T. S., Faris, P., & Carlson, L. E. (2015). Does self-report mindfulness mediate the effect of Mindfulness-Based Stress Reduction (MBSR) on spirituality and posttraumatic growth in cancer patients? The Journal of Positive Psychology, 10, 153–166.

    Article  Google Scholar 

  • Laurenceau, J.-P., Hayes, A. M., & Feldman, G. C. (2007). Some methodological and statistical issues in the study of change processes in psychotherapy. Clinical Psychology Review, 27, 682–695.

    Article  PubMed  PubMed Central  Google Scholar 

  • Lee-Jones, C., Humphris, G., Dixon, R., & Hatcher, M. B. (1997). Fear of cancer recurrence--a literature review and proposed cognitive formulation to explain exacerbation of recurrence fears. Psycho-Oncology, 6(2), 95–105. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/9205967

  • Lengacher, C. A., Johnson-Mallard, V., Barta, M., Fitzgerald, S., Moscoso, M. S., Post-White, J., & Kip, K. E. (2011). Feasibility of a mindfulness-based stress reduction program for early-stage breast cancer survivors. Journal of Holistic Nursing, 29, 107–117.

    Article  PubMed  Google Scholar 

  • Lengacher, C. A., Johnson-Mallard, V., Post-White, J., Moscoso, M. S., Jacobsen, P. B., Klein, T. W., & Kip, K. E. (2009). Randomized controlled trial of mindfulness-based stress reduction (MBSR) for survivors of breast cancer. Psycho-Oncology, 18, 1261–1272.

    Article  PubMed  Google Scholar 

  • Lengacher, C. A., Reich, R., Post-White, J., Moscoso, M., Shelton, M., Barta, M., & Budhrani, P. (2012). Mindfulness based stress reduction in post-treatment breast cancer patients: An examination of symptoms and symptom clusters. Journal of Behavioral Medicine, 35, 86–94.

    Article  PubMed  Google Scholar 

  • Lengacher, C. A., Reich, R. R., Paterson, C. L., Jim, H. S., Ramesar, S., Alinat, C. B., & Kip, K. E. (2015). The effects of mindfulness-based stress reduction on objective and subjective sleep parameters in women with breast cancer: A randomized controlled trial. Psycho-Oncology, 24, 424–43.

    Article  PubMed  Google Scholar 

  • Lengacher, C. A., Reich, R. R., Paterson, C. L., Ramesar, S., Park, J. Y., Alinat, C. B., & Kip, K. E. (2016). Examination of broad symptom improvement due to mindfulness-based stress reduction for breast cancer survivors: A randomized controlled trial. Journal of Clinical Oncology, 37, 2827–2834.

    Article  Google Scholar 

  • Lengacher, C. A., Shelton, M. M., Reich, R. R., Barta, M. K., Johnson-Mallard, V., Moscoso, M. S., & Kip, K. E. (2014). Mindfulness based stress reduction (MBSR(BC)) in breast cancer: Evaluating fear of recurrence (FOR) as a mediator of psychological and physical symptoms in a randomized control trial (RCT). Journal of Behavioral Medicine, 37, 185–195.

    Article  PubMed  Google Scholar 

  • Moyer, A., Goldenberg, M., Hall, M. A., Knapp-Oliver, S. K., Sohl, S. J., Sarma, E. A., & Schneider, S. (2012). Mediators of change in psychosocial interventions for cancer patients: A systematic review. Behavioral Medicine, 38, 90–114.

    Article  PubMed  Google Scholar 

  • O’Bryan, E. M., Luberto, C. M., Kraemer, K. M., & McLeish, A. C. (2018). An examination of mindfulness skills in terms of affect tolerance among individuals with elevated levels of health anxiety. Anxiety, Stress, & Coping, 31, 702–713.

    Article  Google Scholar 

  • Preacher, K. J., & Hayes, A. F. (2004). SPSS and SAS procedures for estimating indirect effects in simple mediation models. Behavior Research Methods, Instruments, & Computers, 36, 717–731.

    Article  Google Scholar 

  • Radloff, L. (1977). The CES-D scale: A self-report depression scale for researching the general population. Application of Psychological Measures, 1, 385–401.

    Article  Google Scholar 

  • Reich, R. R., Lengacher, C. A., Alinat, C. B., Kip, K. E., Paterson, C., Ramesar, S., & Moscoso, M. (2017). Mindfulness-based stress reduction in post-treatment breast cancer patients: Immediate and sustained effects across multiple symptom clusters. Journal of Pain and Symptom Management, 53, 85–95.

    Article  PubMed  Google Scholar 

  • Spielberger, C., Gorsuch, R., & Luschene, R. (1983). Manual for the State-Trait Anxiety Inventory. . Consulting Psychologists.

    Google Scholar 

  • Vickberg, S. M. (2003). The Concerns About Recurrence Scale (CARS): a systematic measure of women's fears about the possibility of breast cancer recurrence. Annuals of Behavioral Medicine, 25(1), 16–24. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12581932

  • Ware, J. H., Kosinski, M., & Keller, M. (1994). SF-36 physical and mental health summary scales, a user’s manual. (2nd ed.). The Health Institute.

    Google Scholar 

  • Xu, W., Zhou, Y., Fu, Z., & Rodriguez, M. (2017). Relationships between dispositional mindfulness, self-acceptance, perceived stress, and psychological symptoms in advanced gastrointestinal cancer patients. Psycho-oncology, 26, 2157–2161.

    Article  PubMed  Google Scholar 

  • Zainal, N. Z., Booth, S., & Huppert, F. A. (2013). The efficacy of mindfulness-based stress reduction on mental health of breast cancer patients: A meta-analysis. Psycho-Oncology, 22, 1457–1465.

    Article  PubMed  Google Scholar 

Download references

Funding

This study was supported by the National Cancer Institute (Award Number 1R01 CA131080-01A2). This work also has been supported in part by the Biostatistics and Bioinformatics Shared Resource at the H. Lee Moffitt Cancer Center & Research Institute, an NCI designated Comprehensive Cancer Center (P30-CA076292). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute or the National Institutes of Health. This study protocol was approved by the Institutional Review Board at the University of South Florida to ensure the ethical treatment of participants.

Author information

Authors and Affiliations

  1. University of South Florida College of Nursing, MDC 22, 12901 Bruce B. Downs Blvd., Tampa, FL, 33612-4476, USA

    Cecile A. Lengacher, L. Forest Gruss, Katterine G. Chauca, Manolete S. Moscoso & Anisha Joshi

  2. University of Pittsburgh Medical Center, Pittsburgh, PA, 15261, USA

    Kevin E. Kip

  3. Moffitt Cancer Center, Tampa, FL, 33612, USA

    Richard R. Reich, Sara Tinsley, Lakeshia Cousin & Jong Y. Park

  4. Texas Woman’s University, Denton, TX, 76204, USA

    Budhrani Shani

  5. Patient-Centered Outcomes Research Institute, Washington, D.C, 20036, USA

    Carly Paterson Khan

  6. University of Virginia, Charlottesville, VA, 22904, USA

    Matthew Goodman

Authors
  1. Cecile A. Lengacher
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. L. Forest Gruss
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kevin E. Kip
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Richard R. Reich
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Katterine G. Chauca
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Manolete S. Moscoso
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Anisha Joshi
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Sara Tinsley
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Budhrani Shani
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Lakeshia Cousin
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Carly Paterson Khan
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Matthew Goodman
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Jong Y. Park
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Cecile A. Lengacher.

Ethics declarations

Conflict of interest

The authors declares that they have no conflicts of interest.

Human and animal rights and informed consent

At orientation for MBSR(BC), BCES, and UC, all participants signed informed consents prior to enrolling in the study. The USF institutional review board at the University of South Florida serves as the University of South Florida's Ethics committee and gave approval, in addition to the Moffitt Cancer Center Scientific Review Committee.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Data repository: data will be archived in accordance with the NIH Data Sharing Plan, a national data repository.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lengacher, C.A., Gruss, L.F., Kip, K.E. et al. Mindfulness-based stress reduction for breast cancer survivors (MBSR(BC)): evaluating mediators of psychological and physical outcomes in a large randomized controlled trial. J Behav Med 44, 591–604 (2021). https://doi.org/10.1007/s10865-021-00214-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10865-021-00214-0

Keywords

Search

Navigation