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Al Onazi et al. Plast Aesthet Res 2020;7:23 I http://dx.doi.org/10.20517/2347-9264.2019.74 Page 3 of 14

Conceptual framework
The survey questions were developed based on clinical experience of the researchers and findings from the
literature around compression therapy adherence. Questions were then framed to align with the Theoretical
Domains Framework (TDF). The TDF is a behavior change model used in the field of implementation
science to inform healthcare practitioner behavior [13,14] . The TDF comprises 14 theoretical domains that are
[15]
considered to influence behavior and behavioral change . Used in conjunction, the TDF and the Behavior
Change Wheel (BCW) link the identified determinants of behavior to appropriate behavior change
techniques. At the center of a proposed BCW is a behavior system involving three essential conditions:
[16]
[15]
capability, opportunity, and motivation (COM-B) . These conditions interact to produce the behavior .
Capability is defined as the individual’s psychological and physical capacity, which includes having the
[16]
necessary knowledge and skills to perform the behavior . Motivation is defined as the intellectual
processes that energize and direct behavior, which includes goals, habits, emotional responses, and
[16]
decision-making . Opportunity is defined as the external influences that impact the individual, making
possible or encouraging the occurrence of the behavior .
[16]
Together, the TDF and BCW allow mapping of behavior change techniques to tailored implementation
[13]
strategies . Although originally developed for use with healthcare practitioners, the TDF is now
[17]
commonly used to behavior change across patient populations .
The survey consisted of 45 questions in six categories: demographic, health and lymphedema status,
garment use, garment knowledge, number and cost of garments, and social and environmental factors.
After development and initial testing for clarity and effectiveness with the research team and clinic staff, the
survey was pilot tested with two women with breast cancer related lymphedema (BCRL) who were not part
of the LYNC study [Supplement Table 1].

Qualitative methodology
For the purpose of this study, we applied an interpretive description (ID) qualitative methodology to
understand participants’ experiences and perspectives on the use of daytime compression as a self-
[18]
management strategy for lymphedema . ID can be applied to qualitative inquiry, as a means to better
understand individual health and illness, and to generate useful knowledge that can be used in clinical
practice [18,19] . Further, ID used in focus groups offers a methodological approach to the discovery and
creation of shared perspectives, rather than simply relying on individual reports .
[18]
Participant sampling
A convenience sample of 93 women who participated in the LYNC study within Alberta (Edmonton and
Calgary) was screened for eligibility through the electronic medical records system.

Eligibility for the survey included: (1) prior participation and completion of the LYNC study; (2) current
residence in Alberta, Canada; and (3) stable breast cancer medical status.

Eligible women were invited via email or phone to participate in the survey. Participants agreeing to the
survey had the option to complete the survey online through REDCap [20,21] (a secure web application for
building and managing online surveys) or to receive a paper copy through regular mail.

Data collection
Findings from the surveys were used to develop the probing questions for the focus group sessions. The
last question of the survey asked participants if they were willing to take part in a focus group session.
Participants indicating interest were then contacted and booked for a session, either at the University of
Alberta in Edmonton or at the Holy Cross Centre in Calgary. The focus group sessions took approximately
90 min each, and were simultaneously audio recorded and manually transcribed. The principal investigator