Electrically-assisted bicycles (e-bikes) are a means through which to increase individual physical activity (PA) and overcome some commonly reported barriers to engaging in conventional cycling. Fatigue is a common side effect to breast cancer treatment, and the rate of PA engagement drops significantly following a breast cancer diagnosis. The aim of this qualitative study was to examine perceptions of e-cycling as a means of increasing PA in this population. Twenty-four participants (mean age = 57.88 (standard deviation 10.8), 100% female) who have had a breast cancer diagnosis, completed two semi-structured interviews via Zoom. One interview was conducted prior to an e-bike taster session and a second, after the session. Taster sessions were conducted by certified cycling instructors in the community. Interviews were conducted between December 2021 and May 2022. Data were transcribed verbatim and analyzed thematically using NVivo 12 software. An inductive and deductive approach to analysis was adopted. Five themes were generated: (1) Perceived role of e-bikes during treatment, (2) The relationship between e-bikes and fatigue, (3) Cancer-specific considerations, (4) Is e-cycling ‘enough’?, and (5) Optimizing the intervention. Negative perceptions of e-bikes noted before the taster session were altered following riding an e-bike. The multiple levels of assistance made cycling manageable and less impacted by fatigue, thereby enabling individuals to re-establish previous cycling habits. E-cycling may be a suitable option to increase PA behavior amongst individuals being treated for breast cancer, with the potential to overcome many of the barriers of conventional cycling. Enabling this population to trial an e-bike elicits positive physical and psychological responses that may help to promote future engagement. Cancer is one of the leading causes of mortality worldwide, totaling approximately 10 million deaths in 2020 . There aCancer places great economic burden on society, with the cost of breast cancer chemotherapy alone mounting to over GBP 248 million, yearly [Physical activity (PA) has been identified as a highly effective, non-pharmaceutical intervention known to complement other breast cancer treatments and modify recurrence rates . The benIn addition, in oncology, PA engagement is recognized to improve both psychological and physiological functions, including the potential to mitigate common side effects such as incidence of fatigue, impaired health-related quality of life (HRQL), mental health decline, and reductions in physical health .It is important to note that an individual’s willingness and their physical and psychological responses to PA can vary depending on the type of treatment they are receiving. A cross-sectional study of 37 breast cancer patients revealed that patients were more likely to experience perceived difficulty engaging in PA if they had undergone more than three types of cancer treatment, in comparison to patients that experience no perceived difficulty  [Despite the known benefits of PA and the intention to increase their PA participation once diagnosed, the number of women meeting national PA guidelines is low . It is dIn 2012, a cohort study revealed that only 48.3% of breast cancer patients met the PA guidelines of 10 metabolic equivalent (MET) hours/week . While tThere are several perceived barriers to PA engagement during breast cancer treatment, including physical, psychosocial, environmental, and organizational factors . PhysicaSmith-Turchyn and colleagues’  qualitatEmery and colleagues’  researchElectrically-assisted bicycles  have been identified as a means through which to increase PA, providing at least moderate intensity PA . ElectriFor older adults, e-cycling is reported as being preferable over conventional cycling due to the reduced physical exertion required on an e-bike, leading to reduced feelings of fatigue following a cycling journey . Use of 2 (95% CI −0.020 to −0.0002) lower per additional day of e-cycling per month. Additionally, maximal power output increased for both untrained men and women  following six weeks of active commuting on an e-bike [Associations have been identified between e-bike use and physiological parameters. A longitudinal study by Dons and colleagues  found thn e-bike . Furthern e-bike . As suchThe aim of this research was to examine perceptions of e-cycling amongst individuals who have had a breast cancer diagnosis.What are the perceived barriers and facilitators to e-bike usage during breast cancer treatment?When, during cancer treatment, is perceived to be optimum for introducing e-cycling?Does the implementation of an e-bike taster session elicit changes in perceptions of e-cycling during breast cancer treatment?Based on this aim, the following research questions were developed:Due to the novel exploration of e-cycling during cancer treatment, a qualitative approach was identified as the most appropriate research method to identify initial perceptions and insights.Two one-to-one semi-structured interviews were conducted with each participant; one before an e-bike taster session (referred to as Interview One) to gather the participants’ initial thoughts of e-cycling, and one post the e-bike taster session (referred to as Interview Two) to identify whether e-cycling opinions had changed. Semi-structured, one-to-one interviews were used due to their ability to keep the interview focused whilst still providing flexibility for the researcher to explore pertinent ideas that may be raised during the conversation . InterviTwenty-four interviews were conducted for Interview One. Following this, five participants were no longer contactable and did not complete the e-bike taster session or Interview Two. Four participants did not require a taster session due to already owning an e-bike. As such, fifteen participants completed the taster session and nineteen completed Interview Two.All data collection was conducted by a female researcher, KMW (MSc). KMW was completing their MSc in Nutrition, Physical Activity and Public Health at the University of Bristol at the time of the study.Participants were eligible to take part in the study if they have had a breast cancer diagnosis. Metastatic cancer is prominent amongst breast cancer patients, therefore individuals with secondary cancer were included . ParticiA convenience sampling technique was used based on the aforementioned inclusion criteria. Participants were recruited via a Bristol-based charity, Penny Brohn UK. Advertisements were placed in two instalments of the monthly newsletters and emails were sent to a consenting mailing list. Additional social media adverts were promoted via Breast Cancer Now, on platforms including Facebook and Instagram. All advertisements contained the researcher’s contact details.The recruitment reach through Penny Brohn UK was 281 via email mailing list and 4800 via monthly newsletter. From this, 34 individuals expressed initial interest in the study (approximately 0.7% of those reached), were sent the participant information sheet (int), and were presented with a link to an online demographic survey. The demographic survey collected data which allowed the researcher to screen individuals for eligibility; a consent form for the survey was also attached which participants were asked to sign and date electronically.In total, 29 out of 34 who were sent the PIS completed the demographic survey. Of these 29, one was not eligible for the study due to not having a breast cancer diagnosis, and four dropped out due to personal reasons unrelated to the study. Data collection and analysis were conducted in parallel, therefore participant recruitment continued until saturation was met . Data saSeparate interview guides were developed for use during Interview One and Two . The aveInterviews were conducted by the primary researcher, KMW. Informal, ice-breaker questions commenced the interviews followed by open-ended questions with probing questions included ad hoc, depending on the participant’s response, with the intention to deepen or expand on a point if necessary . Pilot iE-cycling is a recently popularized mode of PA, therefore it could not be assumed that participants had engaged in e-cycling previously . To ensuTaster sessions were conducted by qualified instructors at Life Cycle, a Bristol-based charity. A full safety briefing was delivered and safety equipment, such as high-visibility jackets and helmets, were provided on request. Participants were given an introductory ride on the e-bike around a Bristol park with a cycle path, which included both flat and hilly routes to ensure maximum exploration of the e-bike. Participants were given the autonomy to switch between levels of assistance and were provided with advice and support on how best to use the e-bike.Ethical approval was obtained via the University of Bristol, School for Policy Studies Research Ethics Committee .Descriptive statistics were extracted from the demographic survey and presented in Interview recordings were held securely on the University of Bristol server until transcriptions were complete, after which they were deleted. All identifiable information was removed or anonymized during the transcription process and each participant was assigned an anonymous identification code.Thematic analysis was used and guided by Braun and Clarke’s  six stepTranscripts were read repeatedly by KMW to ensure the researcher was familiar with the data. Following data familiarization, segments of text were highlighted, and initial codes were derived inductively and deductively . KMW and a second coder (TJC) independently coded three transcripts. These three transcripts were selected by KMW to reflect diverse responses. The researchers met to discuss and refine the codes and a coding framework was developed. The remaining transcripts were coded by KMW, who revisited previously coded transcripts as required if new codes were identified. Codes were organized into categories based on their content through discussion between KMW and the second coder. From these categories sub-themes and higher order themes were generated.To adhere to the quality criteria for all qualitative research, credibility, transferability, dependability, and confirmability were all considered , therefoFive overarching themes were generated from a combination of Interview One and Two: (1) Perceived role of e-bikes during treatment, (2) The relationship between e-bikes and fatigue, (3) Cancer-specific considerations, (4) Is e-cycling ‘enough’?, and (5) Optimizing the intervention .Participants explained that e-bikes could play a significant role in overcoming barriers to cycling that are present following a diagnosis. For some participants, despite having a history of regular cycling, they were no longer able to participate because of their treatment due to factors such as reduced energy, weakness, fatigue, and lacking motivation:P.20: “I liked cycling, but it was hard work. Yeah. And, and now, now that I’m diagnosed and I’m on medication, I don’t think I could do it. I’m just exhausted after physical activity.”, multiple cancer diagnoses, undergoing treatment)Yet, the prospect of an e-bike was appealing, with the electric motor offering the required assistance to get participants back into their previous cycling habits:P.16: “I don’t use my push bike very much at all. I was reluctant to get on it I think for a long time because I hadn’t got the energy levels to do that. So yes, I think an e-bike definitely would help, knowing that you know I’ve got the power behind me.”Participants discussed that an e-bike would facilitate an improvement in cycling performance, providing the ability to cycle further, faster, and with more confidence. Most prominently, the e-bike was perceived to overcome the inability to cycle up hills, due to strength reductions and deterioration in cardiovascular fitness that result from treatment:P.2: “It makes it more do-able, you’d be able to go further distances and hills wouldn’t put you off. So you didn’t, you wouldn’t have to be as fit to cycle with them.”One participant compared up-hill e-cycling to feeling the same as cycling a conventional bike on a flat road, emphasizing that the electrical assistance allowed them to overcome their fear of hills:P.5: “Then we went up on a hill and of course she told me that I can use a higher program to help, then it was just like same like I was going on a straight, you know, it was like cheating almost, feeling that I’m cheating because that’s not the reality.”Cycling was often described as a social sport, with participants enjoying a leisurely ride with their families, friends, or community cycling groups. However, this was often diminished once treatment started, having a negative impact on the participants, both socially and psychologically:P.14: “My partner, and my daughters would go out riding bikes. But I, I wouldn’t go I couldn’t go because I, you know, I just hold them up, I couldn’t keep up with them.”Yet, the e-bike was positively described as a way to overcome this barrier, due to the electrical assistance allowing for increased duration, thereby boosting their confidence to keep up with their peers and enhancing enjoyment:P.20: “There’s lots of people that are using e-bikes to like, so that they can carry on cycling with their partner because their partner is so much fitter and faster than them.”There were several physical benefits of e-cycling described by participants both pre- and post-taster session , such asP.6: “It’s just a wonderful feeling on an e-bike, the freedom the bike gives you, the wind in your hair and going through the countryside is just glorious, and just be able to continue to do that I think is really really important.”Many participants also described the benefit e-cycling will have to their treatment response. In particular, the e-bike was commonly associated with alleviating the stress of both a diagnosis and when undergoing treatment:P.15: “I was very stressed to begin with, not quite knowing where it was all going. And, yeah, to me exercise is a way of releasing stress very definitely, and I think e-cycling is perfect in that way, even more than walking for me.”For some, the taster session raised concerns that introducing e-cycling during treatment could lead to added stress, particularly amongst participants with limited cycling history and a fear of road cycling:P.5: “I guess, because it’s a kind of stress for me that I’m afraid of the traffic. And it was a stress for me to even just, you know, we mostly used the bike road but there were other bikers, there were there were other pedestrians.”Often, negative perceptions of e-bikes noted before the taster session were altered following a trial on the e-bike, with participants stating that cycling was “easier” than expected and a more “tolerable” mode of PA, thus making them more inclined to e-cycle in the future.Many participants reported a loss of identity or feeling like their cancer defines them. Yet, the prospect of an e-bike provided a sense of independence that they had been lacking since receiving their diagnosis:P.16: “Having the e-bike gives you that security but allows you to have the exercise as well, and and the independence, because otherwise you’re relying on someone else drive you or you have to try and park the car.” For some, their diagnosis meant they were no longer able to drive. As such, the e-bike would provide a mode of travel that is quicker and more practical than walking:P.21: “I can’t drive so, I could use the e-bike for exercise and also if I ever wanted to sort of get to a shop or something and you know use it for that, that kind of thing.”P.20: “I was surprised. I just didn’t feel exhausted. I think I was expecting it to take more out of me.”The fear of not getting home due to tiredness once setting off on a conventional bike ride was enough to deter people from cycling completely. However, the use of an e-bike was assumed to address this problem:P.10: “If I cycled an hour there then that’s also an hour back. But with an e-bike, I feel like you just, you’ve that extra assistance so less worry about getting back, so then you just go a little bit further, I think. I’d be encouraged to go to places that you wouldn’t on a push bike.”Yet, anxieties were still raised post-taster session at the thought of the e-bike battery running low or stopping completely, thus leaving participants hesitant about cycling too far:P.8: “If you went on a route that is, like, I’m only choosing this route because I’ve got an electric bike so I know I can make it and then the bike breaks and then you’re like, oh what now.”Although some participants expressed a desire to e-cycle when fatigued, others stated it would be detrimental to their health if they exerted themselves too much:P.15: “You have to be very careful not to overdo it, because it’s quite exciting to get on an e-bike, you know, and you think oh I’ll have a go, but it’s easy to do too much and suffer from it.”Emphasis was placed on the importance of conserving energy for treatments and therefore not participating in e-cycling on days of high fatigue:P.14: “If I lacked energy, I wouldn’t use an e-bike, I would be trying to conserve my energy for areas where I would need that energy.”As a result of a lumpectomy or mastectomy, the restrictions in the arm and armpit were feared to limit the ability to hold the handlebars on the e-bike. However, the taster session appeared to eliminate this concern:P.9: “I thought maybe, you know, the slight weakness I have in my right arm because of the removal of the lymph node might have affected it, but that wasn’t a problem.”For some, it was the strength in the arm that appeared most preventative:P.19: “I don’t think I had the strength in my hand or my arm to hold on and maintain a rigid arm. That was quite difficult.”E-cycling was sometimes described as a “bumpy ride”, with potholes or uneven road surfaces often inducing high, uncomfortable impact onto the bike and the rider. Some participants expressed concerns regarding this impact when undergoing treatment:P.17: “It wasn’t the exercise as much as the sort of the slight pummeling you get by going on the road on a small thing. So I guess that’s what would stop me using them at points when I was having chemo.”As a result, it was suggested that an individual’s stage of cancer should be considered when prescribing e-cycling as a mode of PA:P.20: “I think it’s something you’d, if you’re gonna recommend it you to people with stage 4 you’d have to take it on board, you’d have to find out more about their physical condition and assess if it’s suitable for them, I think.”Yet, participants recognized that the e-bike is no more prone to pummeling when compared to a conventional bicycle:P.18: “I tend to sort of like stand up on the pedals if I know there’s a bump coming or try and avoid it, or whatever. But it’s no more of an issue than it is with an ordinary bike.”Following the taster session, a few participants reported that they expected the e-bike to be a strenuous form of PA that was potentially unmanageable, however, the taster session changed their perceptions:P.20: “The fact that we we went on this this bike ride we got back, and I just didn’t feel exhausted. I think I was expecting it to take it more out of me.”Others’ preconception was that e-cycling may not have provided any form of PA due to the assistance. However, following the taster session, e-cycling was perceived as being of sufficient intensity to provide a sufficient workout:P.19: “I think it was more than I expected because you still feel as though you’re cycling. You don’t feel as though everything’s doing the hard work for you. You feel that you’re having exercise, but just having that extra push when you needed it.”Participants stated that the bike ride raised their heart rate sufficiently, worked their leg muscles, and induced muscle soreness the following day; all of which were claimed to be an indication of a good amount of physical exertion without the expense of fatigue:P.21: “But I was still puffed out when we got to the top, I had to have a little breather. You know I had the full support on I did still need a bit of a breather.”Multiple assistance levels allowed participants to alter their exertion depending on how they were feeling, which was reassuring when experiencing fluctuations in energy and motivation during treatment:P.15: “So because I’m feeling fairly fit at the moment, I only had it on the eco level. So, yeah, even though it’s an e-bike, you can choose your level so that’s why it would be quite good because you could sort of tailor it to different people and how that person feels at the time”Some participants were willing to cycle with little or no assistance to ensure they made the most of the workout:P.7: “Once I finally got used to motor I turned it right down, because I wanted it to be part of my daily exercise.”However, the weight of the e-bike was frequently presented as a barrier to e-cycling , and theSome participants claimed the e-bike played a type of “psychological trick” on them and their willingness to cycle. Despite feeling tired and fatigued, participants suggested they would be more inclined to cycle an e-bike rather than a conventional bike, despite potentially exerting the same amount of energy:P.13: “It could have a psychological effect because you know you wouldn’t maybe go out on a normal bike, because of how you’re feeling yet you’d go out on an e-bike and end up actually doing the same amount of effort.”The opinion of whether e-cycling was possible during specific treatments varied greatly between participants, with only one common conclusion: it is solely down to the individual:P.1: “In general, whether you’d be able to do it with cancer treatments is individual because everyone is so different and everyone’s regime is different.”Regardless of whether cycling throughout breast cancer treatment was seen as beneficial, most participants suggested not to promote an e-bike at the start of the cancer journey, following diagnosis:P.20: “It’s not when you’re first diagnosed, because it was just like you couldn’t even think something new.”However, P.7 suggested using the e-bike as soon as possible following diagnosis to set the patient up best for the treatment that follows:P.7: “The reasons they need it before is so that they can use it to improve their fitness, because the more fit you are before your surgery, the quicker recovery when you come out for chemotherapy.”Regarding surgery, it was popular to assume that the e-bike would not be used until the individual had recovered physically from the surgery. The recovery time appeared to depend on the type of surgery administered:P.9: “I guess it depends what surgery you have. If you’ve just had a lumpectomy, you probably could get onto a bike relatively soon.”Typically, post-surgery was claimed to be an ideal time to present an e-bike. In particular, the e-bike was described to act as a distraction away from the disease and the upcoming treatments :P.6: “It would have been the mindfulness of distracting me from all those dark thoughts and all that gloom and you feel like you haven’t got the future. So anything that takes you away from that.”E-cycling during chemotherapy presented the most controversial opinions. For some, despite chemotherapy being an exhausting time, they were confident they could continue using an e-bike depending on the week the chemotherapy was administered:P.13: “Week one, I wouldn’t be able to go for it. But then on week two and three, I was feeling perfectly well, or getting to the stage where I had enough energy to go for it.”However, the prospect of e-cycling at any stage during chemotherapy seemed impossible for some:P.15: “I think chemo affects the brain too and they have that they say, you know that you have brain fog or kind of things and the dizziness and and all kinds of things which is probably not the very ideal time to go on a bike.”The main concern for e-cycling during radiotherapy was due to time commitments, rather than the treatment itself. The time necessary to attend appointments every day appeared to frequently result in fatigue, which then acts as a barrier to using the e-bike.P.17: “So, the tiredness wasn’t from the radiotherapy, it was more from the driving to the appointment, you know going to and from the appointment every day.”The other barrier to e-cycling during radiotherapy was the skin burns:P.13: “You get radiotherapy burns. Would I have cycled with them? I don’t know, maybe.”Presenting the e-bike post treatment as a method to aid recovery seemed optimal amongst patients:P.20: “That sort of rehabilitation, that rebuilding yourself because after being poisoned and, you know, cut open and radiated, you know it’s a lot for your body to go through.”The e-bike was promoted as a method to return to “normal life”; a way of putting the cancer in the past.This is the first qualitative study to explore perceptions of e-cycling amongst individuals who have had a breast cancer diagnosis. With the aid of a 1-h taster session, this research highlighted the intention and desire for PA engagement during breast cancer treatment, with the e-bikes providing a promising method to overcome perceived barriers to physical exertion. Participants frequently referred to the “ease” of e-cycling, and its ability to re-introduce previous cycling habits that were disenabled because of their diagnosis and treatment. Reservations and considerations were reported regarding specific treatment side effects and the appropriate timing to introduce an e-cycling intervention. The findings of this research can be used by healthcare professionals when prescribing sustainable and manageable physical activity interventions alongside treatment. The emergence of themes and their alignment with current literature are considered below to determine the relevance and significance of e-cycling during breast cancer treatment.During pre-taster session interviews, it was evident that most participants recognized an e-bike’s image and usability, though were yet to consider its benefits for use during breast cancer treatment. Nevertheless, the prospect of e-cycling was desirable in the present study, with many participants claiming the taster session solidified their expectations that e-cycling would be an easier alternative to conventional cycling, allowing for increased distance and speed due to the electric motor. This aligns with previous research findings amongst e-bike owners in the Sacramento, California area, whereby the notion of increased distance inspired their purchase, with many participants disposing of their previously used conventional bicycles . It is pParticipants expressed their perceived importance of PA during treatment through discussion of current exercise patterns. Following the e-cycling taster session, participants described the bodily fatigue and muscular soreness they experienced the next day, as well as the respiratory requirements of e-cycling. Previous research has confirmed the reduction in exertion from an e-bike, but also its suitability for individuals with physical limitations as a result . JohnsonFurthermore, frequent reference was made to the ability to cycle up a hill because of the electric motor, something which previously deterred individuals from getting on a bike. This reinforces previous research that recognized hills as a key barrier to conventional cycling and a key facilitator of e-cycling ,51. A 20Interestingly, participants discussed the desire to turn the electric motor off entirely when cycling on flat terrains. It was perceived that, during the taster sessions, participants felt the need to “push themselves, which consequently resulted in them working harder than anticipated due to the weight of the e-bike. This was described as “psychological trickery”, whereby the absence of the electric motor in fact promoted more intense PA and a greater sense of achievement. This is consistent with previous literature which explained that a perceived sense of achievement is a key facilitator to PA engagement during breast cancer treatment, in a study protocol where exercise instructors and continuous remarks of praise were used as a method to increase exercise self-efficacy . With paEnhancing the psychological benefits is important for improving long-term adherence to e-cycling and PA overall . ResearcMost participants shared their relationship with fatigue during their treatment. Although fatigue was presented as a key barrier to conventional cycling, especially regarding hills and non-flat terrains, many suggested they would still engage in e-cycling when they would consider themselves too fatigued to engage in other, more strenuous types of PA. However, some days, such as during weeks of chemotherapy, e-cycling was deemed “impossible” or “unsuitable” due to the need to conserve energy. This supports previous research which identified a decrease in PA engagement when undergoing adjuvant chemotherapy, as well as significant decreases in energy expended through PA .The greatest concern regarding fatigue was the fear of the e-bike battery running low and therefore cycling home with no assistance. Although advancements in technology mean that e-bike battery life is extending, this does not come without an increase in price . Fears rDespite listing extensive benefits and facilitators to e-cycling, participants were quick to identify limitations and barriers to this mode of PA. As e-bikes are a large financial investment, with prices increasing depending on the make and model , particiProspectively, the initial investment for an e-bike would be eliminated if e-bikes were used within a future intervention amongst cancer patients, as the equipment costs would be covered by research funding. However, investment must be considered when looking to induce long-term e-cycling habits, when participation in research studies is complete. A survey study conducted in Norway found that higher perceived benefits and familiarity with e-bikes were positively related with the intention to buy an e-bike . HoweverA key reported facilitator and, consequently, benefit of e-cycling was the social opportunities that e-cycling provides. Frequently, individuals highlighted that an e-bike would allow them to cycle alongside peers and family, something they had not been capable of since their diagnosis. Rey-Barth and colleagues  found thFears regarding physical limitations resulting from surgery, such as restricted use of the affected arm, are common in literature investigating the barriers to PA during breast cancer treatment. Participants in Sander and colleagues’  study rep = 0.02) in a study where 68 breast cancer patients undertook regular supervized, moderate-intensity, aerobic, and resistance exercise [Uncertainty was displayed when deciding if e-cycling would be manageable and maintainable during other breast cancer treatments, in particular the cyclic nature of chemotherapy doses. Parallel to previous research, exercise adherence was reported lower during chemotherapy in comparison to radiotherapy  to reduce or eliminate negative treatment side effects   and recuFuture researchers can be confident that breast cancer patients support the prospect of e-cycling during treatment and would be keen to partake if the opportunity was presented to them when undergoing treatment. Researchers must recognize that introducing an e-bike immediately after a cancer diagnosis could be detrimental, yet an optimal time to intervene is highly dependent on the individual. Participants in this study valued the taster session to gain a better understanding of the e-bike usability and practicality. Therefore, the implementation of an e-bike taster session will be essential when looking to recruit participants for a future e-bike intervention. Barriers to e-cycling predominantly surrounded initial investment, therefore it is imperative to ensure external funding is secured to cover costs of the e-bike if recruiting for a future intervention. Additionally, knowledge of how to access an e-bike once study involvement has concluded would contribute to long-term e-cycling engagement amongst cancer patients.To address the limitations of the present study, future research should aim to gather perceptions from a more ethnically diverse population to reduce disparities in healthcare research. Additional further research should qualitatively assess the motivations, facilitators, and barriers behind buying an e-bike during a cancer diagnosis. Understanding these factors may assist with prolonging e-cycling engagement throughout cancer treatment and beyond.This qualitative study provides novel insights to the perceived usefulness and practicality of e-bikes during breast cancer treatment. It is presented that individuals who have had a breast cancer diagnosis recognize the importance of engaging in PA during treatment and believe e-cycling is a suitable mode to overcome common barriers to conventional cycling, such as fatigue and physical exertion. There are both physical benefits of e-cycling, such as its suitability for individuals with a cancer diagnosis, and psychological benefits, such as fresh air and the influence to work harder than anticipated. However, worries regarding battery life and theft were prominent, and the initial financial investment deterred some participants from potentially purchasing an e-bike. An optimal time to introduce an e-bike intervention was difficult to discern for participants, as cancer treatment is explained to be highly dependent on the individual. Overall, e-cycling was deemed an appropriate mode of PA to engage in during breast cancer treatment. It suggests promise for increasing PA behaviors in this population, with the potential to overcome many barriers posed by conventional cycling. The positive physical and psychological responses associated with providing e-bike taster sessions in this population may help to promote future engagement.


Leaders of organizations have incessant demands placed on them, including cultivating teams, building culture, and increasing the bottom line, in addition to caring for followers’ well-being and thriving. Numerous resources are required to meet these continuous demands, and vitality is one of the most valuable.Fortune 1,000 companies, this qualitative study answers three important questions: what drains vitality, what fosters it, and how do leaders most effectively utilize vitality for followers?Through interviewing 20 of the most influential and pressured leaders of The results shed light on psychological mechanisms that drain leaders’ vitality, including emotional labor, self-control, loss of job control, the unproductive mindsets of others, and isolation created from the role. In terms of fostering vitality, several of the pathways of the PERMA+4 model of well-being were highlighted, including fostering relationships, physical health, accomplishment, mindset, meaning, environment, and engagement. Two additional themes that foster vitality included job autonomy and time away from work. Themes emerged that underscore how leaders utilize their vitality for followers, and the potentially detrimental impacts to leadership when leaders are drained.Overall, results highlight the importance of vitality and self-care as critical for leaders’ ability to maximize their leadership performance. A recent survey of several thousand senior leaders across the United States found that 72% of leaders reported being burned out . NumerouPrevious studies have shown that leaders are continually faced with enacting self-control in serving followers and putting the needs of others first . Self-coLeaders also have requirements for emotional labor due to the need for leaders to always be “on” for their followers, conveying high levels of positive emotions and vitality to meet the demands of the role even when they are feeling depleted. Emotional labor is defined as the “effort, planning, and control needed to express organizationally desired emotion during interpersonal transaction” , p. 987.Closely related to emotional labor is emotional dissonance, which is created when a leader portrays emotions that they do not feel. Emotional dissonance is defined as the conflict between the actual emotions experienced and organizationally required emotions . Given tFinally, at the heart of many leadership styles is the need for leaders to transfer positive relational energy to impact followers . PositivFortune 1,000 companies. Methods and measurements are defined, and sampling and analysis strategy are reviewed. The results present the themes in what drains and fosters leader vitality, as well as, how vitality is utilized in leadership. The paper concludes with a discussion of the contributions of these potential findings, limitations, and suggestions for future research.This paper first reviews existing theory and research on vitality, followed by a review of the psychological mechanisms that drain vitality, and the antecedents of vitality. The qualitative study explores themes in leader vitality at the CEO level of In sum, the current study explores the perspectives of leaders in high pressure, high visibility roles, to better understand what drains and fosters vitality and awareness. This study additionally sheds light on how leaders utilize their vitality for followers and the potentially detrimental impacts to leadership when leaders are drained. This study serves to enhance the current knowledge in vitality and advance the understanding of the importance of vitality in leadership. This understanding of leader vitality can help organizations support leaders, with the potential for positive long-term benefits for the organization.Chi in China, Ki in Japan, Bayu in Indonesia, and Prana in India  was to understand the concept of leader vitality through the experiences of CEOs in large scale organizations, gaining a list of the factors that both drain and foster leader vitality  was used to determine if the sample size was sufficient, and that point was reached at 12 interviews. However, 8 additional interviews were conducted as a further step in validation .Fortune 500 CEOs are white males  explained “Had I shown everything that I was feeling, they would have just seen me super, super mad. That’s how it would have showed up. So that’s what I am fighting off.” Several leaders shared their use of emotional labor to prevent negative impacts to others from their internal negative emotions.Very few (15%) participants pointed out the emotional dissonance created from the disconnect between their internal and external feelings. One participant (P17) shared that he had become more authentic in his leadership. He explained that he used to believe leaders could not express negative emotions, but now he feels, “To be an authentic leader, you have to be real, acknowledge sometimes that you are not up to par.” He shared that his authenticity has created more opportunities for connection and engagement with his team. His insight aligns with Another mechanism that almost 50% of the leaders cited was self-control. A leader (P9) aware of the importance of withholding information explained, “I cannot necessarily bring that information to my team, because it can create a little bit of uncertainty or loss of confidence, potentially, depending on the topic.” There were several examples given about the need to adjust leadership styles based on the audience.Only 20% of participants discussed energy transference as a drain to vitality, although the number one theme in uses of vitality (65% of leaders) was the transfer of positive relational energy (see Leadership Behaviors section below). One leader (P8) drained from energy transference shared:We have an annual leadership festival. We get everybody together, all our leaders, and it’s usually two and a half days, lots of interactions with people. And I always find myself the next morning, to be spent of energy. I am just ready to just kind of escape, I’ve had two and a half days of having to be on nonstop.Cameron’s research Three other main themes, which are detailed in A key theme highlighted was loss of job control, with the most mentioned area being loss of calendar control due to back-to-back meetings, low value meetings, and unexpected urgent issues. Leader (P16) explained:I get done with a meeting and I have my admin knocking on the door because something else has come up and I’ve literally got a minute to get to the next meeting. Then I’m walking down the hall and there’s the person grabbing me because I’ve been in meetings all day. You’re giving so much of yourself, and you’re still being pulled on.Another participant (P3) stated when he felt most depleted, “It’s a day where I feel as though I’ve lost control of the calendar, and how my time is being spent.”These findings are consistent with research around job control, which is defined as a broad concept referring to the degree to which people can choose their actions . Lack ofAnother theme that emerged was the impact of counterproductive mindsets including team members, the Board, analysts, and employees. Sixty-five percent of leaders shared that they became drained of vitality due to the unproductive mindsets of others. These draining mindsets include: (1) a focus on self, versus the organization [“It’s people doing things for reasons related to their own agenda or their own interest rather than the good of the organization.” (P2)]; (2) people with a fixed mindset or a mindset overly oriented toward the past ; and (3) negative mindsets . Three participants expressed the erosion of trust as a drain to vitality due to people’s negative mindset and self-orientation which made leaders feel that others were being dishonest and manipulative. This finding is consistent The final theme that emerged was the isolation of the CEO role. Leader (P17) shared, “It’s lonely sometimes, I could call somebody, but everybody’s busy.” The feelings of isolation have only increased with working from home. A participant (P5) explained:When I’m in the office, it’s give and take; I give energy and I get replenished from some other conversation happening here. Whereas when I’m working from home, I’m just like giving, giving, giving, giving, and then by the end of the day, I’m just dead.The results of this study illustrate a list of the drains to leader vitality from both the validation of previous research and additional insights gained. Equally important is the understanding of what fosters vitality, the topic of the next set of findings.Overall, the PERMA+4, as a model for fostering leader vitality, was largely supported. Additional themes emerged including the importance of creating thinking space in the day and time away from work.As expected, the PERMA+4 is a key to fostering vitality with 100% of participants citing one or more pathways of the PERMA+4 model of well-being. This finding is supported by A key theme is positive relationships, both personally and professionally, matter when it comes to fostering vitality. Several leaders shared increases in vitality from relationships with family and friends, “I’m able to maintain bonds, with close friends and family, like my son and my wife, and just feeling those bonds is another thing that I think is just something I need” (P5). Another leader (P2) shared that he feels most vital when “I’m feeling particularly connected to my family.”Professionally, 50% of leaders discussed the vitality they gained from their teams, particularly in helping them develop. One leader (P3) expressed that he felt vital when he had the “opportunity to coach people on the team and help them become bigger and help them grow their own capacity and capability.”Another significant theme was the time spent with frontline employees. One CEO (P9) captured the exchange of the energy he felt:Number one, I feed off of their energy, when they talk about how passionate they are about the work that we’re doing. When they clearly appreciate the fact that their CEO is spending time and engaged and asking questions. It’s so validating, this mutual energy that’s going back and forth.The quality of relationships was also discussed as a contributor to vitality with six leaders mentioning trusted relationships, such as P8’s comment: “The closeness to my team, just in terms of, really great, open conversations. I have no boundaries, no barriers to having this really open dialogue.”Physical health was discussed by 85% of participants as a critical element in fostering vitality; from exercise and movement to nutrition to sleep, physical health was discussed repeatedly. “Doing some kind of physical activity gives me great energy, not necessarily in the moment of doing it, but afterwards” (P9). “I sleep so it’s probably the one thing I do. I go to bed early, and I try to always get 8 h” (P7). “You know [I am most vital when], my diet is good. And getting appropriate amounts of rest” (P13). Many leaders also discussed the importance of meditation, “I will take time to do my Calm app” (P17). “I have to find a way to release, which I do at times when I do start to sit down and meditate” (P3). This finding is in alignment with previous research that shows somatic health including physical activity, healthy lifestyle habits, and good sleep are all antecedents of vitality .Another clear vitality booster for 65% of the sample was accomplishment. Many leaders discussed that a day in which they are high in vitality is a day where they feel like they are “winning.” As one leader (P13) expressed, “I do get fulfillment when we win at something.” Another leader (P14) shared it is a day when, “I get to celebrate something. I can celebrate the accomplishment of one of our leaders or in our business metric that we hit.”Half of the leaders discussed the importance of a productive mindset and pointed to the elements of psychological capital including hope, efficacy, resiliency, and optimism. A leader (P5) explained “A can-do attitude, optimism, competence, conviction, those things are critical to me.” The same leader pointed to the importance of self-efficacy, “Confidence is so critical to my levels of vitality.” Another leader (P11) stated very clearly, “Your mindset matters in building your vitality.” Leaders also discussed the importance of a growth mindset, “And so for me a big part of vitality for me personally, is I’ve realized that what has been my fuel my whole life has been the newness of things, the uniqueness of things” (P15). Not only was the leader’s mindset a direct contribution to vitality, but also the positive mindsets of those around them. Leaders gain vitality from people with positive or growth mindsets. A participant (P5) shared, “There are certain people that are a source of energy for me that help me and it’s because they always have that energy, or are super enthusiastic, happy, confident and optimistic.”Connection to impact, meaning and purpose were mentioned by almost half of the leaders. One leader (P15) expressed:It will be the people that have worked with me or for me: I feel a real sense of joy and excitement and accomplishment when that individual reaches out and says something like, you may not remember me, but I was at this meeting and it really impacted my career, or it really impacted my home life, or it really impacted me.Another leader (P17) directly pointed to purpose, “So that’s the piece that has really helped me, living on purpose or purpose driven living. Touching people’s lives gives me energy but also gives them energy as well.” The connection between meaning and vitality has been validated by previous research showing that meaning in life fosters vitality in elderly adults  and anotForty percent of leaders spoke about how their environment impacts their vitality. “Our headquarters, just the colors and the people working and collaboration and walking through the hallways, it fills my cup up, to stop in the hallway” (P5). “Environmentally, just being here or any of our offices or any of our client offices, but that’s a big stimulant, is being among people” (P6). “I have my highest level of vitality when I’m when I’m actually in an office interacting with and able to collaborate quickly, able to ask questions quickly” (P10). Of this subset of 8 leaders, 5 talked about the weather contributing to their vitality, e.g.: “I always feel better in sunny weather” (P2).The final theme of the PERMA+4 that emerged was engagement. Only one quarter of the leaders discussed engagement as a source of vitality; however, over 50% of leaders discussed engagement as an outcome of vitality. It appears from this study that engagement is both an antecedent and an outcome, with more awareness around engagement as a consequence. The greatest recognition of engagement as an antecedent centered around strategy, “I find big strategic movements, energizing, making a deal,” (P2) and another participant (P3) spoke about a sense of flow with the team, “feeling that the team is learning that you are moving forward that things are clicking.” Two participants talked about the vitality gained from utilizing their strengths including focusing on energizing tasks, “I choose to pay attention to the ones (tasks) that give me energy and ignore the ones that suck energy” (P6).Two other themes emerged: (1) job control in terms of space for thinking, and (2) non-work time, which included any time away from work. Refer to The importance of time and calendar control were emphasized in 75% of interviews as a key to fostering vitality. A leader (P2) shared having “white space on my calendar and not over committing” is a key to a day with high vitality. This sentiment was repeated by participants explaining that vitality was highest when there was sufficient space for thinking, planning, and preparing. “The days that I have the most vitality is when I have created the space, or the space has been created throughout the day” (P16).A key theme that emerged was taking time away from work both daily and during “vacation” time. One leader (P7) emphasized, “It’s okay to take a break. And yes, you can take a day off.” Other leaders discussed the importance of the weekend as a time for replenishment, “Trying to disconnect from work on the weekends actually brings me energy” (P9). Creating the space for vacation time was also discussed as a key to vitality.Given the above discussion highlighting leaders’ vitality, the final research question that this study aimed to answer was how leaders effectively utilize vitality for their followers.To explore this theme in greater detail, open ended questions were asked detailed in The number one way that leaders expressed using their vitality was for positive relational energy. Sixty-five percent of leaders shared that when they were high in vitality, they readily shared their energy. A leader (P4) explained:It’s contagious, right. And it’s a big part of what has allowed me to build great teams, and benefit from being a part of great teams, is being able to bring that that energy, to be a spark, to be a source of strength and confidence and influence, it’s rewarding for me, and I think it creates a great environment within which people like to work.The same leader also recognized that the opposite was true when he felt drained of his vitality:I tend to show it so people who know me will see it. Then it creates a different set of challenges, because they begin to wonder, is there more here? Do I have something I need to worry about? And so it ends up having a ripple effect.Not as many leaders (40%) realized the impact of negative energy transference. Another interesting observation was that people who self-identified as extroverts shared that their positive relational energy transference felt automatic and was not a conscious choice. However, leaders that self-identified as introverts shared that transferring energy was more of an intentional choice. As one introverted leader (P12) shared, “When I am highly vital, that is when I turn externally because I have all the energy that I need. I am truly fully charged and so I seek others out.”Leaders’ vitality also impacted their curiosity and communication. Thirty-five percent of the leaders explained that when they were high in vitality, they were able to listen to people more actively, ask good questions, were patient in conversations, and focused more on the development of others. Leader (P15) shared, “I am at my best as a CEO. I’m rarely giving answers. I’m rarely solving problems. I’m just listening.” Leaders recognized that the opposite was true when they felt drained of vitality – they become more closed off, short and abrupt in their communication, less curious of others, lacked patience and were unable to listen actively to others. A participant (P9) explained:When I’m emotionally drained or spent it’s just much more of, just the facts. Let’s do what we need to get through this discussion or this meeting. And there’s just a whole different level of energy that I bring to the discussion.Leaders identified how their facial expression and body language changed based on their vitality levels and how that impacted the environment around them. “It’s easy for people to pick up that something’s not quite right, because my facial expressions change, and my body language changes” (P15).Participants (7 out of 20) in the study explained that when feeling high in vitality they created positive, fun environments for others through expressing positive emotions like happiness, passion, gratitude, humor, and used more engaged body language. One leader (P14) explained he was, “Very energetic, enthusiastic, optimistic, contagiously spirited. I know that I can influence if I’m in a good mood, I can influence those around me to be in a good mood.”Leaders were also aware of the negative environment they create when they are feeling drained. Participants shared that they are more irritable, visibly stressed, lack gratitude, use sarcasm, express more negative emotion, and show their drain in their facial expression and body language. One participant (P4) shared, “I was in a meeting the other day and was irritated by something and I was just holding my head.” Environments were also impacted by their levels of encouragement to others.Leaders acknowledged that there was a clear difference in the amount of encouragement they gave others when they were feeling vital. A leader (P5) discussed that when high in vitality he focused on encouraging the people around him, “I use the energy to point out people’s superpowers, what they are great at.” This sentiment was echoed by several (P7) of the leaders. Drains in vitality lead to an overall lack of awareness and emotional intelligence for others. Leaders shared they were less careful in their word choice and less tolerant of others including any mistakes. One leader (P12) explained she has:No extra space for EQ, even if you intellectually know it’s there, I don’t have time. I don’t have time for your feelings. I’ve got way too many of them on my own and I’m just too tired and can’t you all see that we just need to get things done.Given the ripple effect of leaders’ behaviors, a leader’s lack of emotional intelligence can leave followers feeling discouraged and potentially disengaged.A recognition of varying engagement levels was also identified with half of the leaders discussing the differences. Leaders shared that when they felt vital, they had a higher sense of engagement and presence with others. One participant (P1) noted that when he was feeling vital, he was, “engaged. And when I’m engaged, really engaged, that’s going to probably bring out the best of me.” When leaders felt drained, they felt disengaged, an overall lack of enjoyment of their job and they tended to be quieter or more isolated from others.Leaders acknowledged that vitality had a direct relationship with their mental capacity, with high vitality supporting being clear headed, focused, and ambitious; in contrast, drained vitality often contributed to delayed decision making, less ability to get work accomplished, and being more distracted. A participant (P4) explained, “Being clear headed comes with being fully charged.” Another leader (P10) shared the other side of the equation:I think what happens with me is I feel like I don’t have the focus that I need to make sound decisions, I tend to also, take longer to make a decision, just because I just feel that I haven’t really done my work on something. And then sometimes you lose your motivation.It is not surprising from this finding that leaders also felt differences in their visionary leadership based on their vitality levels.Thirty percent of leaders shared that vitality was a direct contributor to how visionary their leadership was. When high in vitality, leaders shared that they had the ability to create vision, think more broadly about the organization, be more creative, and focus on the big picture, which led to more inspiration and motivation of others. One leader (P5) expressed how he uses his vitality for visionary leadership:And then all of those things enabled me to create a vision that people believe, or they say, I think he’s the right guy to follow. It creates this, emotional connection to the vision and what we’re trying to do as a team that’s beyond what’s on the sheet of paper.When drained of vitality, leaders shared that they lacked visionary leadership, were less creative, and lost the ability to see the broader perspective, “You lose the broader perspective that keeps things balanced” (P3).Vitality also had an impact on whether leaders included or excluded others around them. Leaders explained that when they were high in vitality, they tended to be more collaborative, open, and inclusive. One leader (P16) explained that she had the energy to adjust her leadership style based on the needs of the different groups she was working with. She also shared that “I am more open minded to the team’s feedback and suggestions.” Leaders noted that when they felt drained of vitality that they were less inclusive, less collaborative, and less consistent in their leadership. A leader (P12) explained “It’s the time I am the least flexible. And in some ways, it’s probably the least inclusive version of me and the heaviest handed.”This study shows that vitality is essential for both individual leadership abilities and the positive impact on followers. The leaders interviewed were able to easily recall days in which they felt highly vital and the impact that had on their followers. The participants were also highly aware of how they showed up differently when drained. Leaders recognized that being high in vitality allowed them to show up as their best self as one participant (P3) explained, “I feel it’s my times when I am at my best. There’s energy flowing out of me into vessels of people around me.”Vitality is a key to combat burnout, maximize leadership capacity, and help leaders care for themselves with organizational support. This study contributes to the research base in leader vitality and is an important step in understanding how to protect leaders from burnout.Insights from this study shed light on the psychological mechanisms that leaders are aware drain their vitality including emotional labor, self-control, and energy transference, and shows that leaders are mostly unaware of the drain of emotional dissonance. By bringing more top of mind awareness to the negative impacts of emotional dissonance, there is an opportunity to help leaders align their inner and outer emotional worlds to build stronger, more authentic relationships. Leaders must be educated on the multiple mechanisms that drain vitality to illuminate the importance of continually fostering their resources.Additionally, there are differences in vitality drains from energy transference that potentially correlate with the personality traits of extroversion and introversion. Leaders with more extroverted personalities feel less depleted and more energized from sharing positive relational energy, where more introverted leaders feel depleted, which aligns with personality research . Engin DAdditional insights into vitality drains include loss of job control, the unproductive mindsets of others, and isolation created from the role. We often do not think that CEOs perceive low job control, but this study found otherwise. Support for why leaders feel a drain from loss of control comes from a meta-analytical study conducted by Another insight was the impact of other’s unproductive mindsets in draining vitality. People with negative, fixed, and self-focused mindsets were named as significant factors in vitality drains. This finding is consistent with research from Harvard Business Review’s first CEO Snapshot Survey in 2012 found that half of CEOs report experiencing feelings of loneliness in their role, and of this group, 61 percent thought it hindered their performance  which are characterized by an uplifted feeling a person gets through a positive interaction at work . We see Another critical theme that emerged was physical health. Although many leaders know that physical health is important to vitality, leaders often sacrifice their health due to the high demands of their roles. Unfortunately, top level leaders are often deprioritizing physical health, absorbing high levels of stress, traveling extensively, sleeping less, and consuming unhealthy diets, leading to 50% higher costs for health-related illnesses over other level employees . This stTwo other themes emerged including job autonomy and the importance of time away from work. We see that job autonomy, even at the CEO level, is critical to fostering vitality. Support for this finding comes from This study further supports that CEOs and all leaders need to care for themselves in order to care for others including taking time away from work. Although this insight seems obvious, time away from works continues to be a struggle at both top leadership levels and throughout organizations. A study completed in January of 2022 showed that on average, employees in the U.S. had 9.5 unused vacation days left at the end of 2021 . CEOs noOne of the most interesting insights of the study is how leaders utilize their vitality for their followers and the potential negative consequences to their leadership when drained. This study further underscores the importance of vitality as a key to impacting others. Eight opposing themes emerged around how leaders utilize their vitality for followers. Leaders high in vitality use that positive energy to transfer it to others, create positive and inclusive environments, engage with others, encourage the people around them, show up with curiosity, and overall have more mental capacity for their roles. On the other side, leaders that are drained transfer negative energy, create environments that are negative and exclusive, show up closed and discouraging to others, and have lower mental capacity. Leaders need to care for their vitality not only as a protection against burnout, but also as a key to maximizing their leadership performance.This study also showed that the drains, fosters, and uses of leader vitality are more universal and may not be directly influenced by demographic differences. The sample for this study was intentionally selected to include gender and ethnic diversity as well as cut across multiple industries. Interestingly, there were no significant differences in themes based on demographic or industry factors. This homogeneity shows that leader vitality may be a general concept at the CEO level and potentially more influenced by personality traits. However, more research should be done with larger sample sizes to confirm this finding.This study provides insight into leader vitality from the perspective of some of the most influential and pressured leaders in the country. The hope is that this knowledge can now be applied to a broader leadership audience and make a significant contribution to how organizations support leaders in the future with a focus on leader vitality.There are several limitations of this study that could be addressed with future research. First, this study focused on leaders only in the US, limiting the generalizability of the results. Also, the qualitative study is an extreme sample from the top level of US based organizations. Future research should include international participants and leaders at multiple levels. Another limitation of this study is related to diversity. This study used convenience sampling, which limits the diversity of participants. It is important to study leader vitality and well-being in larger and more diverse samples across multiple countries. This study was also cross-sectional in nature which makes the findings limited. Future longitudinal research could help us better understand leader vitality over extended periods. Future research can further explore the early findings in personality dimensions for vitality and should explore the Big Five factors of personality. Finally, given the unexpected absence of positive emotions as a theme in fostering vitality, additional studies can explore this finding.This study helps to further the academic research in leader vitality by providing a summary of what drains and fosters this important resource. The importance of vitality as a foundation to leadership was clear from the results: leaders need to care for themselves to care for others. “You cannot serve from an empty vessel” . This stThe original contributions presented in the study are included in the article/The studies involving humans were approved by Claremont Graduate University IRB. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.The author confirms being the sole contributor of this work and has approved it for publication.


Haematological patients are more susceptible to infections. Vaccination has always been the most effective primary prevention strategy, even during the COVID-19 pandemic. However, the efficacy of vaccines for some haematological patients is low. Although vaccination of Healthcare Workers (HCWs) could protect patients from vaccine-preventable diseases, there is evidence of a high level of hesitation among healthcare workers in Italy. The aim of this study was to explore the attitudes towards vaccination of HCWs caring for haematology patients. Qualitative descriptive design was conducted. Twenty-one HCWs were interviewed. Content analysis was applied to the qualitative data. The following themes were generated from the analysis: “Trust”, “Decision-making process focusing on individual health”, “Decision-making process focusing on community health”, “Changing opinion”, and “Two sides of vaccination commitment”. The most hesitant HCWs were oriented towards individual health. They perceived a lack of benefit from vaccines, feared side effects, or were influenced by negative experiences of others. In contrast, community-health-oriented HCWs showed more positive attitudes towards vaccination. Some hesitant HCWs changed their opinion on vaccination because they began to reflect on the importance of vaccination for the community. The change in opinion of some HCWs interviewed provided insight into the importance of focusing organisational efforts on collective responsibility. In caseoversial . Frenzeloversial  showed toversial  but alsooversial . Severaloversial , especiaoversial . The sproversial . Vaccineoversial . Among toversial ,23, and oversial . Anotheroversial ,25. In cThe study was conducted in Italy in two different sites. The two centres were chosen as representative of a heterogeneous landscape characterizing the spread of COVID-19 in Italy at the time of interview. Site 1, a University Hospital in the Country’s North-East region, was in an area of moderate risk for contagion. It was subject to medium intensity preventative restrictions. However, it stood geographically close to the nation’s worst hit region, with growing concern of virus circulation. Site 2, a Tertiary Hospital located in the South, was in a low-risk area, with light restriction measures, but witnessed a surge in the number of people affected by SARS-CoV-2 .A Qualitative Descriptive design  was condPurposive sampling was performed. Physicians, nurses, and nurse aides (NAs) were interviewed after signing the informed consent. Inclusion criteria for enrolment were age of 18 and older and active service in the Department of Haematology or Bone Marrow Transplant Centre for at least 1 year.A semi-structured 30 min interview was conducted face-to-face by a single interviewer. The interviews were conducted using a format to guide the questions .The items recorded for each subject included age, gender, education, and years of work experience. The interviews were conducted until the subjects were saturated.The interviews were audio recorded, with permission from the interviewees, and transcribed verbatim by 3 authors . To ensure anonymity, the participants were assigned an identification code upon transcription.Familiarization with the source material through multiple readings of the transcriptions;Identification of meaningful phrases relative to the subject’s inclinations, preconceived ideas, and intentions toward vaccines;Labelling of topical phrases;Arrangement of the labels in patterns based on similarities and definition of categories;Content analysis was applied to the qualitative data, wherein each transcription was analysed independently by 2 authors , and themes were generated. No software was used for data analysis. The analytical process consisted of 4 phases:The analysis process was then reviewed by a third author (T.G.), and the data were tested for coherence with the labels. At this time, field notes gathered during the interviewing and analysis processes were discussed, and the authors examined how their perceptions contributed to the shape and developed their understanding of the data.Field notes were collected during the interviews and data analysis. To increase the validity of the findings, feedback was sought from the participants, ensuring that their meanings and perspectives were represented and not limited to the researchers’ agenda. Ethical approval was obtained from both sites’ Research Ethics Committees (N).Twenty-one HCWs  were interviewed across the two sites from January 2021 to July 2021. The study was conducted during the first vaccination campaign for COVID-19. Most participants were female (85.7%) with an average age of 47 (min–max 26–62). In total, 92.3% of NAs and nurses had more than 10 years of work experience, while 50% of physicians had less than 5 years. The individual demographics of the HCW are given in detail in The intentions to be vaccinated against SARS-CoV-2 and other viruses were mixed: HCWs were more likely to take the COVID-19 vaccine rather than the flu vaccine. The differences and similarities that emerged from the interviews regarding HCWs’ attitudes between the COVID-19 vaccine and other vaccinations will be further reported for each theme/sub-theme. Nurse aides were most hesitant about vaccination, followed by nurses. The physicians interviewed, on the other hand, showed complete adherence to vaccination campaigns for COVID-19 and other infections.Following data analysis, the attitudes of HCWs in Italy toward the vaccines were allocated to one of five themes: “Trust”, “Decision-making process focusing on individual health”, “Decision-making process focusing on community health”, “Changing opinion”, and “Two sides of vaccination commitment”. The most prevalent theme in interviews of HCWs who intended to get vaccinated against COVID-19 was Trust.For most of the NAs and some nurses, trust in the novel COVID-19 vaccine was a direct consequence of trust in the National Regulatory Institutions who presided over vaccine development, safety control, and release for public use . These NAs expressed faith that the health authorities had upheld their role in guaranteeing that shortcuts were not taken in the race to get vaccines approved.“I don’t think and I never thought that the stages to develop a vaccine didn’t get observed, had it been dangerous, they wouldn’t have made it, tested it and got it approved.” (NA)“I tried to learn more about the COVID-19 vaccine, I looked it up on PubMed, I read articles, data-sheet. I looked for pre-clinical data and, although I couldn’t find them for this specific vaccine, I found some for other flu vaccines developed via the same method, in which they explained the pharmacodynamic and pharmacokinetic. Considering what risks, we’re facing; any vaccine is fine.”(Physician)Physicians also expressed trust in Health Institutions but felt the need to make an informed decision that took into consideration the new technologies needed to produce an mRNA vaccine, noting to have reviewed research literature to support their choice.“Actually, I don’t trust it … they haven’t shown us sufficient data, we don’t know how the vaccine works. I am the most doubtful about long-term side effects.”(NA)A minority of HCWs, albeit getting vaccinated and believing it might be beneficial for public health, were wary of the vaccine’s long-term effects, and perceived that clinical data were insufficient at the moment.Other HCWs were firmly opposed to vaccine uptake (both COVID-19 and other vaccines) because they lacked trust in clinical trials or substances administered through vaccines. Being the firsts in the country to get vaccinated left some HCWs feeling as if they were being experimented on. This perception was impacted by biases against the pharmaceutical companies developing the vaccine, supported by the belief that clinical trials had not been carried out rigorously and had been rushed.The theme of “Decision making process focused on individual health” contained three subthemes, including “Lack of Perceived Benefits”, “Fear of Side Effects”, and “Negative Experiences of others”. All sub-themes shared the same thought process, which was that the vaccine was a health treatment that only had an impact on individual health.“Because I have never had the flu since when I was young perhaps, it’s been at least 10 years without having the flu or even just high temperature, nothing at all, so I’m sure I won’t even pass it to the patients, because I don’t have it.”(nurse)Some HCWs, prevalently NAs and nurses, perceived a lack of benefit from vaccination, specifically in regard to the flu vaccination. Having never been sick after contracting the flu, they did not consider themselves vulnerable, which then led them to question if vaccination was at all necessary in their case. They claimed to deem their bodies were equipped to protect themselves from illness. Many HCWs argued that the flu vaccine was not necessary in the absence of chronic diseases. Some disclosed that they could excuse the chronically ill at-risk population too from declining to uptake the flu vaccine, as it is, in their experience, a common ailment that does not manifest with severe signs and symptoms.After contracting the disease, some HCWs came to question how useful the COVID-19 vaccine would be in their case, and few mentioned doubts about its benefits for healthy individuals too. In such cases, they held the immune system capable of fighting the disease on its own, with only minor inconveniences, and that enforcing standard precautions and social distancing were the most advisable means of primary prevention. Some nurses, in fact, preferred to only adopt standard precautions and cautious behaviours rather than vaccinate themselves for COVID-19.“If you get the vaccine, but then you catch the virus, you can’t be sure that you are showing mild symptoms because of the vaccine or of your own immune response. See my experience with COVID.”(NA)“I sincerely prefer to take all precautions and behave correctly, as I have done so far, without… that is, I don’t go to crowded places, I don’t do anything, I do everything I can to avoid contagion.”(Nurse)Moreover, one nurse believed that the vaccine for COVID-19 did not help with antibodies’ production, but rather supplied receptors that helped in the early detection of the virus in case of exposure.“With it not being 100% safe, we don’t know what long term effects it may have, that’s why in beginning I was a bit hesitant.”(NA)“However, I’ve always been a bit hesitant, also because I know that vaccines have excipients like lead in it, so they are dangerous for kids.”(Nurse)Among the HCWs interviewed, some NAs and nurses expressed concern about the delayed side effects of vaccines. They thought the side effects were mainly caused by vaccine excipients. Despite fear, many HCWs have subjected themselves and even their children to various vaccinations.“Not in my case directly, but I met a Healthcare worker who says: << getting a vaccine, her first vaccine, my daughter became autistic.>>”(NA)Anecdotal experiences appeared to be salient factors in vaccine hesitancy. Related events of side effects from vaccines, especially in children, were trusted and unchallenged sources of information that resulted in fear of vaccination and led these healthcare workers to start changing their minds about vaccines in some cases.The theme of “Thought process focused on community health” contained three sub-themes, including “Safekeeping family members”, “Ending the pandemic”, and “Preventing Disease for Frail patients”.“I agreed to all the vaccinations that were recommended to me, even the ones that weren’t mandatory, for my daughter’s benefit.”(Physician)Some HCWs said they felt lucky and glad to have received the vaccine before others, and they felt that they were protecting themselves and family members by getting vaccinated.“I’m fully convinced that if we reach an immunity in the population, it will be possible to protect those who can’t get vaccinated for other reasons, and it’s right to have a public health that it’s as possible.”(Physician)“I would probably get this vaccine because this pandemic is part of it, there are many risks for people, I’ve seen that it’s a very aggressive virus, but at the same time I’m not completely convinced because I’m not sure this vaccine will give total immunity.”(Nurse)Some HCWs argued that the COVID-19 vaccine could protect the entire population. They were convinced that even those who could not be vaccinated would be protected from contagion once Herd Immunity was achieved. Many Interviewees said they believed vaccines were the way to end the pandemic and were eager to get vaccinated, even though they retained doubts and concerns regarding the COVID-19 vaccine.“Clearly vaccinations are fundamental both because we’re Health professionals to prevent infecting our frail patients and also because through vaccinations we’re able to eradicate and prevent many diseases.”(Nurse)“I think vaccinations are very important, because they give an acquired immunity, so they contribute to frail people’s well-being.”(Physician)Many HCWs considered it necessary to undergo vaccinations to protect frail people. They thought that prevention was even more important when assisting patients with haematological diseases.“Look, at first I was saying ”No, I won’t get the vaccine.” Now I changed my mind. Maybe because I heard professor ****** speak. So, if you, a professor, get vaccinated it means you have read about it, seen all the characteristics of this vaccine, so I trust you. So, I think I’ll vaccinate. Yeah, I think so.”(NA)“It made me change my mind, but always not for myself, for others... made me think that the vaccine is needed for the people around me, not so much for me… not for the work that asks me to vaccinate myself.”(NA)Some NAs discussed how they came to change their mind and became positively inclined towards the COVID-19 vaccine uptake. Some said that they turned to prominent experts that were interviewed by media outlets, trusting their opinion because they recognised their professional expertise on virology and vaccines. For many however, the deciding factor in overcoming vaccine hesitancy was an honest exchange and dialogue with colleagues, as all interviewees attested many conversations were had at their place of work regarding the COVID-19 vaccine. One NA reported that a change of mind happened when a colleague made them realise the impact that a vaccine would have on the community, and immunocompromised patients specifically, in their case. They came around the idea of getting vaccinated when they shifted their focus from personal benefit to protecting the community.The theme of “two sides of Vaccination Commitment” contained two subthemes, including “Lack of freedom of choice” and “Moral Requirement”.“I must be free … as there is freedom of speech, freedom of vote. One has the right to say no.”(Nurse)“If it’s mandatory, you have to do it, whether you like it or not, you do it and it ends there, but, remove in this way the free will, the freedom of choice especially because it is a vaccine not totally safe.”(NA)Some Nurses and NAs thought it was very serious to impose vaccination on people because it harmed the sphere of personal health. They emphasised that the freedom of choice regarding vaccination was similar to other existing forms of freedom such as freedom of speech and freedom to vote. They thought that mandatory vaccination removed free will and limited freedom of choice, especially considering that they maintained their perplexities on whether the vaccine was really safe.“It is difficult. OK yes, you can make  mandator(Physician)Some physicians believe that making vaccines mandatory for everyone is quite controversial, and, ideally, it would be preferable to empower to people to make this choice on their own and to consider how their choices affect public health.“It’s a moral obligation that health professionals have towards the population. More than an institutional obligation it should be a moral obligation.”(Physician)“In the past the obligation to vaccinate helped overcome big pandemics and such, so it will with this one! Let’s hope it won’t be needed for people to understand that vaccination is important, even without making it mandatory.”(Nurse)Many healthcare workers, especially physicians, were in favour of the vaccination requirement, especially in regard to the COVID-19 vaccine. They were in favour of the vaccination requirement, especially to achieve herd immunity as soon as possible and to bring benefits to the whole population. They also thought that it was not preposterous to make vaccination COVID-19 mandatory, especially considering that many vaccinations in Italy already were. Some, however, thought that vaccination for health professionals should be perceived as a moral obligation. They hoped that people would understand the importance of vaccination, regardless of the obligation that could be imposed on them.Vaccination attitude is a controversial topic worldwide in different populations, including HCWs . This quOne of the main themes emerged in the interviews was trust. Similar to other findings ,28, mostWe found several reasons behind HCWs’ hesitancy toward vaccination. The most important barrier regarding vaccination was to consider only their individual health in the decision-making process. In this perspective, similar to other findings ,31,32,33One unexpected finding from the interviews was the change in opinion. The triggers that led some participants to decide to vaccinate, despite initially being hesitant, were the opinion of experts and sharing with colleagues. In particular, colleagues seemed to have played a key role in helping an NA understand the importance of vaccination for immunocompromised patients and the community. It could be hypothesised that focusing the minds of vaccine hesitant HCWs on the risks others might face rather than on protecting themselves from the disease might be the key to promoting vaccine uptake. This would be particularly relevant in Haematology departments, where patients are undergoing lymphodepletion treatments, and vaccination is often ineffective for them .The second factor that influenced a change in intentions was the intercession of a persuasive figure. In some cases, the tipping point for the undecided were interviews released by pre-eminent experts in the field of virology and infectious diseases through various media platforms. We also attributed to this category the “lead by example” phenomenon, wherein people felt reassured about the risks and potential side effects once they saw doctors advocating for vaccines, receiving their shots.A persuasive figure could also be a colleague or friend. In this instance, we found that the opinion of a colleague that was held in high regard was indeed more incisive than the recommendation of the Head of Department or Hospital Management. This indicated that we should acknowledge the responsibility of medical professionals to be informed when discussing health-related topics and presenting their own opinions.Lastly, we wanted to explore how HCWs felt towards vaccine mandates. At the time the interviews took place, Italian lawmakers were discussing the possibility of requiring all HCWs to be vaccinated against COVID-19. On 1 April 2021, vaccination for HCWs became mandatory for access to the workplace.Interviewees were split on two stances: those who thought it was necessary to establish mandatory vaccination for COVID-19 for all HCWs and those who dithered on whether that would be an infringement on people’s rights. Many who did not support a state mandate said that they thought it would not be an effective measure to impose vaccine uptake. Some health workers, especially those who had decided to vaccinate for community health, argued that vaccination should be not so much a legal requirement but rather a moral obligation.The study had several limitations. Even if a qualitative approach could explain and deeply understand some complex phenomena such as vaccine hesitancy, it was not possible to characterise the different perspectives between healthcare professions, partly due to the limited number of their representatives. However, the nuances that emerged from the different professionals allowed a deeper description of the categories and a wider framework of the phenomenon. The generalisability of the study findings was limited and was context dependent. Having conducted the interviews over a wide period of time increased the knowledge of the phenomenon studied. However, the interviewees may have been influenced by the contextual and upcoming situations. Although a possible vaccination obligation for healthcare workers was discussed during the first interviews, it had not yet been formalised until 1 April 2021. Therefore, some HCWs may have changed their attitude.Non-vaccinated Health Care Workers may be a potential source of infection for patients Compliance with the immunisation schedule of HCWs working in these settings is even more important. The change in opinion of some HCWs interviewed provided insight into the importance of focusing organisational efforts on collective responsibility. Many HCWs felt that concern for their individual health was not a key element in their choice to vaccinate, yet they changed their perspective when they focused on Collective Health. Strategies focusing on collective responsibility could foster the attitude of the more hesitant HCWs. Vaccination communication campaigns focused on the belief that one’s own vaccination will protect others could be a successful strategy to promote a sense of moral duty.Furthermore, raising awareness among HCWs, especially NAs, about the important risks faced by Haematological patients could encourage their attitude. These communication campaigns should focus on the impact of vaccinations on all preventable diseases for Haematological patients. This also applies to flu vaccinations, which are often not seen as necessary for themselves and others.