A quasi-experimental study was conducted to assess the preliminary efficacy of FPE on psychological health outcomes of BC survivors.

Participants were enrolled in a non-randomized pre-post intervention with a comparison group. Specifically, two groups were involved: an intervention group, composed of women who participated in the photographic and narrative sessions of the FPE, and a comparison group in a waitlist, so that they had the opportunity to participate in the FPE at the end of the intervention (i.e., 3 weeks later). The efficacy of the intervention was measured by a pre-posttest comparison of the selected measures.

Participation in the study was voluntary but limited to the following inclusion criteria: women, aged ≥ 18 years, native Italian speakers, diagnosed with BC, and who had completed their cancer treatments.

Sample size was calculated using G*Power Software 3.1 [22]. Setting α = 0.05 and power (1-β err prob) of 0.80, a total sample of N = 40 was required to detect a small effect size according to criteria for Cohen’s d [23].

Participants were invited to the study using a convenience sampling approach. Patients who met the inclusion criteria were provided with detailed information about the study and the intervention offered as part of the research project. Forty-five women were contacted. Investigators partnered with a non-profit association advocating for psycho-physical rehabilitation for BC survivors who helped to contact the first n = 23 women to whom the study was presented, while the remaining n = 22 were reached through snowball sampling. After a screening for eligibility, forty women accepted to be enrolled in the study and written informed consent was obtained by each of them. Once the a priori sample size was reached, recruitment stopped. As a sign of gratitude and appreciation for their time, participants from the FPE group received a printed copy of the portraits.

The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Approval was obtained from the Ethics Commission for Research in Psychology (CERPS: Commissione Etica per la Ricerca in Psicologia) of the Department of Psychology at Università Cattolica del Sacro Cuore of Milan (Italy), protocol no. 46-23.

A printed data sheet was used to collect detailed socio-demographic and clinical characteristics at pretest. Self-reported questionnaires were administered before and after the intervention. The Italian version of the Body Image Scale (BIS) [24, 25] examined affective, cognitive, and behavioral self-perceptions of body image changes related to the disease and treatment. It consists of 10 items rated on a 4-point Likert scale (from 0 = not at all; to 3 = very much). A total score between 0 (non-compromised body image) and 30 (highly impaired body image) is obtained. BIS is specifically validated with a sample of patients with BC (internal consistency coefficient: α = 0.916); however, since the scientific literature does not provide a cut-off for clinical interpretation, we created 3 ad hoc classes labelled "Good body image" (scores 0–10), “Composite body image” (scores 11–20), and “impaired body image” (scores 21–30), as previously implemented by the authors in earlier works [26].

The Brief-COPE, Coping Orientation toward Problems Experienced questionnaire [27] is designed to measure how individuals cope with stressful life events, and it is often used in health-care settings. It consists of 28 items divided in 14 2-item subscales with good internal consistency, rated on a 4-point Likert-style scale (from 1 = I haven't been doing this at all; to 4 = I’ve been doing this a lot). These subscales can be further grouped into broad categories. Three overarching dimensions considered in the present study, and previously investigated [28], are described below. “Problem focused coping” summarizes facets referring to active coping, use of information support, planning, and positive reframing; high score indicates a hands-on approach to problem solving. “Emotion focused coping” is characterized by venting, use of emotional support, humor, acceptance, self-blame, and religion; a high score shows ability to regulate emotions associated with the stressor. “Avoidant coping” is characterized by self-distraction, denial, substance use, and behavioral disengagement; a high score describes physical or cognitive efforts to disengage from the stressor situation, instead low scores are indicative of respondent’s adaptive coping skills.

The Italian version of the Rosenberg Self-Esteem Scale (RSES) [29, 30] was used to assess patients’ self-esteem. The instrument consists of 10 items, and the respondents are asked to indicate their level of agreement on a 4-point Likert-type scale (from 1 = strongly disagree; to 4 = strongly agree). It has a high internal consistency, with α = 0.84.

The Italian version of General Self-Efficacy Scale (GSE) [31, 32] was utilized to measure one’s belief to reach a goal (i.e., perception of self-efficacy). This instrument consists of 17 items scored on a 5-point Likert scale (from 1 = strongly disagree; to 5 = strongly agree), and it showed good internal consistency with Cronbach’s alpha comprised between 0.64 and 0.74. The scale can be used as mono-dimensional or can allow the detection of three main components (subscales) which refer to Bandura’s socio-cognitive theory [33]: “Magnitude”, measuring the perceived efficacy as regards levels of performance difficulty; “Strength,” as the ability to persevere and cope with obstacles; and finally, “Competence,” referring to a sense of global proficiency in facing problems.

Data were analyzed using IBM SPSS Statistics 27.0. Descriptive statistics (i.e., frequency, mean, and SD) and comparison tests (i.e., χ2 and independent t-test, α = 0.05 two-tailed) were performed to present socio-demographic variables and clinical characteristics of the sample. Independent sample t-tests (p < 0.05) were conducted to assess between-groups differences at pretest. Cohen’s d effect sizes were provided according to criteria (d = 0.2 small effect; d = 0.5 medium effect; d = 0.8 large effect) [23].

Then, a series of mixed between-within 2 (groups: FPE group vs. comparison group) × 2 (assessment times: pretest vs. posttest) repeated measures analyses of variance (ANOVAs) were conducted to compare the two groups at the two measurement timepoints: pretest (T0), posttest (T1: 3 weeks) on body image (BIS), problem-focused coping (Brief-COPE subscale), emotion focused coping (Brief-COPE subscale), avoidant coping (Brief-COPE subscale), self-esteem (RSES), self-efficacy (GSE), magnitude (GSE subscale), strength (GSE subscale), and competence (GSE subscale). Effect size indicators (partial Eta-squared: η2partial) were used to quantify the global difference of the two groups across time. Scores were interpreted with the following benchmarks: small (η2partial = 0.01), moderate (η2partial = 0.06), and large (η2partial = 0.14) [23]. Where interaction effects of the mixed ANOVAs were found to be significant, post-hoc pairwise comparisons with Bonferroni correction were performed.