Characteristics of Participants
Twenty participants were recruited. Mean age was 44.85 ± 10.05 years. Demographic material and disease information of participants were demonstrated in Table 2.
Table 2
Characteristics of enrolled BC patients
Characteristic
|
Participants
|
Age, n (%)
|
|
18–44
|
12 (60)
|
45–54
|
5 (25)
|
55–64
|
1 (5)
|
65–74
|
2 (10)
|
BMI, mean (SD)
|
23.44 (3.72)
|
Marital status, n (%)
|
|
married
|
20 (100)
|
Job, n (%)
|
|
employed
|
16 (80)
|
unemployed
|
4 (20)
|
Education level, n (%)
|
|
Primary school
|
2 (10)
|
Middle school
|
5 (25)
|
High school
|
7 (35)
|
College or above
|
6 (30)
|
Monthly income, n (%)
|
|
<1000
|
1 (5)
|
1000 ~ 3000
|
5 (25)
|
3000 ~ 5000
|
9 (45)
|
> 5000
|
5 (25)
|
Disease stage, n (%)
|
|
Stage Ⅰ
|
4 (20)
|
Stage Ⅱ
|
5 (25)
|
Stage Ⅲ
|
8 (40)
|
Stage Ⅳ
|
3 (15)
|
Surgery, n (%)
|
|
Yes
|
8 (40)
|
Not
|
12 (60)
|
Catheter placement, n (%)
|
|
PICC
|
10 (50)
|
PORT
|
7 (35)
|
Others
|
3 (15)
|
Preferences type of PA, n (%)
|
|
Walking
|
12 (60)
|
Yoga
|
2 (10)
|
Swimming
|
1 (5)
|
None
|
5 (25)
|
Usage of “Breast Care” of phone users
Participants’ usage behavior identified at portal site indicated the accumulated app usage time was 40 minutes a week. Most of the time spent on knowledge browsing, in which headline information were read most. On contrast, clients’ active retrieval behavior was less. Average login time of each participant was three times a week.
Quantitative Results
Baseline PA assessment
Based on PA capability assessment and baseline IPAQ-L investigation, 12 patients were divided into active group and 8 patients were in sedentary group.
Primary Outcome: Change of PA
For primary outcome, the total PA increased 945.70 MET-min/w with a significant improvement (P = .04) after 3-month, details shown in Table 3. Except dimension of occupational PA had a decreased trend (-177.25 MET-min/w), the other three domains of PA showed an increasing tendency. Post-pre leisure-time PA improved the largest with a mean of 592.35 MET-min/w, followed by self-powered transport PA and household and yard work PA. Sedentary mean time declined 112 mins/w, while it didn’t show statistically significant (P = .49). From the point of domains of PA, self-powered transport PA and leisure-time PA demonstrated a significant increasing changing (P = 0.046 & P = .01). Whilst for levels of PA with different intensities aspect, walking displayed a statistically significant improvement after intervention (P = .03).
Table 3
PA behavior changing after intervention of BC patients (MET-min/w)
Variables
|
|
Pre-intervention
|
Post-intervention
|
Post-intervention - pre-intervention
|
Z b
|
P Value
|
|
|
Mean
|
SD
|
Mean
|
SD
|
Mean
|
SD
|
Dimension of PA
|
Occupational PA c
|
258.10
|
586.58
|
80.85
|
212.92
|
-177.25
|
588.80
|
1.153
|
.25
|
|
Self-powered Transport PA d
|
453.98
|
583.35
|
864.08
|
742.75
|
410.10
|
884.56
|
-1.994
|
.046a
|
|
Household and yard work PA d
|
96.25
|
286.64
|
216.75
|
491.63
|
120.50
|
602.82
|
-0.968
|
.33
|
|
Leisure-time PA d
|
478.50
|
715.82
|
1070.85
|
790.73
|
592.35
|
1010.56
|
-2.541
|
.01a
|
Level of PA
|
Walking d
|
1098.08
|
1119.76
|
2002.28
|
1141.07
|
904.20
|
1632.34
|
-2.173
|
.03a
|
|
Moderate PA d
|
140.75
|
372.57
|
230.25
|
487.31
|
89.50
|
659.18
|
-0.785
|
.43
|
|
Vigorous PA c
|
48.00
|
214.66
|
0.00
|
0.00
|
-48.00
|
214.66
|
-1.000
|
.32
|
Sedentary time (mins/week)
|
901.50
|
309.96
|
1013.25
|
449.46
|
-111.75
|
623.99
|
-0.685
|
.49
|
Total PA d
|
1286.83
|
1289.01
|
2232.53
|
1457.76
|
945.70
|
2059.04
|
-2.053
|
.04a
|
a P<0.05
b Wilcoxon signed rank test
c is based on negative rank
d is based on positive rank
|
As shown in classification of different PA levels in Table 4, percentage of participants with sedentary lifestyle decreased from 40–10%, and percentage of participants with moderate PA/active lifestyle increased from 60–90%. An apparent rise was observed in regard with numbers of patients who met guideline PA recommendation.
Table 4
Classification of different PA levels after mHealth intervention
Classification of PA levels
|
Pre-intervention
n (%)
|
Post-intervention n (%)
|
Sedentary
|
8 (40%)
|
2 (10%)
|
Moderate
|
10 (50%)
|
14 (70%)
|
Active
|
2 (10%)
|
4 (20%)
|
Meeting guideline recommendation (above 540 MET-min/w)
|
12 (60%)
|
19 (95%)
|
Second Outcome: Change of exercise self-efficacy, cancer-related fatigue, sleep quality, mood status and QoL
For secondary outcomes, the results presented that there was a significant difference in situational factors of exercise self-efficacy (P = .02) and depression (P = .02) between baseline and after intervention. Notably, mean level of depression of the participants after the intervention showed a higher score than baseline, while still in normal level (mean score = 4.05 VS mean score = 6.30,P = .02). In addition, increasing trend of exercise self-efficacy was found in every domain and the total score. Details were shown in Table 5.
Table 5
Exercise self-efficacy, cancer-related fatigue, sleep quality, depression, anxiety, QoL change from baseline to post-intervention of BC patients
Variables
|
Pre-intervention
|
Post-intervention
|
Post-intervention- pre-intervention
|
t/Z
|
P Value
|
|
Mean
|
SD
|
Mean
|
SD
|
Mean
|
SD
|
Exercise self-efficacy
|
|
|
|
|
|
|
|
|
Total score d
|
46.78
|
21.92
|
53.82
|
13.59
|
7.04
|
21.62
|
-1.207 b
|
.23
|
Situational factors
|
41.00
|
23.85
|
56.08
|
14.34
|
15.08
|
25.31
|
2.665 c
|
.02a
|
Competitive factors d
|
57.30
|
24.24
|
58.70
|
15.22
|
1.40
|
21.56
|
-0.022b
|
.98
|
Interpersonal factors
|
44.21
|
24.83
|
48.40
|
18.35
|
4.19
|
28.69
|
0.652 c
|
.52
|
Cancer-related fatigue
|
|
|
|
|
|
|
|
|
Total score d
|
1.88
|
0.64
|
1.92
|
0.51
|
0.04
|
0.75
|
-0.411 b
|
.68
|
Physical fatigue
|
2.13
|
0.72
|
2.18
|
0.65
|
0.05
|
0.90
|
0.248 c
|
.81
|
Emotional fatigue e
|
1.81
|
0.82
|
1.73
|
0.59
|
-0.08
|
0.81
|
-0.141 b
|
.89
|
Mental state d
|
1.66
|
0.71
|
1.84
|
0.49
|
0.18
|
0.86
|
-1.097 b
|
.27
|
Sleep quality
|
|
|
|
|
|
|
|
|
Total score
|
7.70
|
2.94
|
9.15
|
4.13
|
1.45
|
3.97
|
1.635c
|
.12
|
Subjective sleep quality d
|
1.10
|
0.72
|
1.15
|
0.99
|
0.05
|
1.00
|
-0.159 b
|
.87
|
Sleep latency d
|
1.50
|
0.89
|
1.80
|
0.83
|
0.30
|
0.98
|
-1.396 b
|
.16
|
Sleep duration f
|
2.00
|
0.00
|
2.00
|
0.00
|
0.00
|
0.00
|
0.000 b
|
\
|
Habitual sleep efficiency d
|
0.85
|
1.04
|
1.30
|
1.21
|
0.45
|
1.36
|
-1.468 b
|
.14
|
Sleep disturbance d
|
1.15
|
0.37
|
1.40
|
0.68
|
0.25
|
0.64
|
-1.667 b
|
.10
|
Use of sleeping medication d
|
0.10
|
0.31
|
0.25
|
0.72
|
0.15
|
0.81
|
-0.707 b
|
.48
|
Daytime dysfunction d
|
1.00
|
0.86
|
1.25
|
0.97
|
0.25
|
1.12
|
-0.929 b
|
.35
|
Mood Status
|
|
|
|
|
|
|
|
|
Depression
|
4.05
|
3.56
|
6.30
|
2.81
|
2.25
|
3.89
|
2.586 c
|
.02a
|
Anxiety
|
6.15
|
3.01
|
6.25
|
2.88
|
0.10
|
3.89
|
0.115 c
|
.91
|
QoL
|
|
|
|
|
|
|
|
|
Total score
|
94.45
|
19.48
|
91.60
|
18.01
|
-2.85
|
20.84
|
-0.611 c
|
.55
|
Physical well-beinge
|
20.40
|
5.33
|
20.70
|
5.29
|
0.30
|
5.15
|
-0.119 b
|
.91
|
Social well-being
|
18.70
|
4.86
|
17.35
|
5.25
|
-1.35
|
7.56
|
-0.799 c
|
.43
|
Emotional well-being
|
17.20
|
3.50
|
17.00
|
3.20
|
-0.20
|
3.11
|
-0.288 c
|
.78
|
Functional well-being
|
13.85
|
7.39
|
14.05
|
6.69
|
0.20
|
7.97
|
0.112 c
|
.91
|
Breast specific well-beinge
|
24.30
|
5.69
|
22.50
|
3.87
|
-1.80
|
4.56
|
-1.797 b
|
.07
|
a P < 0.05 |
b Wilcoxon signed rank test |
c Paired t test |
d is based on positive rank |
e is based on negative rank |
f The sum of negative ranks is equal to the sum of positive ranks. |
Qualitative Results
After 3-month intervention, five of twenty participants agreed to receive the interviewing. Basic information of users was displayed in Table 6. Four themes were categorized by content analysis.
Table 6
Basic information of patients participated qualitative interview
Case Number
|
Age
|
Education level
|
Job status
|
Smartphones system
|
U1
|
40
|
Middle school
|
At work
|
iOS
|
U2
|
41
|
Middle school
|
At work
|
Android
|
U3
|
40
|
High school
|
At work
|
Android
|
U4
|
30
|
Associate college
|
At work
|
iOS
|
U5
|
59
|
Middle school
|
Retired
|
Android
|
Improvement on cognition of PA
Positive feedback was received from five participants about improvement on PA cognition. Gained knowledge on PA especially on benefits of PA increased their confidence on PA engagement.
“I feel puzzled in the beginning of chemotherapy. Through the app and weekly SMS reminders, now I know except the two days doing chemo, other days during course of chemo, I could do some exercise.” (U1)
“I need to go back to work when I finish chemotherapy. I am following your instruction to walk 6,000 steps per day, the intensity is acceptable, and I will insist on walking and feel motivated for long-term physical health. (U4)
“My family didn’t allow me to exercise and do housework, they hold opinions of rest for better recovery. While I have nothing to do, information on the app give me confidence to do something I am qualified.” (U5)
Satisfaction with user interface and mobile timely feedback of the App
Of five users, two participants explicitly stated satisfaction of user interface of “Breast Care”. Besides, timely feedback of the app was emphasized by users. They admired the feedback information bringing about a sense of caring and self-controlling.
“The brochures you sent are very clear. Step by step, the application is easy to use and the interface is friendly” (U2)
“Color and collocation of the app's whole interface looks very comfortable” (U4)
“Once receiving short message, I will log on to browse your recommended videos or essay. In addition, your weekly message encourages me to do better next week.” (U2)
“Information pushed to my mobile phone at 9 pm everyday will remind me the gap between actual steps and step goals, with those tips I wound intend to walk more the next day.” (U3)
“I had a good exercise habit before, your weekly SMS told me I rank first, I feel so happy and have a great sense of accomplishment.” (U4)
Perceived benefits of mobile PA intervention
Participants expressed benefits in aspect of getting knowledge and self-management skills through the app.
“Content in the app is good and comprehensive. When I have some questions about treatment, I will log in and look for stuff I am interested in, such as chemotherapy precautions. After all, they are managed by professionals and are relatively trusted.” (U1)
“Headline information in homepage I read the most. I could see it updated frequently. I also use the Calendar to mark dates of chemotherapy, it’s convenient of the automatic calculation.” (U1)
Future advice to application and intervention
Within three months using period, users also pointed out some advice about “Breast Care V1.0” including technique functions and using experiences, especially on desire of online communication with peers.
“To be honest, the usage time of app is not very much. What I should know is almost know already. If it provides continuing feedback for a long time, that will be nice.” (U2)
“Sometimes it's not smooth when watching the video. The buffer is very long, but it's much better to watch it again.” (U3)
“I want to share my feelings with somebody else, but I think the number of people post their feelings in this app is not much. When there are more discussions, I'm willing to use them often.” (U4)