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Regular participation in physical activity (PA) is associated with improved physical and psychosocial outcomes in cancer survivors. However, PA levels are low during and after cancer treatment. Interventions to promote PA in this population are needed. PA mobile apps are popular and have potential to increase PA participation, but little is known about how appropriate or relevant they are for cancer survivors.
This study aims to (1) assess recruitment, study uptake, and engagement for a publicly available PA mobile app (GAINFitness) intervention in cancer survivors; (2) assess cancer survivors’ attitudes towards the app; (3) understand how the app could be adapted to better meet the needs of cancer survivors; and (4) to determine the potential for change in PA participation and psychosocial outcomes over a 6-week period of using the app.
The present study was a one-arm, pre-post design. Cancer survivors (N=11) aged 33 to 62 years with a mean (SD) age of 45 (9.4), and 82% (9/11) female, were recruited (via community/online convenience sampling to use the app for 6 weeks). Engagement with the app was measured using self-reported frequency and duration of usage. Qualitative semi-structured telephone interviews were conducted after the 6-week study period and were analyzed using thematic analysis. PA, well-being, fatigue, quality of life (QOL), sleep quality, and anxiety and depression were self-reported at baseline and at a 6-week follow-up using the Godin Leisure Time Exercise Questionnaire (GLTEQ), the Functional Assessment of Cancer Therapy-General (FACT-G), the Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue Scale Questionnaire, the Health and Quality of Life Outcomes (EQ5D) Questionnaire, the Pittsburgh Sleep Quality Index (PSQI), and the Hospital Anxiety and Depression Scale (HADS), respectively.
Of the people who responded to the study advertisement, 73% (16/22) agreed to participate and 100% (11/11) of the participants who started the study completed all baseline and follow-up outcome measures and the telephone interview. On average, participants used the app twice a week for 25 minutes per session. Four themes were identified from the qualitative interviews surrounding the suitability of the app for cancer survivors and how it could be adapted: (1) barriers to PA, (2) receiving advice about PA from reliable sources, (3) tailoring the application to one’s lifestyle, and (4) receiving social support from others. Pre-post comparison showed significant increases in strenuous PA, improvements in sleep quality, and reductions in mild PA. There were no significant changes in moderate PA or other psychosocial outcomes.
All participants engaged with the app and qualitative interviews highlighted that the app was well-received. A generic PA mobile app could bring about positive improvements in PA participation and psychosocial outcomes among cancer survivors. However, a targeted PA app aimed specifically towards cancer survivors may increase the relevance and suitability of the app for this population.
It is estimated that 1 in 2 people born in the United Kingdom (UK) after 1960 will develop cancer during their lifetime [
Fatigue [
Despite the benefits of PA, only 35% of cancer survivors engage in at least 2 hours of PA per week compared to 45% of those without a history of cancer [
The majority of PA interventions involve considerable contact between health care practitioners and fitness professionals delivering the PA program to participants. They often use face-to-face delivery methods and/or frequent structured support with a health professional or member of the research team [
The rising use of mobile phones and mobile technology has afforded the opportunity to develop a relatively low-cost approach to intervention delivery with the potential to reach a large number of users. The most recent Ofcom report (2015) [
Currently there are few mobile apps specifically aimed at promoting PA among cancer survivors, particularly outside of the research context. Therefore the aims of this study are (1) to assess recruitment, study uptake, and engagement for a publicly available PA mobile app intervention amongst breast, prostate, and colorectal cancer survivors; (2) to assess the attitudes of breast, prostate, and colorectal cancer survivors towards a publicly available PA app; (3) to understand how a PA app for the general population could be adapted to better meet the needs of cancer survivors; and (4) to determine the potential for change in PA and psychosocial outcomes (fatigue, well-being, sleep quality, QOL, anxiety and depression) which could be tested in a future randomized controlled trial (RCT).
This study uses a one-arm pre-post design with a 6-week follow-up using both qualitative and quantitative techniques. Techniques were selected to ascertain qualitative feedback for intervention development and to model the data collection and intervention process, and outcomes in accordance with the Medical Research Council (MRC) guidance for development of complex interventions [
Participants were recruited via posters, short recruitment messages on the Cancer Research UK forum, and social media cancer support groups using online and community-based methods. Eligibility criteria included adults aged 18 years or older who have received a diagnosis of breast, prostate, or colorectal cancer and who have finished primary curative treatment. As the mobile app was only available on the iOS operating system, participants were also required to own an iPhone to test the application during the study period. The recruitment period lasted 10 weeks.
The app chosen for this study was GAINFitness; a free, self-guided PA app aimed towards the general population. GAINFitness is currently available for download on the iOS operating platform via the Apple App Store. The authors have no association with the developers of GAINFitness. GAINFitness was selected as it provides a PA program based on the user’s goals, current fitness level, and equipment they have access to. Moreover, the app incorporates many features that are common among popular PA apps available for public use. On the first use of the app, users are asked a series of questions to tailor the recommended PA program. First, users are asked to identify their fitness goal, the usual location of their PA (eg, at home, the gym, or on-the-go), their desired duration of a workout, and whether they prefer a balanced workout or wish to focus on a particular muscle group (
To the best of our knowledge, no other study has used GAINFitness as a PA intervention nor is there any published literature regarding its development or theoretical basis. Attempts to contact the developers regarding its development and theoretical underpinnings were unsuccessful. However, the Behavior Change Taxonomy [
Identify exercise goal, location, duration, and muscle group.
Identify accessible exercise equipment.
Identify preferences for fitness pack, fitness level, warm up and cool down preferences, and breaks between exercises.
Identify workout schedule and reminders.
Still image from motion video demonstration and trainer tips instructions on how to perform each exercise.
Semi-structured interviews were conducted via telephone after the 6-week study period. The interviews aimed to gain in-depth data about the participants’ opinions and experiences having used the app, whether they felt it was appropriate for cancer survivors, and if appropriate, how it could be better adapted to suit their needs. Interviews were recorded with permission of participants, guided by a semi-structured interview schedule (
Broad interview topic and discussion points
App features
Which features of GAINFitness did participants like and dislike
Features that could be improved and/or were missing
Thoughts about specific features (eg, video instructions)
Types of workout
Which workout packs they chose to use
Their opinions of the types of packs which were available
Which packs were most suited for them in context of cancer
Workout plan
Did they use the tailored workout program
Their experience and opinions of using this (or not)
Tailoring to cancer survivors’ needs
How appropriate the app/exercise program was in promoting PA to cancer survivors
How could and/or should an app motivate cancer survivors to increase PA (if at all)
Technical experience
How easy to use was the app
Any technical issues experienced
Thoughts about app settings and using the app on a mobile phone from a technical perspective (eg, battery life)
Physical activity
Thoughts about whether participants felt using app increased their PA
Stability of those changes (if changes were made)
Pain and injuries
Did participants experience any pain, injuries or discomfort while exercising using the app
Visuals and layout
Participants’ opinions of the visual/aesthetic aspect of the app (e.g. layout, color scheme)
Outcomes
Thoughts about whether participants noticed any changes in physical activity, quality of sleep, fatigue, mood, well-being
Stability of those changes (if any)
Lifestyle
How did using the app fit in with their lifestyle and needs in the context of cancer
General comments
Overall opinions of the app
Whether they’re intending to continue using the app
Any other comments
In the baseline survey, participants were asked to report standard demographics including age, gender, education level and ethnicity, and weight and height to calculate body mass index (BMI). The questionnaire also included questions on cancer type, cancer stage at diagnosis, type of treatment(s), and time since primary treatment ended (in months).
As the authors have no connection with the developers of GAINFitness, we were unable to obtain objective app usage data (eg, frequency and duration). Instead, participants were asked to complete a log sheet to assess engagement with and usage of the mobile app during the 6-week period. Each time participants used the app they reported the date, duration, and type of each workout (eg, yoga, strength training for legs). Participants reported this information to a research assistant each week via telephone.
Participants completed measures to assess PA and psychosocial outcomes at baseline (0 weeks; T0) and at 6-week follow-up (T1). All measures are valid, reliable, and have been used in previous studies with cancer survivors [
On response to study advertisements, participants were contacted to obtain informed consent and were provided with a participant identification (ID) number to enter for the online surveys. Study participants were emailed a URL link to the T0 survey and 6 weeks later to the T1 survey. Both surveys had a “welcome” and “thank you” page. The T0 survey collected information on standard demographics, weight and height, PA, and psychosocial outcomes whereas the T1 survey collected information on PA, weight and height, and psychosocial outcomes only. All questions were mandatory and respondents were able to review and change their answers prior to submission if required. Internet Protocol (IP) addresses and participant ID numbers were used to check for duplicate surveys. Participants completed the log sheets each time they used GAINFitness. After the 6-week period of using the app, participants were telephoned to take part in the qualitative interview (T1). Ethical approval for the study was obtained from University College London Ethics Committee (Reference: 6510/00).
Recruitment success and engagement with the study was evaluated by the number of participants who agreed to participate and completed the study. Self-reported frequency and duration of app use was calculated from log sheets. Changes in T0 and T1 PA and psychosocial outcomes were analyzed using non-parametric tests. Results were considered significant at an alpha level of .05. Qualitative interview data were transcribed verbatim and analyzed using thematic analysis. Initial line-by-line codes were generated and secondary coding involved identifying links between codes to allow for creation of “themes”. Themes were reviewed and defined as coding progressed, and patterns within the data reported.
The flow of participants through the study is shown in
Flow diagram of participants through the study.
Of the 11 participants who took part in the study, 7 (64%, 7/11) were breast cancer survivors, 2 (18%, 2/11) were colorectal cancer survivors, and 2 (18%, 2/11) were prostate cancer survivors. Participants were mostly female (82%, 9/11), and white British (82%, 9/11). Participants’ age ranged from 33 to 62 years with a mean (SD) age of 45 (9.4). The majority of participants (73%, 8/11) had a BMI in the “normal” range (19-24 kg/m2); however one participant was underweight (BMI 17.5 kg/m2), and two were overweight (BMI>25 kg/m2) (
Baseline characteristics of study participants (N=11).
Characteristic | n (%) | |||
Gender | ||||
Female | 9 (82) | |||
Male | 2 (18) | |||
Ethnicity | ||||
White British | 9 (82) | |||
Polish | 2 (18) | |||
Body mass index (BMI; kg/m2) | ||||
Healthy | 8 (73) | |||
Underweight | 1 (9) | |||
Overweight | 2 (18) | |||
Education level | ||||
Below degree level | 5 (45) | |||
Undergraduate degree | 3 (27) | |||
Postgraduate degree | 3 (27) | |||
Cancer type | ||||
Breast | 7 (64) | |||
Colorectal | 2 (18) | |||
Prostate | 2 (18) | |||
Cancer stage at diagnosis | ||||
Stage 2 | 6 (55) | |||
Stage 3 | 4 (36) | |||
Stage 4 | 1 (9) | |||
Treatments undergonea | ||||
Chemotherapy | 8 (73) | |||
Radiotherapy | 7 (64) | |||
Medication | 5 (45) | |||
Surgery | 7 (64) | |||
Hormonal treatment | 2 (18) | |||
High intensity focused ultrasound | 1 (9) |
aPercentages do not equal 100% as most participants experienced more than one type of treatment.
All participants completed telephone interviews at the 6-week follow-up to discuss their experiences of using the app during the study period. During these interviews, participants reported that they did not experience any injuries or pain during or following the use of the app. Thematic analyses identified the following four themes: (1) barriers to PA, (2) receiving advice about PA from reliable sources, (3) tailoring the application to one’s lifestyle, and (4) receiving social support from other cancer survivors.
The participants discussed some of the barriers they faced towards frequent PA participation and the majority highlighted cancer-related fatigue as the main barrier:
My fatigue is much better now since I finished treatment, but it still gets me bad sometimes.
The only thing that holds me back from exercising frequently, is the fatigue, it’s always the fatigue. So […] if an app somehow could consider my fatigue on those bad days. [Because] it really demotivates you…like you know when you just can’t complete a workout because of it.
Some participants suggested ways in which they felt a PA app could be adapted or developed specifically for cancer survivors and how this could help to overcome fatigue to encourage PA participation:
The app should ask about your fatigue levels […]. When the fatigue is bad, [it] could give you some type of a yoga workout, where you just breathe and stretch and relax. I think that would nice because then you still move, you still do something.
Another said: On days that fatigue is bad you could have a lighter workout, like stretching or walking […], so you still get that recommended 30 minutes [of exercise].
Particularly for those participants who had been diagnosed with breast cancer, lymphedema was also highlighted as a barrier to PA participation due to the fear and confusion surrounding what would be appropriate PA to carry out. In general, the participants felt that the app suggested suitable and safe exercises for dealing with lymphedema and the associated limitations:
I still have problems with my arm [from lymph node dissection surgery], but I didn’t experience any pain with the arm when exercising with the app. Those type of exercises [are] what the doctor tells you to do in the hospital after your surgery anyway.
You can’t put too much pressure on your arms [after lymph node dissection surgery], but you have to train them too to avoid lymphedema. So I think in those terms the application was really good, definitely suitable.
The app featured visual instructions that demonstrated how to perform the exercises correctly. Participants reported that together with the voiceover, the instructions were particularly helpful and made them feel confident about how to perform the exercises correctly:
[The visuals] were really good because [they] showed you how to do everything and you felt confident that you are doing it right.’
Another said: “The visuals were set to be really slow, so I had time to get into position and knew what to do, so I wasn’t worried about any injuries.
I personally am scared of getting lymphedema, and still don’t know sometimes what exercises are good to prevent it, so I think that maybe educating people about […] consequences of not exercising from a really good NHS source would be helpful.
The participants reported that the app was suitable for use by cancer survivors and did not cause any injuries or specific problems. However, they believed it could be tailored to better suit the individual’s lifestyle and fitness needs of those who have had cancer:
Anyone with any condition could use this program, which is beneficial, but it could be more beneficial […] more tailored to the type of cancer or disease you had, to your lifestyle and fitness goals. I think it could be more fine-tuned to your circumstances, lifestyle, then that would be really helpful.
I think it should be more of a life context rather than just a general program, so there should be a little bit about what you should do post-treatment, and also in a longer term. At first it should be more about trying to get you more active, […], but once your cancer improves, what are you going to do for the rest of your life? Because you need that fitness to prevent it from coming back.
Several participants highlighted that differentiating between the types of treatment they’d undergone, the types of cancer they’d been diagnosed with, and the associated side effects should be considered when adapting a PA mobile app to cancer survivors’ needs:
The issues I might have as a colorectal cancer survivor are very different from the ones than someone who had breast cancer or prostate cancer.
It is important to think about treatment someone had – I think that different treatments for different cancers have different side effects, and that’s important to consider, because it’s the side effects that stop you from exercising.
It could be fine-tuned better to some of the challenges that I’ve got, like muscle wastage [prostate cancer] and so on, and give me something slightly different to do.
The participants also highlighted the importance of a PA app fitting in with the context of the rest of their life, and in relation to cancer survivorship and health promotion:
It could be even linked through NHS so you could have access to your entire medical stuff and give you a nice history of your progress. If you see that your blood pressure lowered because of exercise, [then] that would motivate you to be more active.
You are told to do 30 minutes of exercise a day, so [getting] something like a reminder telling you that you have completed your half an hour, or how much you have got left [of it] would be really good.
I think the app should maybe have like some health tips you know, like facts about cancer and best ways to be active after treatment.
Several participants also discussed the possibility of an overall cancer survivorship app, rather than just focusing on PA:
I think that the app should help with other things than just exercise; it should be more a lifestyle advice too. [Such as] giving you advice on counselling or tips on how to get better sleep or [listing] foods to eat that could give you more energy.
I think that if an app would ask you about your levels of fatigue and about how you sleep, [it] will be nice, because it will be like some sort of a diary where you can look back at your progress not only in terms of exercise but also your well-being and mood. Something to look back at that documents your recovery, because it will motivate you to keep getting better.
Participants reported that having a social component (eg, forum, social network or ability to add friends) within the app was important to them and this was highlighted as something which was lacking in the current app:
It is so important to get in touch with people who went through the same thing as you have. […] I think that if an app for cancer survivors had a forum on it as a part of the application to motivate each other, that would be amazing.
If you are looking at the issues of cancer survivorship, I think personally that for cancer survivors it would be quite nice to link up with other people and build that community.
Another said:
Also social support of course, that’s good, I use those forums and they are very helpful, even with general stuff, not just exercise. Having support from other cancer survivors is very important.
You do need that bit of motivation from other people. It’s all about motivation when it comes to exercise […]. When you feel low and can’t be bothered to go for a walk, maybe someone else saying‘go on, get up and do it, you can do it’would motivate you.
It was also highlighted that a social support group within the app would be very convenient and a desired component if an app were to be developed and adapted:
We have those support groups in the hospital, but me myself I can’t always make it, because we live far from the hospital. I just got an invitation for one of those and I won’t be attending because I am just too busy. And having that support within an app, without having to leave the house would be really nice, to kind of make some contacts and chat to other people about your experiences.
Only one participant needed additional help to install the application. All participants kept a record of their app usage throughout the 6 weeks, however, 9 participants used the log sheets provided and 2 chose to use their own means of logging their usage (eg, personal diaries). All 11 participants provided this data during weekly telephone calls with a researcher. Participants used the app a mean (SD) of 2.07 (0.68) times per week, with a mean session duration of 25.08 (8.22) minutes. App use duration ranged from 24.50 to 91.00 minutes per week with a mean (SD) of 44.00 (20.50) minutes. In the qualitative telephone interviews at T1, five participants (45%, 5/11) reported that they would continue using the application, and 100% (11/11) of participants said that they would continue using the app if it was adapted to better suit the needs of cancer survivors.
The results from quantitative analyses are shown in
Comparisons of baseline (T0) and the 6-week follow-up (T1) physical activity and psychosocial outcome measures using Wilcoxon signed rank tests.
Outcome | T0, median (IQR) | T1, median (IQR) | |||||
Sleep qualityb (PSQI) | 8.0 (15.0) | 6.0 (10.0) | -2.53 | .008 | |||
Strenuous physical activity, min/week | 40.0 (105.0) | 120.0 (150.0) | -2.80 | .002 | |||
Moderate physical activity, min/week | 180.0 (150.0) | 180.0 (330.0) | -0.76 | .563 | |||
Mild physical activity, min/week | 150.0 (90.0) | 80.0 (120.0) | -2.21 | .031 | |||
Fatigue (FACIT-Fatigue scale) | 34.0 (18) | 39.0 (14.0) | -1.27 | .242 | |||
Quality of Life (EQ5D) | |||||||
Mobility | 1.0 (1.0) | 1.0 (0.0) | -1.41 | .500 | |||
Self-care | 1.0 (0.0) | 1.0 (0.0) | 0.00 | 1.000 | |||
Activity | 1.0 (1.0) | 1.0 (1.0) | 0.00 | 1.000 | |||
Pain | 2.0 (1.0) | 2.0 (1.0) | -1.00 | 1.000 | |||
Anxiety | 1.0 (1.0) | 1.0 (1.0) | -1.00 | 1.000 | |||
Well-being (FACT-G) | 40.0 (7.0) | 47.0 (10.0) | -1.85 | .064 | |||
Anxiety (HADS-anxiety scale) | 4.0 (8.0) | 3.0 (7.0) | -1.61 | .137 | |||
Depression (HADS-depression scale) | 2.0 (5.0) | 2.0 (6.0) | -0.32 | .844 | |||
BMI | 23.9 (5.2) | 23.4 (5.0) | -0.25 | .828 |
aExact significance.
bHigher PSQI scores indicate increased reported sleeping problems.
The present study utilized a one-arm, pre-post, mixed-methods design to examine experiences of using a publicly available PA mobile application (GAINFitness) in breast, prostate, and colorectal cancer survivors. All participants (N=11) engaged with the app and qualitative interviews highlighted that the app was well-received. Recommendations were identified on how a PA app may be adapted or developed to increase the relevance and suitability for cancer survivors. Willingness and ability to complete the quantitative PA and psychosocial measures was established as all participants completed survey measures at both time points, with no missing data or reports of dissatisfaction with measurements or study procedures. Significant increases in strenuous PA participation, improvements in sleep quality, and reductions in mild PA participation were observed. There were no significant changes for any other PA or psychosocial outcomes.
Qualitative telephone interviews investigated cancer survivors’ attitudes towards GAINFitness in order to understand the appropriateness of the app for use in this population. Findings from this study suggest that the app and this approach to intervention delivery were well received. Given the rising use of mobile phones and mobile technology [
Interviews showed that video demonstrations twinned with voiceover instructions explaining how to do exercises were valued by participants. The videos provided participants with reassurance that they were performing the exercises correctly and safely. This, in combination with their desire to receive PA recommendations and advice following a cancer diagnosis from reliable (eg, NHS) sources highlights a lack of knowledge of PA and a lack of confidence to perform PA among cancer survivors. Similar findings have been previously reported. For example, one study showed that cancer survivors feel they are given insufficient information regarding PA, diet, and weight [
In interviews, cancer-related fatigue was consistently discussed as an important barrier to PA participation. This supports previous literature that has found similar findings [
The participants’ feedback pertaining to the desire for a feature within the app for social support was also highlighted. The participants felt that it was important to build a sense of community among cancer survivors and an environment in which they could share their experiences and support each other to increase PA participation. This supports findings from a similar Web-based PA intervention for older cancer survivors in which the social community within the program was particularly well-received [
The quantitative outcome measures and online approach to data collection was intended to model the process and outcome of intervention evaluation in line with MRC guidance [
The current study should be viewed in light of a number of limitations. The majority of participants were white, female, breast cancer survivors. Therefore, the results may not be generalized to other cancer survivor populations. Participants in the present study had high baseline levels of PA. Owing to limited awareness of the benefits of PA and guidelines for cancer survivors among health professionals [
The current study demonstrates that cancer survivors engaged with a PA app and this approach to intervention delivery was well-received. However, important factors which are not included in GAINFitness were highlighted. This included not accounting for the effects of cancer-related fatigue, the lack of information provision surrounding PA participation in the context of cancer from reliable sources, the need to consider limitations associated with specific cancer types in relation to PA, and the desire for a way to receive social support from other cancer survivors within the app. There is potential for change in PA and psychosocial outcomes among cancer survivors through the use of this publicly available PA app, however, we recommend that a more targeted PA app aimed towards cancer survivors may increase the relevance and suitability of the intervention for this population and may prove more effective. The findings of this study can be taken forward for intervention development to adapt or develop a PA app for cancer survivors, which should be tested in a larger RCT with objective measures of PA.
behavior change technique
body mass index
Health and Quality of Life Outcomes Questionnaire
Functional Assessment of Chronic Illness Therapy -Fatigue Scale Questionnaire
Functional Assessment of Cancer Therapy-General,
Godin Leisure Time Exercise Questionnaire
Hospital Anxiety and Depression Scale
identification
Living With and Beyond Cancer
mobile health
Medical Research Council
National Health Service
physical activity
Pittsburgh Sleep Quality Index
quality of life
randomized controlled trial
time at baseline
time at the 6-week follow-up
We would like to dedicate this paper in memory of Professor Jane Wardle (1950-2015). AF, LS, and JW are funded by Cancer Research UK. AR is funded by an MRC PhD studentship.
None declared.