This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Cancer, is properly cited. The complete bibliographic information, a link to the original publication on http://cancer.jmir.org/, as well as this copyright and license information must be included.
Advancements in mobile technology allow innovative data collection techniques such as measuring time use (ie, how individuals structure their time) for the purpose of improving health behavior change interventions.
The aim of this study was to examine the acceptability of a 5-day trial of the Life in a Day mobile phone app measuring time use in breast cancer survivors to advance technology-based measurement of time use.
Acceptability data were collected from participants (N=40; 100% response rate) using a self-administered survey after 5 days of Life in a Day use.
Overall, participants had a mean age of 55 years (SD 8) and completed 16 years of school (SD 2). Participants generally agreed that learning to use Life in a Day was easy (83%, 33/40) and would prefer to log activities using Life in a Day over paper-and-pencil diary (73%, 29/40). A slight majority felt that completing Life in a Day for 5 consecutive days was not too much (60%, 24/40) or overly time-consuming (68%, 27/40). Life in a Day was rated as easy to read (88%, 35/40) and navigate (70%, 32/40). Participants also agreed that it was easy to log activities using the activity timer at the start and end of an activity (90%, 35/39). Only 13% (5/40) downloaded the app on their personal phone, whereas 63% (19/30) of the remaining participants would have preferred to use their personal phone. Overall, 77% (30/39) of participants felt that the Life in a Day app was
A mobile phone app is an acceptable time-use measurement modality. Improving convenience, user interface, and memory prompts while addressing the needs of older participants is needed to enhance app utility.
ClinicalTrials.gov NCT00929617; https://clinicaltrials.gov/ct2/show/NCT00929617 (Archived by WebCite at http://www.webcitation.org/6z2bZ4P7X)
As mobile phone technology becomes more widely accessible, so does its potential to act as a platform for high-reach physical activity promotion with increased personalization. This area of research is particularly relevant for breast cancer survivors, as it remains one of the most common cancers among women, regardless of race or ethnicity, with approximately 252,710 expected new cases in 2017 [
One limitation of physical activity research to date has been inadequate data relevant to the activitystat hypothesis, which suggests that an increase in physical activity in 1 domain often leads to a decrease in another domain in an effort to keep energy expenditure constant through biological regulation [
In general, many published studies in this area of research have utilized the Multimedia Activity Recall for Children and Adolescents (MARCA), a computerized self-report instrument for time-use measurement [
This study utilized a posttest-only, embedded evaluation research design with concurrent quantitative and qualitative data collection [
Participants in this study included adult women aged 18 to 70 years with a history of ductal carcinoma in situ or stage I-IIIA breast cancer who had completed primary treatment (ie, surgery, radiation, and/or chemotherapy). All participants met eligibility criteria for the parent study, which are described in detail in a previous report [
Following study enrollment, participants attended an orientation session in which they either received a mobile device (ie, Android) with the Life in a Day time-use measurement app (National Cancer Institute prototype version) installed or chose to download the app on their personal phone if it was an Android device. Staff instructed participants on how to generate a user profile and log daily activities within the app. Participants also received a paper-based start-up instruction guide with this information for reference if needed. Participants had access to 23 user customizable activity buttons, one private button, and a
Following orientation, participants were asked to use the time use app to log all activities for 5 consecutive 24-hour days (including sleep time) by pressing the appropriate customized button at the beginning of the activity and again at the end. When logging activities during this period, participants were asked to select up to 3 categories (eg, walking, errand, or appointment) to identify the purpose of the activity. Participants could review and, if necessary, edit tracked activities from the daily log screen of the app (see
Customizable activity buttons for Life in a Day time use mobile app.
Daily log with example activity for Life in a Day time use mobile app.
A self-administered questionnaire assessed baseline demographics (age, race or ethnicity, education, household income, and marital status). Participants also self-reported cancer-related information such as cancer stage, treatment(s) received, and time since treatment. As memory could influence acceptability of the app use, participants self-reported memory difficulties using the 10-item Frequency of Forgetting scale using a 7-point Likert scale [
A self-administered 16-item questionnaire assessed functionality and participant experiences with the time use app (see
Statistical analyses were conducted using SAS 9.4 (SAS Institute Inc, USA). Sample characteristics and Life in a Day satisfaction questionnaire data were summarized using descriptive statistics. Independent samples
A total of 40 participants (response rate of 100%) completed the satisfaction questionnaire after a 5-day trial of the Life in a Day mobile phone app. Sociodemographic, cancer-related, and self-reported memory characteristics are presented in
Baseline sociodemographic, cancer, and memory characteristics (N=40).
Characteristics | Statistics | |
Gender (female), n (%) | 40 (100) | |
Age in years, mean (SD) | 55 (8) | |
Education in years, mean (SD) | 16 (2) | |
White | 29 (73) | |
African American | 9 (22) | |
Other | 2 (5) | |
<10,000 | 2 (5) | |
10,000-19,999 | 1 (3) | |
20,000-34,999 | 4 (10) | |
35,000-49,000 | 6 (15) | |
≥50,000 | 26 (65) | |
Single | 3 (8) | |
Married | 22 (55) | |
Divorced/separated | 9 (22) | |
Widowed | 4 (10) | |
Not married | 2 (5) | |
0 | 4 (10) | |
I | 17 (42) | |
II | 15 (38) | |
III | 4 (10) | |
IV | 0 (0) | |
Yes | 30 (75) | |
No | 10 (25) | |
Yes | 22 (55) | |
No | 18 (45) | |
Less than 1 year | 4 (10) | |
1 to <2 years | 12 (30) | |
2 to <3 years | 7 (18) | |
3 to <4 years | 6 (15) | |
4 to <5 years | 2 (5) | |
5 or more years | 9 (22) | |
Frequency of forgetting (subscore; possible range 5-35) | 23 (6) |
an=39.
Overall, participants had a mean age of 55 years (SD 8) and completed 16 years of school (SD 2). Moreover, the study sample was a majority white (73%, 29/40), married (55%, 22/40), and had an annual income ≥US $50,000 (65%, 26/39). All participants enrolled in the study were female, and most had undergone prior chemotherapy (75%, 30/40) or radiation (55%, 22/40) treatments. Reported time since cancer diagnosis varied between participants, although most (90%, 36/40) indicated that it had been more than a year.
A summary of quantitative responses to Life in a Day evaluation questionnaire items is presented in
Participant age was found to be associated with 2 Life in a Day survey items. Participants who agreed it was easy to edit activities were statistically significantly younger when compared with those who disagreed (mean 53 vs 58 years,
The qualitative dataset consisted of 35 comments across 2 survey items from the sample of 40 participants. For survey item 13a (“what could have made it easier?”), 14 out of 40 (35%) participants provided responses. Moreover, 21 out of 40 (53%) participants provided responses to survey item 16 (other comments). A total of 26 out of 40 participants (65%) responded to at least one of the open-ended survey items, whereas 9 provided comments on both. Qualitative coding of these 2 open-ended survey items yielded several major themes for improving the Life in a Day app. A list of themes and subthemes identified via conventional content analysis is provided in
Participants only completed this open-ended follow-up item if they stated that it was not easy to remember to log activities with the app. A total of 14 participants completed this open-ended item. As noted in
One theme that emerged from the responses was the need for an adjustment period when first using the app with practice time being particularly important for the participants ≥60 years. Issues with multitasking were commonly identified in participant responses (both age groups). Difficulties arose with activity tracking when participants were involved in activities such as running errands or caretaking. In addition to difficulties with tracking activity due to multitasking, some participants expressed the need for a built-in reminder system for the app, with older participants expressing difficulty with the cognitive load burden specifically (
Life in a Day participant mean age by survey item agreement. All statistically significant (P<.05) interactions are denoted with an asterisk (*).
User interface
Multitasking
Convenience
General
Personal phone
Wearability
Reminders
Adjustment period
Improved set-up/orientation
Platform expansion
Minimization of cognitive overload
User interface
Adding activities
Changing activities
Changing categories
Choosing categories
Editing activities
Multitasking
Convenience
Personal phone
Readability
Wearability
Burden
General
Easier than pen and paper
Preferred pen and paper
Time
Adjustment period
Improved training
Insight into time use
Instruction clarity
Minimization of cognitive overload
Comfort with technology
Joint display of participant responses by age category.
Item | Representative open-ended responses | ||
Participant A | “Trial was too short. I needed a small period to get adjusted to having the app.” | ||
Participant B | “If there could be a way to have this device on you, it would be easier to remember to change the activities. Often I had to go find where my phone was, and if I could not locate it, I could not ‘call it’ to locate it!” | ||
Participant C | “I didn’t add enough activities to cover my day adequately and did not adjust it once I left the office.” | ||
Participant D | “...give me a electric shock so that I would remember.” | ||
Participant E | “My biggest problem was remembering to change from one activity to another—running errands was a real pain!” | ||
Participant F | “I did not have a place to keep it. I had to wear pockets and it was difficult to remember to carry it. Would be focused on other things.” | ||
Participant G | “It is hard to remember to track every activity. A sound prompt every 1/2 to 2 hours to remind you to check and see if you are on track and logging the correct or current activity. For example, when you are on the go, and not thinking ahead from 1 thing to the next.” | ||
Participant H | “...time/practice [this was all new so it was easy to forget].” | ||
Participant B | “I found it awkward keeping up with my phone; my real cell phone; the paper handout describing the quick start guide, especially if I was multitasking. Much of my 5 days usage was with my mom who is in a wheelchair, is diabetic, and requires much help. So as I said, trying to keep up with her, keep up with the phone, change my activities, go back to her, take care of myself and family and things I needed to do, go find the phone to change my activities, etc. did become somewhat overwhelming and confusing. Perhaps a device that can be on the person and simplified would be better [at least for people like me!]” | ||
Participant I | “…I found it interesting to document my day. Hopefully, it will encourage me to make some changes for the good to my lifestyle.” | ||
Participant J | “I’m not particularly savvy with the use of all smart ph. I have a blackberry. Honestly, I probably needed a bit more training but my fault for not asking.” | ||
Participant K | “It would be easy to track if you did the same activity for 6-8 hours. However, I might sit down and do accounting for my company, then jump up and load clothes, then jump in the car and travel to the store. I have too many activities during the day for this app. I felt as if it ‘took over my life.’ Not good for an active person that changes activities all day long.” | ||
Participant F | “Did not do correct categories. Item was easy, I was the problem. Does not come easily for me so when I am focused on doing my responsibilities using app suffered.” | ||
Participant H | “I would have less of a problem if this was not a brand new thing for me. The phone seemed to have a mind of its own sometimes. It did not function as easily as it should have probably because I didn't know how to correct an error or find the right item when it went astray.” | ||
Participant E | “I felt the activity tracker did not provide a way to accurately track my activity. TV time, for example, does not mean long term activity as I am constantly up- getting dogs in and out, taking care of my husband, answering the phone, etc.” |
aRepresentative open-ended responses chosen from the 14 respondents.
bRepresentative open-ended responses chosen from the 21 respondents.
Participants were asked if they had any comment regarding the app, and these responses also highlighted issues regarding comfort with technology and burden (eg, time). A total of 21 participants completed this open-ended item. Several participants described experiences in which it was difficult or inconvenient to operate the app due to it not being installed on a personal phone or available in a platform for wearable devices. As presented in
Some participants identified barriers to activity tracking as it relates to the Life in a Day app user interface. Specifically, scenarios involving numerous successive activities were often referenced, and participants found it difficult to perform tasks such as adding or editing activities in these situations. As mentioned before, quantitative data from the survey indicates that older cancer survivors were significantly less likely to agree that it was easy to edit activities. Participants highlighted the need for a more user-friendly interface for individuals with busy lifestyles. Despite the aforementioned limitations with the Life in a Day trial, participants did anticipate positive benefits from utilizing the Life in a Day app.
This mixed-methods study of the Life in a Day time use app provides insight into the acceptability of utilizing mobile apps for activity tracking among breast cancer survivors and advances efforts to address physical inactivity among this population. The Life in a Day app for time-use measurement demonstrated satisfactory acceptability (ie, favorable satisfaction questionnaire ratings), with 77% (30/39) rating it as
Our utilization of quantitative data allowed further exploration into characteristics (ie., age, education, frequency of forgetting) that may have contributed to satisfaction survey responses. Although no associations were found regarding education or frequency of forgetting, results from the analyses indicated that age was significantly associated with both perceived ease of editing activities and ease of remembering to log activities. These findings suggest that older cancer survivors may have increased difficulty when engaged in these 2 aspects of mobile activity tracking. Responses to several other elements of Life in a Day were found to have an agreement rate >80% (ie, easy learning to use the app, easy to read, clear navigation, easy to log activities). These responses were not significantly associated with age and highlight strengths of the app perceived by the overall sample rather than younger or older cancer survivors only. Recently, a 2016 study of health intervention delivery modalities among cancer survivors found that age was negatively correlated with preferences for mobile phone apps [
To our knowledge, this is the first trial testing the acceptability of a time use app in cancer survivors. Additionally, Life in a Day goes beyond existing time use-measurement tools such as the previously described computerized MARCA by utilizing a platform for select mobile devices.
Life in a Day also aims to address limitations associated with 24-hour recall by creating opportunities for real-time assessment, although the option for recall assessment could be used if an activity was missed.
However, some relevant ecological momentary assessment (EMA) studies have been conducted. Although EMA can be used to measure time use, it is distinct from the current app in that EMA uses repeated sampling techniques (eg, every 45 min) to measure behavior or experience rather than continuous, ongoing measurement and, thus, may rely more on retrospection. Moreover, EMA is generally used to study specific behaviors of interest (eg, panic attack/s) [
Moreover, 2 past EMA studies were conducted on specific behaviors (vs general time use) in populations similar to this study (eg, sleep, symptoms, and mood among breast cancer patients receiving chemotherapy [
Another 2 EMA studies were conducted in a different population (college students), with 1 work focused on mind wandering [
Overall strengths of the trial include the use of innovative technology to provide insights into time use of cancer survivors with generally high rates of physical inactivity. Additionally, our mixed-methods approach allowed for a more in-depth understanding of participant experiences with the Life in a Day app. Moreover, our data can assist with developing interventions to improve acceptability and use among older individuals. Limitations of this study include the use of open-ended questions that may limit the breadth of qualitative data obtained as exemplified by the small number of responses across our 2 open-ended survey items. Nevertheless, data obtained yielded qualitative information that expanded our understanding of the age differences noted, with the quantitative data achieving the purpose desired when using a mixed-methods approach. Our study was also limited by a small sample size and completion of the evaluation after only 5 days of app use. Moreover, limited platform availability at the time of the study (Android phones only) may have restricted the number of participants who downloaded the app on their personal phone, which may limit generalizability to future use as platform availability increases. For those participants unable to download the app, the adoption of an extra phone might have confounded acceptability findings. Furthermore, time spent orienting participants to the app might be considered a limitation of this study, as participants attended one 30-min session before beginning the trial to learn the Life in a Day time-use system. Our findings also might not be generalizable beyond groups meeting the study inclusion criteria (eg, noncancer survivors).
This line of research explores the acceptability of mobile time-use measurement among breast cancer survivors and has potential for informing future physical activity intervention development. Although further study is needed to determine usability of the Life in a Day time use app, this study demonstrated acceptability among this population, with survey responses highlighting areas of improvement in which future research should address. Our quantitative analyses indicate that participants generally perceived adding forgotten activities in the app as difficult, regardless of age. This finding suggests an area of improvement relevant to all survivors. This study also has several public health implications. First, such apps require further refinement and testing but will likely provide more accurate time-use data than retrospective surveys and can be used to augment documentation of physical activity recorded by accelerometry. Additionally, such apps could help promote better health in cancer survivors by making them more aware of their habits and providing potential insights into how and when physical activity could be added to their daily life. The integration of such apps could substantially benefit public health, given the rising number of survivors and the large need for physical activity in this population.
Life in a Day phone app evaluation.
Life in a Day survey item and percent agreement (N=40).
ecological momentary assessment
Multimedia Activity Recall for Children and Adolescents
This work was supported by the National Cancer Institute [U01CA136859]; the National Heart, Lung, and Blood Institute [T32HL105349]; and the American Cancer Society [PF-16-021-01-CPPB].
None declared.